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Tax Questions Frequently Asked by Physicians
Physicians spend years of their lives in education and training. There are countless hours devoted to studying, researching, and clinical training, not to mention residency and possible fellowships. Then literally overnight, they transition out of a resident salary into a full-time attending pay with little to no education around what to do with this significant increase in salary.
Every job position is unique in terms of benefits, how compensation is earned, job expectations, etc. But they all share one thing in common — taxes. Increased income comes with increased taxes. 
FAQ 1. What is the difference between W2 income and 1099 income?
A: If you are a W2 employee, your employer is responsible for paying half of your Social Security and Medicare taxes. You, as the employee, are then responsible only for the remaining half of your Social Security and Medicare taxes. Additionally, your employer will withhold these taxes, along with federal income taxes, from your paycheck each pay period. You are not responsible for remitting any taxes to the IRS or state agencies, as your employer will do this for you. As a W2 employee, you are not able to deduct any employee expenses against your income.
As a 1099 contractor, you are considered self-employed and are responsible for the employer and employee portion of the Social Security and Medicare taxes. You are also responsible for remitting these taxes, as well as quarterly estimated federal withholding, to the IRS and state agencies. You can deduct work-related expenses against your 1099 income.
Both types of income have pros and cons. Either of these can be more beneficial to a specific situation.
FAQ 2. How do I know if I am withholding enough taxes?
A: This is a very common issue I see, especially with physicians who are transitioning out of training into their full-time attending salary. Because this transition happens mid-year, often the first half of the year you are withholding at a rate much lower than what you will be earning as an attending and end up with a tax surprise at filing. One way to remedy this is to look at how much taxes are being withheld from your paycheck and compare this to what tax bracket you anticipate to be in, depending on filing status (Figure 1). If you do this and realize you are not withholding enough taxes, you can submit an amended form W4 to your employer to have additional withholding taken out each pay period.
FAQ 3. I am a 1099 contractor; do I need a PLLC, and should I file as an S-Corporation?
A: The term “S-Corp” gets mentioned often related to 1099 contractors and can be extremely beneficial from a tax savings perspective. Often physicians may moonlight — in addition to working in their W2 positions — and would receive this compensation as a 1099 contractor rather than an employee. This is an example of when a Professional Limited Liability Company (PLLC) might be advisable. A PLLC is created at a state level and helps shield owners from potential litigation. The owner of a PLLC pays Social Security and Medicare taxes on all income earned from the entity, and the PLLC is included in the owner’s individual income tax return.
A Small-Corporation (S-Corporation) is a tax classification that passes income through to the owners. The PLLC is now taxed as an S-Corporation, rather than a disregarded entity. The shareholders of the S-Corporation are required to pay a reasonable salary (W2 income). The remaining income passes through to the owner and is not subject to Social Security and Medicare taxes, only federal income tax. This taxation status requires an additional tax return and payroll service. Because there are additional expenses with being taxed as an S-Corporation, a cost-benefit analysis should be done before changing the tax classification to confirm that the tax savings are greater than the additional costs.
FAQ 4. What is the ‘backdoor Roth’ strategy? Should I implement it?
A: A Roth IRA is a specific type of Individual Retirement Account (IRA) that is funded with after-tax dollars. The contributions and growth in a Roth IRA can be withdrawn at retirement, tax free. As physicians who are typically high earners, you are not able to contribute directly to a Roth IRA because of income limitations. This is where the Roth conversion strategy — the backdoor Roth — comes into play. This strategy allows you to make a nondeductible traditional IRA contribution and then convert those dollars into a Roth IRA. In 2023, you can contribute up to $6,500 into this type of account. There are many additional considerations that must be made before implementing this strategy. Discussion with a financial advisor or CPA is recommended.
FAQ 5. I’ve always done my own taxes. Do I need to hire a CPA?
A: For many physicians, especially during training, your tax situation may not warrant the need for a Certified Public Accountant (CPA). However, as your income and tax complexity increase, working with a CPA not only decreases your risk for error, but also helps ensure you are not overpaying in taxes. There are many different types of services that a CPA can offer, the most basic being tax preparation. This is simply compiling your tax return based on the circumstances that occurred in the prior year. Tax planning is an additional level of service that may not be included in tax preparation cost. Tax planning is a proactive approach to taxes and helps maximize tax savings opportunities before return preparation. When interviewing a potential CPA, you can ask what level of services are included in the fees quoted.
These are just a few of the questions I regularly answer related to physicians’ taxation. The tax code is complex and ever changing. Recommendations that are made today might not be applicable or advisable in the future to any given situation. Working with a professional can ensure you have the most up-to-date and accurate information related to your taxes.
Ms. Anderson is with Physician’s Resource Services and is on Instagram @physiciansrs . Dr. Anderson is a CA-1 Resident in Anesthesia at Baylor Scott and White Health. The authors have no conflicts of interest.
Physicians spend years of their lives in education and training. There are countless hours devoted to studying, researching, and clinical training, not to mention residency and possible fellowships. Then literally overnight, they transition out of a resident salary into a full-time attending pay with little to no education around what to do with this significant increase in salary.
Every job position is unique in terms of benefits, how compensation is earned, job expectations, etc. But they all share one thing in common — taxes. Increased income comes with increased taxes.
FAQ 1. What is the difference between W2 income and 1099 income?
A: If you are a W2 employee, your employer is responsible for paying half of your Social Security and Medicare taxes. You, as the employee, are then responsible only for the remaining half of your Social Security and Medicare taxes. Additionally, your employer will withhold these taxes, along with federal income taxes, from your paycheck each pay period. You are not responsible for remitting any taxes to the IRS or state agencies, as your employer will do this for you. As a W2 employee, you are not able to deduct any employee expenses against your income.
As a 1099 contractor, you are considered self-employed and are responsible for the employer and employee portion of the Social Security and Medicare taxes. You are also responsible for remitting these taxes, as well as quarterly estimated federal withholding, to the IRS and state agencies. You can deduct work-related expenses against your 1099 income.
Both types of income have pros and cons. Either of these can be more beneficial to a specific situation.
FAQ 2. How do I know if I am withholding enough taxes?
A: This is a very common issue I see, especially with physicians who are transitioning out of training into their full-time attending salary. Because this transition happens mid-year, often the first half of the year you are withholding at a rate much lower than what you will be earning as an attending and end up with a tax surprise at filing. One way to remedy this is to look at how much taxes are being withheld from your paycheck and compare this to what tax bracket you anticipate to be in, depending on filing status (Figure 1). If you do this and realize you are not withholding enough taxes, you can submit an amended form W4 to your employer to have additional withholding taken out each pay period.
FAQ 3. I am a 1099 contractor; do I need a PLLC, and should I file as an S-Corporation?
A: The term “S-Corp” gets mentioned often related to 1099 contractors and can be extremely beneficial from a tax savings perspective. Often physicians may moonlight — in addition to working in their W2 positions — and would receive this compensation as a 1099 contractor rather than an employee. This is an example of when a Professional Limited Liability Company (PLLC) might be advisable. A PLLC is created at a state level and helps shield owners from potential litigation. The owner of a PLLC pays Social Security and Medicare taxes on all income earned from the entity, and the PLLC is included in the owner’s individual income tax return.
A Small-Corporation (S-Corporation) is a tax classification that passes income through to the owners. The PLLC is now taxed as an S-Corporation, rather than a disregarded entity. The shareholders of the S-Corporation are required to pay a reasonable salary (W2 income). The remaining income passes through to the owner and is not subject to Social Security and Medicare taxes, only federal income tax. This taxation status requires an additional tax return and payroll service. Because there are additional expenses with being taxed as an S-Corporation, a cost-benefit analysis should be done before changing the tax classification to confirm that the tax savings are greater than the additional costs.
FAQ 4. What is the ‘backdoor Roth’ strategy? Should I implement it?
A: A Roth IRA is a specific type of Individual Retirement Account (IRA) that is funded with after-tax dollars. The contributions and growth in a Roth IRA can be withdrawn at retirement, tax free. As physicians who are typically high earners, you are not able to contribute directly to a Roth IRA because of income limitations. This is where the Roth conversion strategy — the backdoor Roth — comes into play. This strategy allows you to make a nondeductible traditional IRA contribution and then convert those dollars into a Roth IRA. In 2023, you can contribute up to $6,500 into this type of account. There are many additional considerations that must be made before implementing this strategy. Discussion with a financial advisor or CPA is recommended.
FAQ 5. I’ve always done my own taxes. Do I need to hire a CPA?
A: For many physicians, especially during training, your tax situation may not warrant the need for a Certified Public Accountant (CPA). However, as your income and tax complexity increase, working with a CPA not only decreases your risk for error, but also helps ensure you are not overpaying in taxes. There are many different types of services that a CPA can offer, the most basic being tax preparation. This is simply compiling your tax return based on the circumstances that occurred in the prior year. Tax planning is an additional level of service that may not be included in tax preparation cost. Tax planning is a proactive approach to taxes and helps maximize tax savings opportunities before return preparation. When interviewing a potential CPA, you can ask what level of services are included in the fees quoted.
These are just a few of the questions I regularly answer related to physicians’ taxation. The tax code is complex and ever changing. Recommendations that are made today might not be applicable or advisable in the future to any given situation. Working with a professional can ensure you have the most up-to-date and accurate information related to your taxes.
Ms. Anderson is with Physician’s Resource Services and is on Instagram @physiciansrs . Dr. Anderson is a CA-1 Resident in Anesthesia at Baylor Scott and White Health. The authors have no conflicts of interest.
Physicians spend years of their lives in education and training. There are countless hours devoted to studying, researching, and clinical training, not to mention residency and possible fellowships. Then literally overnight, they transition out of a resident salary into a full-time attending pay with little to no education around what to do with this significant increase in salary.
Every job position is unique in terms of benefits, how compensation is earned, job expectations, etc. But they all share one thing in common — taxes. Increased income comes with increased taxes.
FAQ 1. What is the difference between W2 income and 1099 income?
A: If you are a W2 employee, your employer is responsible for paying half of your Social Security and Medicare taxes. You, as the employee, are then responsible only for the remaining half of your Social Security and Medicare taxes. Additionally, your employer will withhold these taxes, along with federal income taxes, from your paycheck each pay period. You are not responsible for remitting any taxes to the IRS or state agencies, as your employer will do this for you. As a W2 employee, you are not able to deduct any employee expenses against your income.
As a 1099 contractor, you are considered self-employed and are responsible for the employer and employee portion of the Social Security and Medicare taxes. You are also responsible for remitting these taxes, as well as quarterly estimated federal withholding, to the IRS and state agencies. You can deduct work-related expenses against your 1099 income.
Both types of income have pros and cons. Either of these can be more beneficial to a specific situation.
FAQ 2. How do I know if I am withholding enough taxes?
A: This is a very common issue I see, especially with physicians who are transitioning out of training into their full-time attending salary. Because this transition happens mid-year, often the first half of the year you are withholding at a rate much lower than what you will be earning as an attending and end up with a tax surprise at filing. One way to remedy this is to look at how much taxes are being withheld from your paycheck and compare this to what tax bracket you anticipate to be in, depending on filing status (Figure 1). If you do this and realize you are not withholding enough taxes, you can submit an amended form W4 to your employer to have additional withholding taken out each pay period.
FAQ 3. I am a 1099 contractor; do I need a PLLC, and should I file as an S-Corporation?
A: The term “S-Corp” gets mentioned often related to 1099 contractors and can be extremely beneficial from a tax savings perspective. Often physicians may moonlight — in addition to working in their W2 positions — and would receive this compensation as a 1099 contractor rather than an employee. This is an example of when a Professional Limited Liability Company (PLLC) might be advisable. A PLLC is created at a state level and helps shield owners from potential litigation. The owner of a PLLC pays Social Security and Medicare taxes on all income earned from the entity, and the PLLC is included in the owner’s individual income tax return.
A Small-Corporation (S-Corporation) is a tax classification that passes income through to the owners. The PLLC is now taxed as an S-Corporation, rather than a disregarded entity. The shareholders of the S-Corporation are required to pay a reasonable salary (W2 income). The remaining income passes through to the owner and is not subject to Social Security and Medicare taxes, only federal income tax. This taxation status requires an additional tax return and payroll service. Because there are additional expenses with being taxed as an S-Corporation, a cost-benefit analysis should be done before changing the tax classification to confirm that the tax savings are greater than the additional costs.
FAQ 4. What is the ‘backdoor Roth’ strategy? Should I implement it?
A: A Roth IRA is a specific type of Individual Retirement Account (IRA) that is funded with after-tax dollars. The contributions and growth in a Roth IRA can be withdrawn at retirement, tax free. As physicians who are typically high earners, you are not able to contribute directly to a Roth IRA because of income limitations. This is where the Roth conversion strategy — the backdoor Roth — comes into play. This strategy allows you to make a nondeductible traditional IRA contribution and then convert those dollars into a Roth IRA. In 2023, you can contribute up to $6,500 into this type of account. There are many additional considerations that must be made before implementing this strategy. Discussion with a financial advisor or CPA is recommended.
FAQ 5. I’ve always done my own taxes. Do I need to hire a CPA?
A: For many physicians, especially during training, your tax situation may not warrant the need for a Certified Public Accountant (CPA). However, as your income and tax complexity increase, working with a CPA not only decreases your risk for error, but also helps ensure you are not overpaying in taxes. There are many different types of services that a CPA can offer, the most basic being tax preparation. This is simply compiling your tax return based on the circumstances that occurred in the prior year. Tax planning is an additional level of service that may not be included in tax preparation cost. Tax planning is a proactive approach to taxes and helps maximize tax savings opportunities before return preparation. When interviewing a potential CPA, you can ask what level of services are included in the fees quoted.
These are just a few of the questions I regularly answer related to physicians’ taxation. The tax code is complex and ever changing. Recommendations that are made today might not be applicable or advisable in the future to any given situation. Working with a professional can ensure you have the most up-to-date and accurate information related to your taxes.
Ms. Anderson is with Physician’s Resource Services and is on Instagram @physiciansrs . Dr. Anderson is a CA-1 Resident in Anesthesia at Baylor Scott and White Health. The authors have no conflicts of interest.
Survival-Toxicity Trade-off With T-DM1 in HER+ Breast Cancer
SAN ANTONIO — in older patients with advanced human epidermal growth factor receptor 2–positive (HER2+) breast cancer, although toxicity is much lower, results from the HERB TEA study show.
Overall, the standard-of-care triple regimen of monoclonal antibodies pertuzumab and trastuzumab plus docetaxel remains the “first-line treatment for HER2-positive advanced breast cancer, regardless of age,” said study author Akihiko Shimomura, MD, PhD, who presented the findings (abstract RF02-04) on December 7 at the San Antonio Breast Cancer Symposium.
However, he noted that the standard-of-care regimen appears to be “intolerable mentally and physically” in those older than 65 years, and “impairs” quality of life.
Therefore a “new standard treatment with less toxicity and noninferior efficacy for older patients is needed,” said Dr. Shimomura, Department of Breast and Medical Oncology, National Center for Global Health and Medicine, Tokyo.
Dr. Shimomura and colleagues recruited patients aged 65 years or older with advanced HER2+ breast cancer who had received no prior chemotherapy for metastatic breast cancer and had a good performance status.
Patients were randomly assigned to either pertuzumab and trastuzumab plus docetaxel or T-DM1 until disease progression. The planned sample size was 250 patients, but the study was terminated after 148 participants were recruited because an interim analysis showed that T-DM1 failed to show noninferiority.
Among 75 patients assigned to the standard-of-care regimen, the mean age was 71 years, with 64% aged 65-74 years. Sixty-five percent had stage IV disease, and 35% had relapsed. These baseline characteristics were similar among the 73 patients given T-DM1.
At the data cutoff of June 15, 2023, the median progression-free survival was comparable between the two groups, at 15.6 months with the triple therapy vs 11.3 months with T-DM1 (hazard ratio [HR], 1.358; P =.1236).
There was also no significant difference in overall survival between the two groups (HR, 1.263; P =.95322).
However, T-DM1 failed to meet its primary endpoint of noninferiority to pertuzumab and trastuzumab plus docetaxel, defined as a hazard ratio for overall survival of 1.35.
Nevertheless, T-DM1 was associated with significantly less toxicity than the standard-of care-regimen, with rates of grade 3 or worse adverse events of 36.1% vs 56.8%, Shimomura reported.
The most common hematologic adverse events with the triple therapy were leukopenia (34.2%) and neutropenia (52.0%), whereas thrombocytopenia was the most common event with T-DM1 (16.7%).
Liver toxicities were also increased with the antibody-drug conjugate, whereas fatigue, diarrhea, and appetite loss were more frequently seen with the standard-of-care regimen.
Although T-DM1 did not achieve noninferiority, given its lower toxicity profile, a “detailed analysis, including geriatric assessment, is needed to identify the patient population for whom T-DM1 may be used as first line treatment,” said Shimomura.
Virginia Kaklamani, MD, codirector of the SABCS and leader of the Breast Cancer Program at the UT Health San Antonio Cancer Center, Texas, said in an interview that the trial shows T-DM1 could be “a good alternative to our first line therapy in HER2+ metastatic breast cancer” for some patients.
“It is, however, unlikely to change the standard of care due to several changes in the field including the results from the KATHERINE trial and the DESTINY-Breast trials,” she said.
The study was funded by the Japanese National Cancer Center. Dr. Shimomura declares relationships with Daiichi Sankyo, Pfizer, AstraZeneca K.K., Chugai Pharmaceutical Co. Ltd, Eli Lilly Japan K.K., MSD Co. Ltd, Eisai Co. Ltd, Gilead Sciences, and Taiho Pharmaceutical Co. Ltd.
A version of this article appeared on Medscape.com.
SAN ANTONIO — in older patients with advanced human epidermal growth factor receptor 2–positive (HER2+) breast cancer, although toxicity is much lower, results from the HERB TEA study show.
Overall, the standard-of-care triple regimen of monoclonal antibodies pertuzumab and trastuzumab plus docetaxel remains the “first-line treatment for HER2-positive advanced breast cancer, regardless of age,” said study author Akihiko Shimomura, MD, PhD, who presented the findings (abstract RF02-04) on December 7 at the San Antonio Breast Cancer Symposium.
However, he noted that the standard-of-care regimen appears to be “intolerable mentally and physically” in those older than 65 years, and “impairs” quality of life.
Therefore a “new standard treatment with less toxicity and noninferior efficacy for older patients is needed,” said Dr. Shimomura, Department of Breast and Medical Oncology, National Center for Global Health and Medicine, Tokyo.
Dr. Shimomura and colleagues recruited patients aged 65 years or older with advanced HER2+ breast cancer who had received no prior chemotherapy for metastatic breast cancer and had a good performance status.
Patients were randomly assigned to either pertuzumab and trastuzumab plus docetaxel or T-DM1 until disease progression. The planned sample size was 250 patients, but the study was terminated after 148 participants were recruited because an interim analysis showed that T-DM1 failed to show noninferiority.
Among 75 patients assigned to the standard-of-care regimen, the mean age was 71 years, with 64% aged 65-74 years. Sixty-five percent had stage IV disease, and 35% had relapsed. These baseline characteristics were similar among the 73 patients given T-DM1.
At the data cutoff of June 15, 2023, the median progression-free survival was comparable between the two groups, at 15.6 months with the triple therapy vs 11.3 months with T-DM1 (hazard ratio [HR], 1.358; P =.1236).
There was also no significant difference in overall survival between the two groups (HR, 1.263; P =.95322).
However, T-DM1 failed to meet its primary endpoint of noninferiority to pertuzumab and trastuzumab plus docetaxel, defined as a hazard ratio for overall survival of 1.35.
Nevertheless, T-DM1 was associated with significantly less toxicity than the standard-of care-regimen, with rates of grade 3 or worse adverse events of 36.1% vs 56.8%, Shimomura reported.
The most common hematologic adverse events with the triple therapy were leukopenia (34.2%) and neutropenia (52.0%), whereas thrombocytopenia was the most common event with T-DM1 (16.7%).
Liver toxicities were also increased with the antibody-drug conjugate, whereas fatigue, diarrhea, and appetite loss were more frequently seen with the standard-of-care regimen.
Although T-DM1 did not achieve noninferiority, given its lower toxicity profile, a “detailed analysis, including geriatric assessment, is needed to identify the patient population for whom T-DM1 may be used as first line treatment,” said Shimomura.
Virginia Kaklamani, MD, codirector of the SABCS and leader of the Breast Cancer Program at the UT Health San Antonio Cancer Center, Texas, said in an interview that the trial shows T-DM1 could be “a good alternative to our first line therapy in HER2+ metastatic breast cancer” for some patients.
“It is, however, unlikely to change the standard of care due to several changes in the field including the results from the KATHERINE trial and the DESTINY-Breast trials,” she said.
The study was funded by the Japanese National Cancer Center. Dr. Shimomura declares relationships with Daiichi Sankyo, Pfizer, AstraZeneca K.K., Chugai Pharmaceutical Co. Ltd, Eli Lilly Japan K.K., MSD Co. Ltd, Eisai Co. Ltd, Gilead Sciences, and Taiho Pharmaceutical Co. Ltd.
A version of this article appeared on Medscape.com.
SAN ANTONIO — in older patients with advanced human epidermal growth factor receptor 2–positive (HER2+) breast cancer, although toxicity is much lower, results from the HERB TEA study show.
Overall, the standard-of-care triple regimen of monoclonal antibodies pertuzumab and trastuzumab plus docetaxel remains the “first-line treatment for HER2-positive advanced breast cancer, regardless of age,” said study author Akihiko Shimomura, MD, PhD, who presented the findings (abstract RF02-04) on December 7 at the San Antonio Breast Cancer Symposium.
However, he noted that the standard-of-care regimen appears to be “intolerable mentally and physically” in those older than 65 years, and “impairs” quality of life.
Therefore a “new standard treatment with less toxicity and noninferior efficacy for older patients is needed,” said Dr. Shimomura, Department of Breast and Medical Oncology, National Center for Global Health and Medicine, Tokyo.
Dr. Shimomura and colleagues recruited patients aged 65 years or older with advanced HER2+ breast cancer who had received no prior chemotherapy for metastatic breast cancer and had a good performance status.
Patients were randomly assigned to either pertuzumab and trastuzumab plus docetaxel or T-DM1 until disease progression. The planned sample size was 250 patients, but the study was terminated after 148 participants were recruited because an interim analysis showed that T-DM1 failed to show noninferiority.
Among 75 patients assigned to the standard-of-care regimen, the mean age was 71 years, with 64% aged 65-74 years. Sixty-five percent had stage IV disease, and 35% had relapsed. These baseline characteristics were similar among the 73 patients given T-DM1.
At the data cutoff of June 15, 2023, the median progression-free survival was comparable between the two groups, at 15.6 months with the triple therapy vs 11.3 months with T-DM1 (hazard ratio [HR], 1.358; P =.1236).
There was also no significant difference in overall survival between the two groups (HR, 1.263; P =.95322).
However, T-DM1 failed to meet its primary endpoint of noninferiority to pertuzumab and trastuzumab plus docetaxel, defined as a hazard ratio for overall survival of 1.35.
Nevertheless, T-DM1 was associated with significantly less toxicity than the standard-of care-regimen, with rates of grade 3 or worse adverse events of 36.1% vs 56.8%, Shimomura reported.
The most common hematologic adverse events with the triple therapy were leukopenia (34.2%) and neutropenia (52.0%), whereas thrombocytopenia was the most common event with T-DM1 (16.7%).
Liver toxicities were also increased with the antibody-drug conjugate, whereas fatigue, diarrhea, and appetite loss were more frequently seen with the standard-of-care regimen.
Although T-DM1 did not achieve noninferiority, given its lower toxicity profile, a “detailed analysis, including geriatric assessment, is needed to identify the patient population for whom T-DM1 may be used as first line treatment,” said Shimomura.
Virginia Kaklamani, MD, codirector of the SABCS and leader of the Breast Cancer Program at the UT Health San Antonio Cancer Center, Texas, said in an interview that the trial shows T-DM1 could be “a good alternative to our first line therapy in HER2+ metastatic breast cancer” for some patients.
“It is, however, unlikely to change the standard of care due to several changes in the field including the results from the KATHERINE trial and the DESTINY-Breast trials,” she said.
The study was funded by the Japanese National Cancer Center. Dr. Shimomura declares relationships with Daiichi Sankyo, Pfizer, AstraZeneca K.K., Chugai Pharmaceutical Co. Ltd, Eli Lilly Japan K.K., MSD Co. Ltd, Eisai Co. Ltd, Gilead Sciences, and Taiho Pharmaceutical Co. Ltd.
A version of this article appeared on Medscape.com.
AT SABCS 2023
10% of US physicians work for or under UnitedHealth. Is that a problem?
as more payers and private equity firms pursue medical practice acquisitions.
The company added 20,000 physicians in the last year alone, including a previously physician-owned multispecialty group practice of 400 doctors in New York. They join the growing web of doctors — about 90,000 of the 950,000 active US physicians — working for the UnitedHealth Group subsidiary, Optum Health, providing primary, specialty, urgent, and surgical care. Amar Desai, MD, chief executive officer of Optum Health, shared the updated workforce numbers during the health care conglomerate’s annual investor conference.
Health care mergers and consolidations have become more common as physician groups struggle to stay afloat amid dwindling payer reimbursements. Although private equity and health systems often acquire practices, payers like UHC are increasingly doing so as part of their model to advance value-based care.
Yashaswini Singh, PhD, health care economist and assistant professor of health services, policy, and practice at Brown University, says such moves mirror the broader trend in corporate consolidation of physician practices. She said in an interview that the integrated models could possibly enhance care coordination and improve outcomes, but the impact of payer-led consolidation has not been extensively studied.
Meanwhile, evidence considering private equity ownership is just emerging. In a 2022 study published in JAMA Health Forum, with Dr. Singh as lead author, findings showed that private equity involvement increased healthcare spending through higher prices and utilization.
Consolidation can also raise anti-trust concerns. “If payers incentivize referral patterns of their employed physicians to favor other physicians employed by the payer, it can reduce competition by restricting consumer choice,” said Dr. Singh.
A potential merger between Cigna and Humana that could happen by the end of the year will likely face intense scrutiny as it would create a company that rivals the size of UnitedHealth Group or CVS Health. If it goes through, the duo could streamline its insurance offerings and leverage each other’s care delivery platforms, clinics, and provider workforce.
The Biden Administration has sought to strengthen anti-trust statutes to prevent industry monopolies and consumer harm, and the US Department of Justice and Federal Trade Commission have proposed new merger guidelines that have yet to be finalized.
According to Dr. Singh, some of Optum’s medical practice purchases may bypass anti-trust statutes since most prospective mergers and acquisitions are reviewed only if they exceed a specific value ($101 million for 2023). Limited transparency in ownership structures further complicates matters. Plus, Dr. Singh said instances where physicians are hired instead of acquired through mergers would not be subject to current anti-trust laws.
The ‘corporatization’ of health care is not good for patients or physicians, said Robert McNamara, MD, chief medical officer of the American Academy of Emergency Medicine Physician Group and cofounder of Take Medicine Back, a physician group advocating to remove corporate interests from health care.
“If you ask a physician what causes them the most moral conflict, they’ll tell you it’s the insurance companies denying something they want to do for their patients,” he said. “To have the doctors now working for the insurance industry conflicts with a physician’s duty to put the patient first.”
Dr. McNamara, chair of emergency medicine at Temple University’s Katz School of Medicine, said in an interview that more than half the states in the United States have laws or court rulings that support protecting physician autonomy from corporate interests. Still, he hopes a federal prohibition on private equity’s involvement in healthcare can soon gain traction. In November, Take Medicine Back raised a resolution at the American Medical Association’s interim House of Delegates meeting, which he said was subsequently referred to a committee.
Emergency medicine was among the first specialties to succumb to private equity firms, but Dr. McNamara said that all types of health care providers and entities — from cardiology and urology to addiction treatment centers and nursing homes — are being swallowed up by larger organizations, including payers.
UHC was named in a class action suit recently for allegedly shirking doctors’ orders and relying on a flawed algorithm to determine the length of skilled nursing facility stays for Medicare Advantage policyholders.
At the investor meeting, Dr. Desai reiterated Optum’s desire to continue expanding care delivery options, especially in its pharmacy and behavioral health business lines, and focus on adopting value-based care. He credited the rapid growth to developing strong relationships with providers and standardizing technology and clinical systems.
A version of this article appeared on Medscape.com.
as more payers and private equity firms pursue medical practice acquisitions.
The company added 20,000 physicians in the last year alone, including a previously physician-owned multispecialty group practice of 400 doctors in New York. They join the growing web of doctors — about 90,000 of the 950,000 active US physicians — working for the UnitedHealth Group subsidiary, Optum Health, providing primary, specialty, urgent, and surgical care. Amar Desai, MD, chief executive officer of Optum Health, shared the updated workforce numbers during the health care conglomerate’s annual investor conference.
Health care mergers and consolidations have become more common as physician groups struggle to stay afloat amid dwindling payer reimbursements. Although private equity and health systems often acquire practices, payers like UHC are increasingly doing so as part of their model to advance value-based care.
Yashaswini Singh, PhD, health care economist and assistant professor of health services, policy, and practice at Brown University, says such moves mirror the broader trend in corporate consolidation of physician practices. She said in an interview that the integrated models could possibly enhance care coordination and improve outcomes, but the impact of payer-led consolidation has not been extensively studied.
Meanwhile, evidence considering private equity ownership is just emerging. In a 2022 study published in JAMA Health Forum, with Dr. Singh as lead author, findings showed that private equity involvement increased healthcare spending through higher prices and utilization.
Consolidation can also raise anti-trust concerns. “If payers incentivize referral patterns of their employed physicians to favor other physicians employed by the payer, it can reduce competition by restricting consumer choice,” said Dr. Singh.
A potential merger between Cigna and Humana that could happen by the end of the year will likely face intense scrutiny as it would create a company that rivals the size of UnitedHealth Group or CVS Health. If it goes through, the duo could streamline its insurance offerings and leverage each other’s care delivery platforms, clinics, and provider workforce.
The Biden Administration has sought to strengthen anti-trust statutes to prevent industry monopolies and consumer harm, and the US Department of Justice and Federal Trade Commission have proposed new merger guidelines that have yet to be finalized.
According to Dr. Singh, some of Optum’s medical practice purchases may bypass anti-trust statutes since most prospective mergers and acquisitions are reviewed only if they exceed a specific value ($101 million for 2023). Limited transparency in ownership structures further complicates matters. Plus, Dr. Singh said instances where physicians are hired instead of acquired through mergers would not be subject to current anti-trust laws.
The ‘corporatization’ of health care is not good for patients or physicians, said Robert McNamara, MD, chief medical officer of the American Academy of Emergency Medicine Physician Group and cofounder of Take Medicine Back, a physician group advocating to remove corporate interests from health care.
“If you ask a physician what causes them the most moral conflict, they’ll tell you it’s the insurance companies denying something they want to do for their patients,” he said. “To have the doctors now working for the insurance industry conflicts with a physician’s duty to put the patient first.”
Dr. McNamara, chair of emergency medicine at Temple University’s Katz School of Medicine, said in an interview that more than half the states in the United States have laws or court rulings that support protecting physician autonomy from corporate interests. Still, he hopes a federal prohibition on private equity’s involvement in healthcare can soon gain traction. In November, Take Medicine Back raised a resolution at the American Medical Association’s interim House of Delegates meeting, which he said was subsequently referred to a committee.
Emergency medicine was among the first specialties to succumb to private equity firms, but Dr. McNamara said that all types of health care providers and entities — from cardiology and urology to addiction treatment centers and nursing homes — are being swallowed up by larger organizations, including payers.
UHC was named in a class action suit recently for allegedly shirking doctors’ orders and relying on a flawed algorithm to determine the length of skilled nursing facility stays for Medicare Advantage policyholders.
At the investor meeting, Dr. Desai reiterated Optum’s desire to continue expanding care delivery options, especially in its pharmacy and behavioral health business lines, and focus on adopting value-based care. He credited the rapid growth to developing strong relationships with providers and standardizing technology and clinical systems.
A version of this article appeared on Medscape.com.
as more payers and private equity firms pursue medical practice acquisitions.
The company added 20,000 physicians in the last year alone, including a previously physician-owned multispecialty group practice of 400 doctors in New York. They join the growing web of doctors — about 90,000 of the 950,000 active US physicians — working for the UnitedHealth Group subsidiary, Optum Health, providing primary, specialty, urgent, and surgical care. Amar Desai, MD, chief executive officer of Optum Health, shared the updated workforce numbers during the health care conglomerate’s annual investor conference.
Health care mergers and consolidations have become more common as physician groups struggle to stay afloat amid dwindling payer reimbursements. Although private equity and health systems often acquire practices, payers like UHC are increasingly doing so as part of their model to advance value-based care.
Yashaswini Singh, PhD, health care economist and assistant professor of health services, policy, and practice at Brown University, says such moves mirror the broader trend in corporate consolidation of physician practices. She said in an interview that the integrated models could possibly enhance care coordination and improve outcomes, but the impact of payer-led consolidation has not been extensively studied.
Meanwhile, evidence considering private equity ownership is just emerging. In a 2022 study published in JAMA Health Forum, with Dr. Singh as lead author, findings showed that private equity involvement increased healthcare spending through higher prices and utilization.
Consolidation can also raise anti-trust concerns. “If payers incentivize referral patterns of their employed physicians to favor other physicians employed by the payer, it can reduce competition by restricting consumer choice,” said Dr. Singh.
A potential merger between Cigna and Humana that could happen by the end of the year will likely face intense scrutiny as it would create a company that rivals the size of UnitedHealth Group or CVS Health. If it goes through, the duo could streamline its insurance offerings and leverage each other’s care delivery platforms, clinics, and provider workforce.
The Biden Administration has sought to strengthen anti-trust statutes to prevent industry monopolies and consumer harm, and the US Department of Justice and Federal Trade Commission have proposed new merger guidelines that have yet to be finalized.
According to Dr. Singh, some of Optum’s medical practice purchases may bypass anti-trust statutes since most prospective mergers and acquisitions are reviewed only if they exceed a specific value ($101 million for 2023). Limited transparency in ownership structures further complicates matters. Plus, Dr. Singh said instances where physicians are hired instead of acquired through mergers would not be subject to current anti-trust laws.
The ‘corporatization’ of health care is not good for patients or physicians, said Robert McNamara, MD, chief medical officer of the American Academy of Emergency Medicine Physician Group and cofounder of Take Medicine Back, a physician group advocating to remove corporate interests from health care.
“If you ask a physician what causes them the most moral conflict, they’ll tell you it’s the insurance companies denying something they want to do for their patients,” he said. “To have the doctors now working for the insurance industry conflicts with a physician’s duty to put the patient first.”
Dr. McNamara, chair of emergency medicine at Temple University’s Katz School of Medicine, said in an interview that more than half the states in the United States have laws or court rulings that support protecting physician autonomy from corporate interests. Still, he hopes a federal prohibition on private equity’s involvement in healthcare can soon gain traction. In November, Take Medicine Back raised a resolution at the American Medical Association’s interim House of Delegates meeting, which he said was subsequently referred to a committee.
Emergency medicine was among the first specialties to succumb to private equity firms, but Dr. McNamara said that all types of health care providers and entities — from cardiology and urology to addiction treatment centers and nursing homes — are being swallowed up by larger organizations, including payers.
UHC was named in a class action suit recently for allegedly shirking doctors’ orders and relying on a flawed algorithm to determine the length of skilled nursing facility stays for Medicare Advantage policyholders.
At the investor meeting, Dr. Desai reiterated Optum’s desire to continue expanding care delivery options, especially in its pharmacy and behavioral health business lines, and focus on adopting value-based care. He credited the rapid growth to developing strong relationships with providers and standardizing technology and clinical systems.
A version of this article appeared on Medscape.com.
Supercharge your medical practice with ChatGPT: Here’s why you should upgrade
Artificial intelligence (AI) has already demonstrated its potential in various areas of healthcare, from early disease detection and drug discovery to genomics and personalized care. OpenAI’s ChatGPT, a large language model, is one AI tool that has been transforming practices across the globe, including mine.
Let me walk you through it.
ChatGPT is essentially an AI-fueled assistant, capable of interpreting and generating human-like text in response to user inputs. Imagine a well-informed and competent trainee working with you, ready to tackle tasks from handling patient inquiries to summarizing intricate medical literature.
Currently, ChatGPT works on the “freemium” pricing model; there is a free version built upon GPT-3.5 as well as a subscription “ChatGPT Plus” version based on GPT-4 which offers additional features such as the use of third-party plug-ins.
Now, you may ask, “Isn’t the free version enough?” The free version is indeed impressive, but upgrading to the paid version for $20 per month unlocks the full potential of this tool, particularly if we add plug-ins.
Here are some of the best ways to incorporate ChatGPT Plus into your practice.
Time saver and efficiency multiplier. The paid version of ChatGPT is an extraordinary time-saving tool. It can help you sort through vast amounts of medical literature in a fraction of the time it would normally take. Imagine having to sift through hundreds of articles to find the latest research relevant to a patient’s case. With the paid version of ChatGPT, you can simply ask it to provide summaries of the most recent and relevant studies, all in seconds.
Did you forget about that PowerPoint you need to make but know the potential papers you would use? No problem. ChatGPT can create slides in a few minutes. It becomes your on-demand research assistant.
Of course, you need to provide the source you find most relevant to you. Using plug-ins such as ScholarAI and Link Reader are great.
Improved patient communication. Explaining complex medical terminology and procedures to patients can sometimes be a challenge. ChatGPT can generate simplified and personalized explanations for your patients, fostering their understanding and involvement in their care process.
Epic is currently collaborating with Nuance Communications, Microsoft’s speech recognition subsidiary, to use generative AI tools for medical note-taking in the electronic health record. However, you do not need to wait for it; it just takes a prompt in ChatGPT and then copying/pasting the results into the chart.
Smoother administrative management. The premium version of ChatGPT can automate administrative tasks such as creating letters of medical necessity, clearance to other physicians for services, or even communications to staff on specific topics. This frees you to focus more on your core work: providing patient care.
Precision medicine aid. ChatGPT can be a powerful ally in the field of precision medicine. Its capabilities for analyzing large datasets and unearthing valuable insights can help deliver more personalized and potentially effective treatment plans. For example, one can prompt ChatGPT to query the reported frequency of certain genomic variants and their implications; with the upgraded version and plug-ins, the results will have fewer hallucinations — inaccurate results — and key data references.
Unlimited accessibility. Uninterrupted access is a compelling reason to upgrade. While the free version may have usage limitations, the premium version provides unrestricted, round-the-clock access. Be it a late-night research quest or an early-morning patient query, your AI assistant will always be available.
Strengthened privacy and security. The premium version of ChatGPT includes heightened privacy and security measures. Just make sure to follow HIPAA and not include identifiers when making queries.
Embracing AI tools like ChatGPT in your practice can help you stay at the cutting edge of medical care, saving you time, enhancing patient communication, and supporting you in providing personalized care.
While the free version can serve as a good starting point (there are apps for both iOS and Android), upgrading to the paid version opens up a world of possibilities that can truly supercharge your practice.
I would love to hear your comments on this column or on future topics. Contact me at [email protected].
Arturo Loaiza-Bonilla, MD, MSEd, is the cofounder and chief medical officer at Massive Bio, a company connecting patients to clinical trials using artificial intelligence. His research and professional interests focus on precision medicine, clinical trial design, digital health, entrepreneurship, and patient advocacy. Dr. Loaiza-Bonilla is Assistant Professor of Medicine, Drexel University School of Medicine, Philadelphia, Pennsylvania, and serves as medical director of oncology research at Capital Health in New Jersey, where he maintains a connection to patient care by attending to patients 2 days a week. He has financial relationships with Verify, PSI CRO, Bayer, AstraZeneca, Cardinal Health, BrightInsight, The Lynx Group, Fresenius, Pfizer, Ipsen, Guardant, Amgen, Eisai, Natera, Merck, and Bristol Myers Squibb.
A version of this article appeared on Medscape.com.
Artificial intelligence (AI) has already demonstrated its potential in various areas of healthcare, from early disease detection and drug discovery to genomics and personalized care. OpenAI’s ChatGPT, a large language model, is one AI tool that has been transforming practices across the globe, including mine.
Let me walk you through it.
ChatGPT is essentially an AI-fueled assistant, capable of interpreting and generating human-like text in response to user inputs. Imagine a well-informed and competent trainee working with you, ready to tackle tasks from handling patient inquiries to summarizing intricate medical literature.
Currently, ChatGPT works on the “freemium” pricing model; there is a free version built upon GPT-3.5 as well as a subscription “ChatGPT Plus” version based on GPT-4 which offers additional features such as the use of third-party plug-ins.
Now, you may ask, “Isn’t the free version enough?” The free version is indeed impressive, but upgrading to the paid version for $20 per month unlocks the full potential of this tool, particularly if we add plug-ins.
Here are some of the best ways to incorporate ChatGPT Plus into your practice.
Time saver and efficiency multiplier. The paid version of ChatGPT is an extraordinary time-saving tool. It can help you sort through vast amounts of medical literature in a fraction of the time it would normally take. Imagine having to sift through hundreds of articles to find the latest research relevant to a patient’s case. With the paid version of ChatGPT, you can simply ask it to provide summaries of the most recent and relevant studies, all in seconds.
Did you forget about that PowerPoint you need to make but know the potential papers you would use? No problem. ChatGPT can create slides in a few minutes. It becomes your on-demand research assistant.
Of course, you need to provide the source you find most relevant to you. Using plug-ins such as ScholarAI and Link Reader are great.
Improved patient communication. Explaining complex medical terminology and procedures to patients can sometimes be a challenge. ChatGPT can generate simplified and personalized explanations for your patients, fostering their understanding and involvement in their care process.
Epic is currently collaborating with Nuance Communications, Microsoft’s speech recognition subsidiary, to use generative AI tools for medical note-taking in the electronic health record. However, you do not need to wait for it; it just takes a prompt in ChatGPT and then copying/pasting the results into the chart.
Smoother administrative management. The premium version of ChatGPT can automate administrative tasks such as creating letters of medical necessity, clearance to other physicians for services, or even communications to staff on specific topics. This frees you to focus more on your core work: providing patient care.
Precision medicine aid. ChatGPT can be a powerful ally in the field of precision medicine. Its capabilities for analyzing large datasets and unearthing valuable insights can help deliver more personalized and potentially effective treatment plans. For example, one can prompt ChatGPT to query the reported frequency of certain genomic variants and their implications; with the upgraded version and plug-ins, the results will have fewer hallucinations — inaccurate results — and key data references.
Unlimited accessibility. Uninterrupted access is a compelling reason to upgrade. While the free version may have usage limitations, the premium version provides unrestricted, round-the-clock access. Be it a late-night research quest or an early-morning patient query, your AI assistant will always be available.
Strengthened privacy and security. The premium version of ChatGPT includes heightened privacy and security measures. Just make sure to follow HIPAA and not include identifiers when making queries.
Embracing AI tools like ChatGPT in your practice can help you stay at the cutting edge of medical care, saving you time, enhancing patient communication, and supporting you in providing personalized care.
While the free version can serve as a good starting point (there are apps for both iOS and Android), upgrading to the paid version opens up a world of possibilities that can truly supercharge your practice.
I would love to hear your comments on this column or on future topics. Contact me at [email protected].
Arturo Loaiza-Bonilla, MD, MSEd, is the cofounder and chief medical officer at Massive Bio, a company connecting patients to clinical trials using artificial intelligence. His research and professional interests focus on precision medicine, clinical trial design, digital health, entrepreneurship, and patient advocacy. Dr. Loaiza-Bonilla is Assistant Professor of Medicine, Drexel University School of Medicine, Philadelphia, Pennsylvania, and serves as medical director of oncology research at Capital Health in New Jersey, where he maintains a connection to patient care by attending to patients 2 days a week. He has financial relationships with Verify, PSI CRO, Bayer, AstraZeneca, Cardinal Health, BrightInsight, The Lynx Group, Fresenius, Pfizer, Ipsen, Guardant, Amgen, Eisai, Natera, Merck, and Bristol Myers Squibb.
A version of this article appeared on Medscape.com.
Artificial intelligence (AI) has already demonstrated its potential in various areas of healthcare, from early disease detection and drug discovery to genomics and personalized care. OpenAI’s ChatGPT, a large language model, is one AI tool that has been transforming practices across the globe, including mine.
Let me walk you through it.
ChatGPT is essentially an AI-fueled assistant, capable of interpreting and generating human-like text in response to user inputs. Imagine a well-informed and competent trainee working with you, ready to tackle tasks from handling patient inquiries to summarizing intricate medical literature.
Currently, ChatGPT works on the “freemium” pricing model; there is a free version built upon GPT-3.5 as well as a subscription “ChatGPT Plus” version based on GPT-4 which offers additional features such as the use of third-party plug-ins.
Now, you may ask, “Isn’t the free version enough?” The free version is indeed impressive, but upgrading to the paid version for $20 per month unlocks the full potential of this tool, particularly if we add plug-ins.
Here are some of the best ways to incorporate ChatGPT Plus into your practice.
Time saver and efficiency multiplier. The paid version of ChatGPT is an extraordinary time-saving tool. It can help you sort through vast amounts of medical literature in a fraction of the time it would normally take. Imagine having to sift through hundreds of articles to find the latest research relevant to a patient’s case. With the paid version of ChatGPT, you can simply ask it to provide summaries of the most recent and relevant studies, all in seconds.
Did you forget about that PowerPoint you need to make but know the potential papers you would use? No problem. ChatGPT can create slides in a few minutes. It becomes your on-demand research assistant.
Of course, you need to provide the source you find most relevant to you. Using plug-ins such as ScholarAI and Link Reader are great.
Improved patient communication. Explaining complex medical terminology and procedures to patients can sometimes be a challenge. ChatGPT can generate simplified and personalized explanations for your patients, fostering their understanding and involvement in their care process.
Epic is currently collaborating with Nuance Communications, Microsoft’s speech recognition subsidiary, to use generative AI tools for medical note-taking in the electronic health record. However, you do not need to wait for it; it just takes a prompt in ChatGPT and then copying/pasting the results into the chart.
Smoother administrative management. The premium version of ChatGPT can automate administrative tasks such as creating letters of medical necessity, clearance to other physicians for services, or even communications to staff on specific topics. This frees you to focus more on your core work: providing patient care.
Precision medicine aid. ChatGPT can be a powerful ally in the field of precision medicine. Its capabilities for analyzing large datasets and unearthing valuable insights can help deliver more personalized and potentially effective treatment plans. For example, one can prompt ChatGPT to query the reported frequency of certain genomic variants and their implications; with the upgraded version and plug-ins, the results will have fewer hallucinations — inaccurate results — and key data references.
Unlimited accessibility. Uninterrupted access is a compelling reason to upgrade. While the free version may have usage limitations, the premium version provides unrestricted, round-the-clock access. Be it a late-night research quest or an early-morning patient query, your AI assistant will always be available.
Strengthened privacy and security. The premium version of ChatGPT includes heightened privacy and security measures. Just make sure to follow HIPAA and not include identifiers when making queries.
Embracing AI tools like ChatGPT in your practice can help you stay at the cutting edge of medical care, saving you time, enhancing patient communication, and supporting you in providing personalized care.
While the free version can serve as a good starting point (there are apps for both iOS and Android), upgrading to the paid version opens up a world of possibilities that can truly supercharge your practice.
I would love to hear your comments on this column or on future topics. Contact me at [email protected].
Arturo Loaiza-Bonilla, MD, MSEd, is the cofounder and chief medical officer at Massive Bio, a company connecting patients to clinical trials using artificial intelligence. His research and professional interests focus on precision medicine, clinical trial design, digital health, entrepreneurship, and patient advocacy. Dr. Loaiza-Bonilla is Assistant Professor of Medicine, Drexel University School of Medicine, Philadelphia, Pennsylvania, and serves as medical director of oncology research at Capital Health in New Jersey, where he maintains a connection to patient care by attending to patients 2 days a week. He has financial relationships with Verify, PSI CRO, Bayer, AstraZeneca, Cardinal Health, BrightInsight, The Lynx Group, Fresenius, Pfizer, Ipsen, Guardant, Amgen, Eisai, Natera, Merck, and Bristol Myers Squibb.
A version of this article appeared on Medscape.com.
Few with inflammatory breast cancer get guideline-based care
SAN ANTONIO — Yet, a retrospective study of patients with inflammatory breast carcinoma shows that the majority of patients don’t receive it.
The study also showed that overall survival was lowest for Black women who didn’t receive guideline-concordant care, said Brian Diskin, MD, with the Division of Breast Surgery, Memorial Sloan Kettering Cancer Center, New York City, here at the San Antonio Breast Cancer Symposium.
The results highlight the importance of adhering to guidelines in inflammatory breast carcinoma and suggest that improving the rates among Black patients “may help to mitigate racial disparities and survival,” Dr.Diskin told the conference.
Inflammatory breast carcinoma is an aggressive form of breast cancer associated with worse survival outcomes compared with other subtypes of breast cancer. Yet, it’s unclear how often and consistently guideline-concordant care — defined as treatment with neoadjuvant chemotherapy followed by modified radical mastectomy without immediate reconstruction, and postmastectomy radiotherapy — is received and what factors play a role in receiving recommended care.
To investigate, Dr. Diskin and colleagues identified 6945 women from the National Cancer Database with nonmetastatic inflammatory breast cancer treated from 2010-2018. Guideline-concordant care was defined as trimodality treatment administered in the correct sequence, with neoadjuvant chemotherapy started within 60 days of diagnosis.
Most patients (88%) did not start neoadjuvant chemotherapy within 60 days of diagnosis.
Black and Asian patients were less likely than were White patients to start chemotherapy within 60 days (odds ratio [OR] 0.54 and 0.51, respectively; P < .001), while patients with Medicare or private insurance were more likely to receive chemotherapy within 60 days of diagnosis than uninsured patients (OR 1.37 and 1.87, respectively; P < .001).
Roughly half of all patients didn’t receive appropriate surgical treatment (modified radical mastectomy without immediate reconstruction and postmastectomy radiotherapy).
Overall, only about one third of the cohort received guideline-concordant treatment, Dr. Diskin reported.
Patients aged 60-69 were more likely than were patients aged 40-49 to receive guideline-concordant treatment (odds ratio [OR], 1.24; P < .001), as were patients with a higher clinical nodal burden (OR, 1.34 for N1; OR, 1.28 for N2; OR, 1.15 for N3 vs N0; P < .001 for N1 and N2).
Patients treated between 2014 and 2018 were less likely to receive guideline-concordant treatment than patients treated between 2010 and 2013 (OR, 0.63; P <.001).
Receiving guideline-concordant care and being privately insured were both positively associated with improved overall survival (OR, 0.75 and 0.62, respectively; P < .001). Conversely, triple-negative subtype and Black race were associated with worse overall survival (HR, 1.6 and 1.4, respectively; P < .001).
However, timely receipt of guideline-concordant care for Black patients with triple-negative disease did lead to improved overall survival. Among recipients of guideline-based care with triple-negative disease, there was no racial disparity in overall survival.
Study discussant Kathryn Hudson, MD, director of survivorship and medical oncologist at Texas Oncology, Austin, said it’s important to note that Black women have a 4% lower incidence of breast cancer than do White women but a 40% higher breast cancer death rate.
“This study is important because it confirms that those who receive guideline-based care have better outcomes and that Black women have worse survival in [inflammatory breast cancer],” Dr. Hudson said.
The finding that Black and Asian women in the study were less likely to have timely neoadjuvant chemotherapy, “likely reflects worse access to care, and this may play a role in why Black women had worse outcomes,” she added.
Dr. Hudson said she found it “surprising” that only about one third of patients received guideline-concordant care.
In her view, “the take-home message is that improving guideline-concordant will improve outcomes for all patients with inflammatory breast cancer. And it’s really important, as a next step, to examine the barriers to guideline-concordant care in inflammatory breast cancer and continue to understand the reasons for worse [rates of] survival of Black women.”
Dr. Diskin has disclosed no relevant financial relationships. Dr. Hudson has received honoraria from the Menarini Group and Gilead.
A version of this article appeared on Medscape.com.
SAN ANTONIO — Yet, a retrospective study of patients with inflammatory breast carcinoma shows that the majority of patients don’t receive it.
The study also showed that overall survival was lowest for Black women who didn’t receive guideline-concordant care, said Brian Diskin, MD, with the Division of Breast Surgery, Memorial Sloan Kettering Cancer Center, New York City, here at the San Antonio Breast Cancer Symposium.
The results highlight the importance of adhering to guidelines in inflammatory breast carcinoma and suggest that improving the rates among Black patients “may help to mitigate racial disparities and survival,” Dr.Diskin told the conference.
Inflammatory breast carcinoma is an aggressive form of breast cancer associated with worse survival outcomes compared with other subtypes of breast cancer. Yet, it’s unclear how often and consistently guideline-concordant care — defined as treatment with neoadjuvant chemotherapy followed by modified radical mastectomy without immediate reconstruction, and postmastectomy radiotherapy — is received and what factors play a role in receiving recommended care.
To investigate, Dr. Diskin and colleagues identified 6945 women from the National Cancer Database with nonmetastatic inflammatory breast cancer treated from 2010-2018. Guideline-concordant care was defined as trimodality treatment administered in the correct sequence, with neoadjuvant chemotherapy started within 60 days of diagnosis.
Most patients (88%) did not start neoadjuvant chemotherapy within 60 days of diagnosis.
Black and Asian patients were less likely than were White patients to start chemotherapy within 60 days (odds ratio [OR] 0.54 and 0.51, respectively; P < .001), while patients with Medicare or private insurance were more likely to receive chemotherapy within 60 days of diagnosis than uninsured patients (OR 1.37 and 1.87, respectively; P < .001).
Roughly half of all patients didn’t receive appropriate surgical treatment (modified radical mastectomy without immediate reconstruction and postmastectomy radiotherapy).
Overall, only about one third of the cohort received guideline-concordant treatment, Dr. Diskin reported.
Patients aged 60-69 were more likely than were patients aged 40-49 to receive guideline-concordant treatment (odds ratio [OR], 1.24; P < .001), as were patients with a higher clinical nodal burden (OR, 1.34 for N1; OR, 1.28 for N2; OR, 1.15 for N3 vs N0; P < .001 for N1 and N2).
Patients treated between 2014 and 2018 were less likely to receive guideline-concordant treatment than patients treated between 2010 and 2013 (OR, 0.63; P <.001).
Receiving guideline-concordant care and being privately insured were both positively associated with improved overall survival (OR, 0.75 and 0.62, respectively; P < .001). Conversely, triple-negative subtype and Black race were associated with worse overall survival (HR, 1.6 and 1.4, respectively; P < .001).
However, timely receipt of guideline-concordant care for Black patients with triple-negative disease did lead to improved overall survival. Among recipients of guideline-based care with triple-negative disease, there was no racial disparity in overall survival.
Study discussant Kathryn Hudson, MD, director of survivorship and medical oncologist at Texas Oncology, Austin, said it’s important to note that Black women have a 4% lower incidence of breast cancer than do White women but a 40% higher breast cancer death rate.
“This study is important because it confirms that those who receive guideline-based care have better outcomes and that Black women have worse survival in [inflammatory breast cancer],” Dr. Hudson said.
The finding that Black and Asian women in the study were less likely to have timely neoadjuvant chemotherapy, “likely reflects worse access to care, and this may play a role in why Black women had worse outcomes,” she added.
Dr. Hudson said she found it “surprising” that only about one third of patients received guideline-concordant care.
In her view, “the take-home message is that improving guideline-concordant will improve outcomes for all patients with inflammatory breast cancer. And it’s really important, as a next step, to examine the barriers to guideline-concordant care in inflammatory breast cancer and continue to understand the reasons for worse [rates of] survival of Black women.”
Dr. Diskin has disclosed no relevant financial relationships. Dr. Hudson has received honoraria from the Menarini Group and Gilead.
A version of this article appeared on Medscape.com.
SAN ANTONIO — Yet, a retrospective study of patients with inflammatory breast carcinoma shows that the majority of patients don’t receive it.
The study also showed that overall survival was lowest for Black women who didn’t receive guideline-concordant care, said Brian Diskin, MD, with the Division of Breast Surgery, Memorial Sloan Kettering Cancer Center, New York City, here at the San Antonio Breast Cancer Symposium.
The results highlight the importance of adhering to guidelines in inflammatory breast carcinoma and suggest that improving the rates among Black patients “may help to mitigate racial disparities and survival,” Dr.Diskin told the conference.
Inflammatory breast carcinoma is an aggressive form of breast cancer associated with worse survival outcomes compared with other subtypes of breast cancer. Yet, it’s unclear how often and consistently guideline-concordant care — defined as treatment with neoadjuvant chemotherapy followed by modified radical mastectomy without immediate reconstruction, and postmastectomy radiotherapy — is received and what factors play a role in receiving recommended care.
To investigate, Dr. Diskin and colleagues identified 6945 women from the National Cancer Database with nonmetastatic inflammatory breast cancer treated from 2010-2018. Guideline-concordant care was defined as trimodality treatment administered in the correct sequence, with neoadjuvant chemotherapy started within 60 days of diagnosis.
Most patients (88%) did not start neoadjuvant chemotherapy within 60 days of diagnosis.
Black and Asian patients were less likely than were White patients to start chemotherapy within 60 days (odds ratio [OR] 0.54 and 0.51, respectively; P < .001), while patients with Medicare or private insurance were more likely to receive chemotherapy within 60 days of diagnosis than uninsured patients (OR 1.37 and 1.87, respectively; P < .001).
Roughly half of all patients didn’t receive appropriate surgical treatment (modified radical mastectomy without immediate reconstruction and postmastectomy radiotherapy).
Overall, only about one third of the cohort received guideline-concordant treatment, Dr. Diskin reported.
Patients aged 60-69 were more likely than were patients aged 40-49 to receive guideline-concordant treatment (odds ratio [OR], 1.24; P < .001), as were patients with a higher clinical nodal burden (OR, 1.34 for N1; OR, 1.28 for N2; OR, 1.15 for N3 vs N0; P < .001 for N1 and N2).
Patients treated between 2014 and 2018 were less likely to receive guideline-concordant treatment than patients treated between 2010 and 2013 (OR, 0.63; P <.001).
Receiving guideline-concordant care and being privately insured were both positively associated with improved overall survival (OR, 0.75 and 0.62, respectively; P < .001). Conversely, triple-negative subtype and Black race were associated with worse overall survival (HR, 1.6 and 1.4, respectively; P < .001).
However, timely receipt of guideline-concordant care for Black patients with triple-negative disease did lead to improved overall survival. Among recipients of guideline-based care with triple-negative disease, there was no racial disparity in overall survival.
Study discussant Kathryn Hudson, MD, director of survivorship and medical oncologist at Texas Oncology, Austin, said it’s important to note that Black women have a 4% lower incidence of breast cancer than do White women but a 40% higher breast cancer death rate.
“This study is important because it confirms that those who receive guideline-based care have better outcomes and that Black women have worse survival in [inflammatory breast cancer],” Dr. Hudson said.
The finding that Black and Asian women in the study were less likely to have timely neoadjuvant chemotherapy, “likely reflects worse access to care, and this may play a role in why Black women had worse outcomes,” she added.
Dr. Hudson said she found it “surprising” that only about one third of patients received guideline-concordant care.
In her view, “the take-home message is that improving guideline-concordant will improve outcomes for all patients with inflammatory breast cancer. And it’s really important, as a next step, to examine the barriers to guideline-concordant care in inflammatory breast cancer and continue to understand the reasons for worse [rates of] survival of Black women.”
Dr. Diskin has disclosed no relevant financial relationships. Dr. Hudson has received honoraria from the Menarini Group and Gilead.
A version of this article appeared on Medscape.com.
AT SABCS 2023
‘Baby TAM’ effective, tolerable for breast cancer prevention
SAN ANTONIO — The drug can reduce incidence of breast cancer in high-risk individuals, but side effects that mimic menopause have led to low rates of uptake. Lower-dose tamoxifen aims to reduce those side effects, but there remains some uncertainty about the minimum dose required to maintain efficacy.
The TAM-01 study, first published in 2019, demonstrated that a 5-mg dose of tamoxifen led to a reduction in recurrence of invasive breast cancer or ductal carcinoma in situ (DCIS). At the San Antonio Breast Cancer Symposium, two studies were presented that provided insight into dose efficacy and likelihood of medication adherence in women taking baby TAM.
“We all know that women who are at increased risk for breast cancer may benefit from the use of tamoxifen to help lower their risk, although historical uptake to tamoxifen in the prevention setting has been quite low,” said Lauren Cornell, MD, during a presentation. Her team investigated the impact of patient counseling on how well they understood their risk, as well as their likelihood of adherence to the medication.
The study included 41 women, and 31 completed follow-up at 1 year. “We saw that 90% of our patients reported good or complete understanding of their breast cancer risk after the consultation, emphasizing the benefit of that consult, and 73% reported that the availability of baby tamoxifen helped in their decision to consider a preventative medication,” said Dr. Cornell during her presentation. After 1 year of follow-up, 74% said that they had initiated baby tamoxifen, and 78% of those who started taking the drug were still taking it at 1 year.
Participants who continued to take baby TAM at 1 year had a higher estimated breast cancer risk (IBIS 10-year risk, 12.7% vs 7.6%; P = .027) than those who discontinued. “We saw that uptake to baby TAM after informed discussion in patients who qualify is high, especially in those patients with high risk and intraepithelial lesions or DCIS, and adherence and tolerability at 1 year follow up is improved, compared to what we would expect with traditional dosing of tamoxifen. It’s important to note that the NCCN guidelines and the ASCO clinical practice update now include low-dose tamoxifen as an option for select women, and future randomized control trials on de-escalation of tamoxifen and high-risk patients based on their risk model assessment still need to be done. Future study should also focus on markers to identify candidates best suited for low versus standard dose of tamoxifen,” said Dr. Cornell, who is an assistant professor of medicine at Mayo Clinic Florida in Jacksonville.
At another SABCS session, Per Hall, MD, PhD, discussed findings from the previously published KARISMA-2 study, which examined efficacy of various doses of tamoxifen. A total of 1440 participants, 240 in each arm, received tamoxifen doses of 20 mg, 10 mg, 5 mg, 2.5 mg, 1 mg, or placebo. During his talk, Dr. Hall pointed out that measuring outcomes would take a very large number of participants to identify small differences in breast cancer rates. Therefore, the researchers examined breast density changes as a proxy. As a noninferiority outcome, the researchers used the proportion of women in each arm who achieved the median decrease in breast density seen at 20 mg of tamoxifen, which is 10.1%.
The women underwent mammograms at baseline and again at 6 months to determine change in breast density. Among all women in the study, the proportion of patients who had a similar breast density reduction as the 20-mg dose were very similar in the 10 mg (50.0%; P = .002), 5 mg (49.3%; P < .001), and 2.5 mg (52.5%; P < .001) groups. The 1 mg group had a proportion of 39.5% (P = .138), while the placebo group had 38.9% (P = .161). However, the results were driven by premenopausal women, where the values were 63.3%, 70.7%, 74.4%, and 69.7% in the 20-mg, 10-mg, 5-mg, and 2.5-mg groups, respectively, and 32.9% at 1 mg and 29.7% on placebo. In postmenopausal women, the values were 41.9%, 36.7%, 33.3%, and 41.9% in the 20-mg, 10-mg, 5-mg, and 2.5-mg groups, with values of 44.2% in the 1-mg group and 43.8% in the placebo group.
The median density change was 18.5% in premenopausal women and 4.0% in postmenopausal women.
“We didn’t see anything in the postmenopausal women. The decrease for those on 20 milligrams and those on placebo were exactly the same. Why this is, we still don’t know because we do know that tamoxifen in the adjuvant setting could be used for postmenopausal women. It could be that 6 months is too short of a time [to see a benefit]. We don’t know,” said Dr. Hall, who is a medical epidemiologist and biostatistician at Karolinska Institutet, Stockholm, Sweden.
Severe vasomotor side effects like hot flashes, cold flashes, and night sweats were reduced by about 50% in the lower tamoxifen doses, compared with 20 mg.
Dr. Hall also pointed out that tamoxifen is a prodrug. The CYP2D6 enzyme produces a range of metabolites, with endoxifen having the strongest affinity to the estrogen receptor and being present at the highest plasma concentration. He showed a table of endoxifen plasma levels at various tamoxifen doses in women of various metabolizer status, ranging from poor to ultrafast. Among intermediate, normal, and ultrarapid metabolizers, 5- and 10-mg doses produced plasma endoxifen levels ranging from 2.4 to 6.2 ng/mL, which represents a good therapeutic window. “For intermediate and normal metabolizers, it could be that 5 mg [of tamoxifen] is enough, but I want to underline that we didn’t use breast cancer incidence or recurrence in this study, we used density change, so we should be careful when we use these results,” said Dr. Hall. His group is now conducting the KARISMA Endoxifen trial, which will test endoxifen directly at doses of 1 and 2 mg.
Dr. Cornell has no relevant financial disclosures. Dr. Hall is a member of the scientific advisory board for Atossa Therapeutics.
SAN ANTONIO — The drug can reduce incidence of breast cancer in high-risk individuals, but side effects that mimic menopause have led to low rates of uptake. Lower-dose tamoxifen aims to reduce those side effects, but there remains some uncertainty about the minimum dose required to maintain efficacy.
The TAM-01 study, first published in 2019, demonstrated that a 5-mg dose of tamoxifen led to a reduction in recurrence of invasive breast cancer or ductal carcinoma in situ (DCIS). At the San Antonio Breast Cancer Symposium, two studies were presented that provided insight into dose efficacy and likelihood of medication adherence in women taking baby TAM.
“We all know that women who are at increased risk for breast cancer may benefit from the use of tamoxifen to help lower their risk, although historical uptake to tamoxifen in the prevention setting has been quite low,” said Lauren Cornell, MD, during a presentation. Her team investigated the impact of patient counseling on how well they understood their risk, as well as their likelihood of adherence to the medication.
The study included 41 women, and 31 completed follow-up at 1 year. “We saw that 90% of our patients reported good or complete understanding of their breast cancer risk after the consultation, emphasizing the benefit of that consult, and 73% reported that the availability of baby tamoxifen helped in their decision to consider a preventative medication,” said Dr. Cornell during her presentation. After 1 year of follow-up, 74% said that they had initiated baby tamoxifen, and 78% of those who started taking the drug were still taking it at 1 year.
Participants who continued to take baby TAM at 1 year had a higher estimated breast cancer risk (IBIS 10-year risk, 12.7% vs 7.6%; P = .027) than those who discontinued. “We saw that uptake to baby TAM after informed discussion in patients who qualify is high, especially in those patients with high risk and intraepithelial lesions or DCIS, and adherence and tolerability at 1 year follow up is improved, compared to what we would expect with traditional dosing of tamoxifen. It’s important to note that the NCCN guidelines and the ASCO clinical practice update now include low-dose tamoxifen as an option for select women, and future randomized control trials on de-escalation of tamoxifen and high-risk patients based on their risk model assessment still need to be done. Future study should also focus on markers to identify candidates best suited for low versus standard dose of tamoxifen,” said Dr. Cornell, who is an assistant professor of medicine at Mayo Clinic Florida in Jacksonville.
At another SABCS session, Per Hall, MD, PhD, discussed findings from the previously published KARISMA-2 study, which examined efficacy of various doses of tamoxifen. A total of 1440 participants, 240 in each arm, received tamoxifen doses of 20 mg, 10 mg, 5 mg, 2.5 mg, 1 mg, or placebo. During his talk, Dr. Hall pointed out that measuring outcomes would take a very large number of participants to identify small differences in breast cancer rates. Therefore, the researchers examined breast density changes as a proxy. As a noninferiority outcome, the researchers used the proportion of women in each arm who achieved the median decrease in breast density seen at 20 mg of tamoxifen, which is 10.1%.
The women underwent mammograms at baseline and again at 6 months to determine change in breast density. Among all women in the study, the proportion of patients who had a similar breast density reduction as the 20-mg dose were very similar in the 10 mg (50.0%; P = .002), 5 mg (49.3%; P < .001), and 2.5 mg (52.5%; P < .001) groups. The 1 mg group had a proportion of 39.5% (P = .138), while the placebo group had 38.9% (P = .161). However, the results were driven by premenopausal women, where the values were 63.3%, 70.7%, 74.4%, and 69.7% in the 20-mg, 10-mg, 5-mg, and 2.5-mg groups, respectively, and 32.9% at 1 mg and 29.7% on placebo. In postmenopausal women, the values were 41.9%, 36.7%, 33.3%, and 41.9% in the 20-mg, 10-mg, 5-mg, and 2.5-mg groups, with values of 44.2% in the 1-mg group and 43.8% in the placebo group.
The median density change was 18.5% in premenopausal women and 4.0% in postmenopausal women.
“We didn’t see anything in the postmenopausal women. The decrease for those on 20 milligrams and those on placebo were exactly the same. Why this is, we still don’t know because we do know that tamoxifen in the adjuvant setting could be used for postmenopausal women. It could be that 6 months is too short of a time [to see a benefit]. We don’t know,” said Dr. Hall, who is a medical epidemiologist and biostatistician at Karolinska Institutet, Stockholm, Sweden.
Severe vasomotor side effects like hot flashes, cold flashes, and night sweats were reduced by about 50% in the lower tamoxifen doses, compared with 20 mg.
Dr. Hall also pointed out that tamoxifen is a prodrug. The CYP2D6 enzyme produces a range of metabolites, with endoxifen having the strongest affinity to the estrogen receptor and being present at the highest plasma concentration. He showed a table of endoxifen plasma levels at various tamoxifen doses in women of various metabolizer status, ranging from poor to ultrafast. Among intermediate, normal, and ultrarapid metabolizers, 5- and 10-mg doses produced plasma endoxifen levels ranging from 2.4 to 6.2 ng/mL, which represents a good therapeutic window. “For intermediate and normal metabolizers, it could be that 5 mg [of tamoxifen] is enough, but I want to underline that we didn’t use breast cancer incidence or recurrence in this study, we used density change, so we should be careful when we use these results,” said Dr. Hall. His group is now conducting the KARISMA Endoxifen trial, which will test endoxifen directly at doses of 1 and 2 mg.
Dr. Cornell has no relevant financial disclosures. Dr. Hall is a member of the scientific advisory board for Atossa Therapeutics.
SAN ANTONIO — The drug can reduce incidence of breast cancer in high-risk individuals, but side effects that mimic menopause have led to low rates of uptake. Lower-dose tamoxifen aims to reduce those side effects, but there remains some uncertainty about the minimum dose required to maintain efficacy.
The TAM-01 study, first published in 2019, demonstrated that a 5-mg dose of tamoxifen led to a reduction in recurrence of invasive breast cancer or ductal carcinoma in situ (DCIS). At the San Antonio Breast Cancer Symposium, two studies were presented that provided insight into dose efficacy and likelihood of medication adherence in women taking baby TAM.
“We all know that women who are at increased risk for breast cancer may benefit from the use of tamoxifen to help lower their risk, although historical uptake to tamoxifen in the prevention setting has been quite low,” said Lauren Cornell, MD, during a presentation. Her team investigated the impact of patient counseling on how well they understood their risk, as well as their likelihood of adherence to the medication.
The study included 41 women, and 31 completed follow-up at 1 year. “We saw that 90% of our patients reported good or complete understanding of their breast cancer risk after the consultation, emphasizing the benefit of that consult, and 73% reported that the availability of baby tamoxifen helped in their decision to consider a preventative medication,” said Dr. Cornell during her presentation. After 1 year of follow-up, 74% said that they had initiated baby tamoxifen, and 78% of those who started taking the drug were still taking it at 1 year.
Participants who continued to take baby TAM at 1 year had a higher estimated breast cancer risk (IBIS 10-year risk, 12.7% vs 7.6%; P = .027) than those who discontinued. “We saw that uptake to baby TAM after informed discussion in patients who qualify is high, especially in those patients with high risk and intraepithelial lesions or DCIS, and adherence and tolerability at 1 year follow up is improved, compared to what we would expect with traditional dosing of tamoxifen. It’s important to note that the NCCN guidelines and the ASCO clinical practice update now include low-dose tamoxifen as an option for select women, and future randomized control trials on de-escalation of tamoxifen and high-risk patients based on their risk model assessment still need to be done. Future study should also focus on markers to identify candidates best suited for low versus standard dose of tamoxifen,” said Dr. Cornell, who is an assistant professor of medicine at Mayo Clinic Florida in Jacksonville.
At another SABCS session, Per Hall, MD, PhD, discussed findings from the previously published KARISMA-2 study, which examined efficacy of various doses of tamoxifen. A total of 1440 participants, 240 in each arm, received tamoxifen doses of 20 mg, 10 mg, 5 mg, 2.5 mg, 1 mg, or placebo. During his talk, Dr. Hall pointed out that measuring outcomes would take a very large number of participants to identify small differences in breast cancer rates. Therefore, the researchers examined breast density changes as a proxy. As a noninferiority outcome, the researchers used the proportion of women in each arm who achieved the median decrease in breast density seen at 20 mg of tamoxifen, which is 10.1%.
The women underwent mammograms at baseline and again at 6 months to determine change in breast density. Among all women in the study, the proportion of patients who had a similar breast density reduction as the 20-mg dose were very similar in the 10 mg (50.0%; P = .002), 5 mg (49.3%; P < .001), and 2.5 mg (52.5%; P < .001) groups. The 1 mg group had a proportion of 39.5% (P = .138), while the placebo group had 38.9% (P = .161). However, the results were driven by premenopausal women, where the values were 63.3%, 70.7%, 74.4%, and 69.7% in the 20-mg, 10-mg, 5-mg, and 2.5-mg groups, respectively, and 32.9% at 1 mg and 29.7% on placebo. In postmenopausal women, the values were 41.9%, 36.7%, 33.3%, and 41.9% in the 20-mg, 10-mg, 5-mg, and 2.5-mg groups, with values of 44.2% in the 1-mg group and 43.8% in the placebo group.
The median density change was 18.5% in premenopausal women and 4.0% in postmenopausal women.
“We didn’t see anything in the postmenopausal women. The decrease for those on 20 milligrams and those on placebo were exactly the same. Why this is, we still don’t know because we do know that tamoxifen in the adjuvant setting could be used for postmenopausal women. It could be that 6 months is too short of a time [to see a benefit]. We don’t know,” said Dr. Hall, who is a medical epidemiologist and biostatistician at Karolinska Institutet, Stockholm, Sweden.
Severe vasomotor side effects like hot flashes, cold flashes, and night sweats were reduced by about 50% in the lower tamoxifen doses, compared with 20 mg.
Dr. Hall also pointed out that tamoxifen is a prodrug. The CYP2D6 enzyme produces a range of metabolites, with endoxifen having the strongest affinity to the estrogen receptor and being present at the highest plasma concentration. He showed a table of endoxifen plasma levels at various tamoxifen doses in women of various metabolizer status, ranging from poor to ultrafast. Among intermediate, normal, and ultrarapid metabolizers, 5- and 10-mg doses produced plasma endoxifen levels ranging from 2.4 to 6.2 ng/mL, which represents a good therapeutic window. “For intermediate and normal metabolizers, it could be that 5 mg [of tamoxifen] is enough, but I want to underline that we didn’t use breast cancer incidence or recurrence in this study, we used density change, so we should be careful when we use these results,” said Dr. Hall. His group is now conducting the KARISMA Endoxifen trial, which will test endoxifen directly at doses of 1 and 2 mg.
Dr. Cornell has no relevant financial disclosures. Dr. Hall is a member of the scientific advisory board for Atossa Therapeutics.
FROM SABCS 2023
Oncotype Score Helps Avoid Unnecessary Radiation in DCIS
SAN ANTONIO — There’s a long-standing concern among oncologists that many women with ductal carcinoma in situ (DCIS), a potential precursor to invasive breast cancer, receive more treatment than they need. The potential for overtreatment largely revolves around the extent of surgery and the use of radiation.
Using the Oncotype DX Breast DCIS Score test, a laboratory test that estimates DCIS recurrence risk, may help identify patients with low-risk DCIS who can safely avoid adjuvant radiation after surgery, according to new research (abstract GS03-01) presented at the San Antonio Breast Cancer Symposium.
Low-risk patients who skipped adjuvant radiotherapy after breast-conserving surgery demonstrated similar 5-year recurrence rates compared with high-risk patients who received adjuvant radiotherapy.
This is the first prospective study to evaluate radiation decisions among patients with DCIS.
Lead author Seema A. Khan, MD, who presented the research, called the findings “reassuring.”
However, “we need larger and better trials” as well as longer follow-up to confirm this less-is-more approach, said Dr. Khan, a breast cancer surgeon and researcher at Northwestern University, Chicago.
Virginia Kaklamani, MD, who moderated the presentation, noted that it is good to finally have prospective data on this topic. And although they are not definitive, “I personally think these results should be used” for counseling, said Dr. Kaklamani, leader of the breast cancer program at UT Health San Antonio.
To reduce the risk for DCIS recurrence or progression to invasive breast cancer, most patients with DCIS undergo breast-conserving surgery followed by adjuvant radiotherapy, Dr. Khan explained. Instead of breast-conserving surgery, about one in four patients opt for mastectomy.
Earlier results from this trial revealed that MRI helped identify patients who can safely receive breast-conserving surgery instead of mastectomy.
The current results assessed whether the Oncotype DX score can guide radiation treatment decisions.
The study included 171 patients with DCIS who had wide local excisions after MRI confirmed that they could forgo more extensive surgery.
Surgical specimens were then sent for testing to determine the DCIS score using the 12-gene Oncotype DX test.
Women who scored < 39 points on the 100-point Oncotype DX scale were considered to be at low risk for recurrence and were advised to skip radiation. Women who scored > 39 were advised to undergo radiation. Overall, 93% of the patients followed the radiation recommendations: 75 of 82 patients (91.4%) deemed as low risk skipped adjuvant radiotherapy and 84 of 89 patients (94.4%) deemed as high risk had radiotherapy.
At a median follow-up of 5 years, 5.1% (4 of 82) of low-risk patients experienced a recurrence vs. 4.5% (4 of 89) of higher-risk patients.
Recurrence rates among patients who followed the radiation recommendations mirrored these overall findings: 5.5% of 75 patients with low-risk DCIS who skipped radiotherapy experienced disease recurrence vs. 4.8% of 84 patients with high-risk DCIS who received radiotherapy.
Age did not appear to affect the outcomes. Among the 33 women younger than 50 years, two experienced a recurrence (4%), both invasive. One occurred in the low-risk group and the other in the higher-risk group. Among the 138 older women, six had recurrences, three in each group, and one recurrence in each was invasive.
In short, “women who skipped radiation based on this score did not experience an excess risk of” ipsilateral recurrence over 5 years, said Dr. Khan.
Overall, the study offers “strong evidence” that the DCIS score might help “prevent excessive treatment for some patients,” she concluded, adding that 10-year outcomes will be reported.
The work was funded by the National Cancer Institute. Dr. Khan has no conflicts of interest. Dr. Kaklamani has extensive industry ties, including being a speaker for Pfizer, Genentech, Novartis, and AstraZeneca.
A version in the article appeared on Medscape.com.
SAN ANTONIO — There’s a long-standing concern among oncologists that many women with ductal carcinoma in situ (DCIS), a potential precursor to invasive breast cancer, receive more treatment than they need. The potential for overtreatment largely revolves around the extent of surgery and the use of radiation.
Using the Oncotype DX Breast DCIS Score test, a laboratory test that estimates DCIS recurrence risk, may help identify patients with low-risk DCIS who can safely avoid adjuvant radiation after surgery, according to new research (abstract GS03-01) presented at the San Antonio Breast Cancer Symposium.
Low-risk patients who skipped adjuvant radiotherapy after breast-conserving surgery demonstrated similar 5-year recurrence rates compared with high-risk patients who received adjuvant radiotherapy.
This is the first prospective study to evaluate radiation decisions among patients with DCIS.
Lead author Seema A. Khan, MD, who presented the research, called the findings “reassuring.”
However, “we need larger and better trials” as well as longer follow-up to confirm this less-is-more approach, said Dr. Khan, a breast cancer surgeon and researcher at Northwestern University, Chicago.
Virginia Kaklamani, MD, who moderated the presentation, noted that it is good to finally have prospective data on this topic. And although they are not definitive, “I personally think these results should be used” for counseling, said Dr. Kaklamani, leader of the breast cancer program at UT Health San Antonio.
To reduce the risk for DCIS recurrence or progression to invasive breast cancer, most patients with DCIS undergo breast-conserving surgery followed by adjuvant radiotherapy, Dr. Khan explained. Instead of breast-conserving surgery, about one in four patients opt for mastectomy.
Earlier results from this trial revealed that MRI helped identify patients who can safely receive breast-conserving surgery instead of mastectomy.
The current results assessed whether the Oncotype DX score can guide radiation treatment decisions.
The study included 171 patients with DCIS who had wide local excisions after MRI confirmed that they could forgo more extensive surgery.
Surgical specimens were then sent for testing to determine the DCIS score using the 12-gene Oncotype DX test.
Women who scored < 39 points on the 100-point Oncotype DX scale were considered to be at low risk for recurrence and were advised to skip radiation. Women who scored > 39 were advised to undergo radiation. Overall, 93% of the patients followed the radiation recommendations: 75 of 82 patients (91.4%) deemed as low risk skipped adjuvant radiotherapy and 84 of 89 patients (94.4%) deemed as high risk had radiotherapy.
At a median follow-up of 5 years, 5.1% (4 of 82) of low-risk patients experienced a recurrence vs. 4.5% (4 of 89) of higher-risk patients.
Recurrence rates among patients who followed the radiation recommendations mirrored these overall findings: 5.5% of 75 patients with low-risk DCIS who skipped radiotherapy experienced disease recurrence vs. 4.8% of 84 patients with high-risk DCIS who received radiotherapy.
Age did not appear to affect the outcomes. Among the 33 women younger than 50 years, two experienced a recurrence (4%), both invasive. One occurred in the low-risk group and the other in the higher-risk group. Among the 138 older women, six had recurrences, three in each group, and one recurrence in each was invasive.
In short, “women who skipped radiation based on this score did not experience an excess risk of” ipsilateral recurrence over 5 years, said Dr. Khan.
Overall, the study offers “strong evidence” that the DCIS score might help “prevent excessive treatment for some patients,” she concluded, adding that 10-year outcomes will be reported.
The work was funded by the National Cancer Institute. Dr. Khan has no conflicts of interest. Dr. Kaklamani has extensive industry ties, including being a speaker for Pfizer, Genentech, Novartis, and AstraZeneca.
A version in the article appeared on Medscape.com.
SAN ANTONIO — There’s a long-standing concern among oncologists that many women with ductal carcinoma in situ (DCIS), a potential precursor to invasive breast cancer, receive more treatment than they need. The potential for overtreatment largely revolves around the extent of surgery and the use of radiation.
Using the Oncotype DX Breast DCIS Score test, a laboratory test that estimates DCIS recurrence risk, may help identify patients with low-risk DCIS who can safely avoid adjuvant radiation after surgery, according to new research (abstract GS03-01) presented at the San Antonio Breast Cancer Symposium.
Low-risk patients who skipped adjuvant radiotherapy after breast-conserving surgery demonstrated similar 5-year recurrence rates compared with high-risk patients who received adjuvant radiotherapy.
This is the first prospective study to evaluate radiation decisions among patients with DCIS.
Lead author Seema A. Khan, MD, who presented the research, called the findings “reassuring.”
However, “we need larger and better trials” as well as longer follow-up to confirm this less-is-more approach, said Dr. Khan, a breast cancer surgeon and researcher at Northwestern University, Chicago.
Virginia Kaklamani, MD, who moderated the presentation, noted that it is good to finally have prospective data on this topic. And although they are not definitive, “I personally think these results should be used” for counseling, said Dr. Kaklamani, leader of the breast cancer program at UT Health San Antonio.
To reduce the risk for DCIS recurrence or progression to invasive breast cancer, most patients with DCIS undergo breast-conserving surgery followed by adjuvant radiotherapy, Dr. Khan explained. Instead of breast-conserving surgery, about one in four patients opt for mastectomy.
Earlier results from this trial revealed that MRI helped identify patients who can safely receive breast-conserving surgery instead of mastectomy.
The current results assessed whether the Oncotype DX score can guide radiation treatment decisions.
The study included 171 patients with DCIS who had wide local excisions after MRI confirmed that they could forgo more extensive surgery.
Surgical specimens were then sent for testing to determine the DCIS score using the 12-gene Oncotype DX test.
Women who scored < 39 points on the 100-point Oncotype DX scale were considered to be at low risk for recurrence and were advised to skip radiation. Women who scored > 39 were advised to undergo radiation. Overall, 93% of the patients followed the radiation recommendations: 75 of 82 patients (91.4%) deemed as low risk skipped adjuvant radiotherapy and 84 of 89 patients (94.4%) deemed as high risk had radiotherapy.
At a median follow-up of 5 years, 5.1% (4 of 82) of low-risk patients experienced a recurrence vs. 4.5% (4 of 89) of higher-risk patients.
Recurrence rates among patients who followed the radiation recommendations mirrored these overall findings: 5.5% of 75 patients with low-risk DCIS who skipped radiotherapy experienced disease recurrence vs. 4.8% of 84 patients with high-risk DCIS who received radiotherapy.
Age did not appear to affect the outcomes. Among the 33 women younger than 50 years, two experienced a recurrence (4%), both invasive. One occurred in the low-risk group and the other in the higher-risk group. Among the 138 older women, six had recurrences, three in each group, and one recurrence in each was invasive.
In short, “women who skipped radiation based on this score did not experience an excess risk of” ipsilateral recurrence over 5 years, said Dr. Khan.
Overall, the study offers “strong evidence” that the DCIS score might help “prevent excessive treatment for some patients,” she concluded, adding that 10-year outcomes will be reported.
The work was funded by the National Cancer Institute. Dr. Khan has no conflicts of interest. Dr. Kaklamani has extensive industry ties, including being a speaker for Pfizer, Genentech, Novartis, and AstraZeneca.
A version in the article appeared on Medscape.com.
FROM SABCS 2023
What will help ease the financial toll of breast cancer?
SAN ANTONIO — , new survey findings show.
Almost half of patients surveyed reported a “significant” or “catastrophic” financial burden related to their breast cancer care. But patients also found a range of resources helpful for minimizing this burden, including direct assistance programs that reduce the cost of medications, grants from nonprofits that can cover cancer-related expenses, as well as programs that offer free or low-cost transportation to medical appointments.
Financial toxicity remains a “pervasive problem in the breast cancer community and we really need to go to the next step, which is designing patient-centered, patient-facing interventions to make improvements,” Fumiko Chino, MD, with Memorial Sloan Kettering Cancer Center in New York City, said when presenting the survey results at the San Antonio Breast Cancer Symposium.
A growing body of evidence shows that cancer care, especially for breast cancer, can take a heavy financial toll on patients. However, routine screening for financial toxicity is not necessarily a routine part of clinical care, and providers may not know the types of financial assistance patients value most, Dr. Chino explained.
Dr. Chino and colleagues surveyed 1437 women with breast cancer about their level of financial distress as well as the specific interventions or education initiatives they found most helpful.
Most patients (60%) were White, 27% were Hispanic, and 8% Black. Three quarters of patients were on active treatments, 89% had nonmetastatic disease, and 11% had metastatic disease.
Overall, 47% of patients reported a significant or catastrophic financial burden related to their breast cancer diagnosis and care. This burden was higher for those with metastatic disease (61% vs 45%).
Patients assessed 10 strategies for coping with the financial burdens of care. The top-rated interventions included patient assistance programs offered by pharmaceutical or medical test companies, rated highly by 32% of respondents, and grants from nonprofits, rated highly by 31% of respondents. Patients also found financial assistance departments at cancer centers or hospitals helpful (29%); coupons and savings cards to reduce the cost of prescription drugs (28%); and programs that provide free or low-cost transportation to medical appointments (28%).
In terms of education, respondents said having a checklist of questions to ask their oncology team as well as a list of breast cancer-specific financial grants to apply for would be especially helpful when navigating the financial burdens of breast cancer care.
These preferences, however, did vary by race/ethnicity and disease status. Hispanic patients, for instance, found patient assistance programs offered by companies and cancer centers as well as transportation assistance more helpful than other groups.
Patients with metastatic disease found patient assistance programs offered by medical companies particularly helpful compared with patients with nonmetastatic disease. And compared with patients with metastatic disease, those with nonmetastatic breast cancer found assistance through clinical trials and professional medical billing advocates helpful.
This study confirms the high rates of financial burden in women with breast cancer and clearly demonstrates that intervention preferences vary by sociodemographic and clinical characteristics, study discussant Claire C. Conley, PhD, from Georgetown University, Washington, DC, commented.
“This highlights that one size really doesn’t fit all when it comes to those financial burden interventions,” Dr. Conley said. “We need to think about factors at the patient level, the organizational level, and the environment level.”
The study had no commercial funding. Dr. Chino and Dr. Conley have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
SAN ANTONIO — , new survey findings show.
Almost half of patients surveyed reported a “significant” or “catastrophic” financial burden related to their breast cancer care. But patients also found a range of resources helpful for minimizing this burden, including direct assistance programs that reduce the cost of medications, grants from nonprofits that can cover cancer-related expenses, as well as programs that offer free or low-cost transportation to medical appointments.
Financial toxicity remains a “pervasive problem in the breast cancer community and we really need to go to the next step, which is designing patient-centered, patient-facing interventions to make improvements,” Fumiko Chino, MD, with Memorial Sloan Kettering Cancer Center in New York City, said when presenting the survey results at the San Antonio Breast Cancer Symposium.
A growing body of evidence shows that cancer care, especially for breast cancer, can take a heavy financial toll on patients. However, routine screening for financial toxicity is not necessarily a routine part of clinical care, and providers may not know the types of financial assistance patients value most, Dr. Chino explained.
Dr. Chino and colleagues surveyed 1437 women with breast cancer about their level of financial distress as well as the specific interventions or education initiatives they found most helpful.
Most patients (60%) were White, 27% were Hispanic, and 8% Black. Three quarters of patients were on active treatments, 89% had nonmetastatic disease, and 11% had metastatic disease.
Overall, 47% of patients reported a significant or catastrophic financial burden related to their breast cancer diagnosis and care. This burden was higher for those with metastatic disease (61% vs 45%).
Patients assessed 10 strategies for coping with the financial burdens of care. The top-rated interventions included patient assistance programs offered by pharmaceutical or medical test companies, rated highly by 32% of respondents, and grants from nonprofits, rated highly by 31% of respondents. Patients also found financial assistance departments at cancer centers or hospitals helpful (29%); coupons and savings cards to reduce the cost of prescription drugs (28%); and programs that provide free or low-cost transportation to medical appointments (28%).
In terms of education, respondents said having a checklist of questions to ask their oncology team as well as a list of breast cancer-specific financial grants to apply for would be especially helpful when navigating the financial burdens of breast cancer care.
These preferences, however, did vary by race/ethnicity and disease status. Hispanic patients, for instance, found patient assistance programs offered by companies and cancer centers as well as transportation assistance more helpful than other groups.
Patients with metastatic disease found patient assistance programs offered by medical companies particularly helpful compared with patients with nonmetastatic disease. And compared with patients with metastatic disease, those with nonmetastatic breast cancer found assistance through clinical trials and professional medical billing advocates helpful.
This study confirms the high rates of financial burden in women with breast cancer and clearly demonstrates that intervention preferences vary by sociodemographic and clinical characteristics, study discussant Claire C. Conley, PhD, from Georgetown University, Washington, DC, commented.
“This highlights that one size really doesn’t fit all when it comes to those financial burden interventions,” Dr. Conley said. “We need to think about factors at the patient level, the organizational level, and the environment level.”
The study had no commercial funding. Dr. Chino and Dr. Conley have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
SAN ANTONIO — , new survey findings show.
Almost half of patients surveyed reported a “significant” or “catastrophic” financial burden related to their breast cancer care. But patients also found a range of resources helpful for minimizing this burden, including direct assistance programs that reduce the cost of medications, grants from nonprofits that can cover cancer-related expenses, as well as programs that offer free or low-cost transportation to medical appointments.
Financial toxicity remains a “pervasive problem in the breast cancer community and we really need to go to the next step, which is designing patient-centered, patient-facing interventions to make improvements,” Fumiko Chino, MD, with Memorial Sloan Kettering Cancer Center in New York City, said when presenting the survey results at the San Antonio Breast Cancer Symposium.
A growing body of evidence shows that cancer care, especially for breast cancer, can take a heavy financial toll on patients. However, routine screening for financial toxicity is not necessarily a routine part of clinical care, and providers may not know the types of financial assistance patients value most, Dr. Chino explained.
Dr. Chino and colleagues surveyed 1437 women with breast cancer about their level of financial distress as well as the specific interventions or education initiatives they found most helpful.
Most patients (60%) were White, 27% were Hispanic, and 8% Black. Three quarters of patients were on active treatments, 89% had nonmetastatic disease, and 11% had metastatic disease.
Overall, 47% of patients reported a significant or catastrophic financial burden related to their breast cancer diagnosis and care. This burden was higher for those with metastatic disease (61% vs 45%).
Patients assessed 10 strategies for coping with the financial burdens of care. The top-rated interventions included patient assistance programs offered by pharmaceutical or medical test companies, rated highly by 32% of respondents, and grants from nonprofits, rated highly by 31% of respondents. Patients also found financial assistance departments at cancer centers or hospitals helpful (29%); coupons and savings cards to reduce the cost of prescription drugs (28%); and programs that provide free or low-cost transportation to medical appointments (28%).
In terms of education, respondents said having a checklist of questions to ask their oncology team as well as a list of breast cancer-specific financial grants to apply for would be especially helpful when navigating the financial burdens of breast cancer care.
These preferences, however, did vary by race/ethnicity and disease status. Hispanic patients, for instance, found patient assistance programs offered by companies and cancer centers as well as transportation assistance more helpful than other groups.
Patients with metastatic disease found patient assistance programs offered by medical companies particularly helpful compared with patients with nonmetastatic disease. And compared with patients with metastatic disease, those with nonmetastatic breast cancer found assistance through clinical trials and professional medical billing advocates helpful.
This study confirms the high rates of financial burden in women with breast cancer and clearly demonstrates that intervention preferences vary by sociodemographic and clinical characteristics, study discussant Claire C. Conley, PhD, from Georgetown University, Washington, DC, commented.
“This highlights that one size really doesn’t fit all when it comes to those financial burden interventions,” Dr. Conley said. “We need to think about factors at the patient level, the organizational level, and the environment level.”
The study had no commercial funding. Dr. Chino and Dr. Conley have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM SABCS 2023
Are you sure your patient is alive?
This transcript has been edited for clarity.
Much of my research focuses on what is known as clinical decision support — prompts and messages to providers to help them make good decisions for their patients. I know that these things can be annoying, which is exactly why I study them — to figure out which ones actually help.
When I got started on this about 10 years ago, we were learning a lot about how best to message providers about their patients. My team had developed a simple alert for acute kidney injury (AKI). We knew that providers often missed the diagnosis, so maybe letting them know would improve patient outcomes.
As we tested the alert, we got feedback, and I have kept an email from an ICU doctor from those early days. It read:
Dear Dr. Wilson: Thank you for the automated alert informing me that my patient had AKI. Regrettably, the alert fired about an hour after the patient had died. I feel that the information is less than actionable at this time.
Our early system had neglected to add a conditional flag ensuring that the patient was still alive at the time it sent the alert message. A small oversight, but one that had very large implications. Future studies would show that “false positive” alerts like this seriously degrade physician confidence in the system. And why wouldn’t they?
Not knowing the vital status of a patient can have major consequences.
Health systems send messages to their patients all the time: reminders of appointments, reminders for preventive care, reminders for vaccinations, and so on.
But what if the patient being reminded has died? It’s a waste of resources, of course, but more than that, it can be painful for their families and reflects poorly on the health care system. Of all the people who should know whether someone is alive or dead, shouldn’t their doctor be at the top of the list?
A new study in JAMA Internal Medicine quantifies this very phenomenon.
Researchers examined 11,658 primary care patients in their health system who met the criteria of being “seriously ill” and followed them for 2 years. During that period of time, 25% were recorded as deceased in the electronic health record. But 30.8% had died. That left 676 patients who had died, but were not known to have died, left in the system.
And those 676 were not left to rest in peace. They received 221 telephone and 338 health portal messages not related to death, and 920 letters reminding them about unmet primary care metrics like flu shots and cancer screening. Orders were entered into the health record for things like vaccines and routine screenings for 158 patients, and 310 future appointments — destined to be no-shows — were still on the books. One can only imagine the frustration of families checking their mail and finding yet another letter reminding their deceased loved one to get a mammogram.
How did the researchers figure out who had died? It turns out it’s not that hard. California keeps a record of all deaths in the state; they simply had to search it. Like all state death records, they tend to lag a bit so it’s not clinically terribly useful, but it works. California and most other states also have a very accurate and up-to-date death file which can only be used by law enforcement to investigate criminal activity and fraud; health care is left in the lurch.
Nationwide, there is the real-time fact of death service, supported by the National Association for Public Health Statistics and Information Systems. This allows employers to verify, in real time, whether the person applying for a job is alive. Healthcare systems are not allowed to use it.
Let’s also remember that very few people die in this country without some health care agency knowing about it and recording it. But sharing of medical information is so poor in the United States that your patient could die in a hospital one city away from you and you might not find out until you’re calling them to see why they missed a scheduled follow-up appointment.
These events — the embarrassing lack of knowledge about the very vital status of our patients — highlight a huge problem with health care in our country. The fragmented health care system is terrible at data sharing, in part because of poor protocols, in part because of unfounded concerns about patient privacy, and in part because of a tendency to hoard data that might be valuable in the future. It has to stop. We need to know how our patients are doing even when they are not sitting in front of us. When it comes to life and death, the knowledge is out there; we just can’t access it. Seems like a pretty easy fix.
Dr. Wilson is associate professor of medicine and public health and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Connecticut. He has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com .
This transcript has been edited for clarity.
Much of my research focuses on what is known as clinical decision support — prompts and messages to providers to help them make good decisions for their patients. I know that these things can be annoying, which is exactly why I study them — to figure out which ones actually help.
When I got started on this about 10 years ago, we were learning a lot about how best to message providers about their patients. My team had developed a simple alert for acute kidney injury (AKI). We knew that providers often missed the diagnosis, so maybe letting them know would improve patient outcomes.
As we tested the alert, we got feedback, and I have kept an email from an ICU doctor from those early days. It read:
Dear Dr. Wilson: Thank you for the automated alert informing me that my patient had AKI. Regrettably, the alert fired about an hour after the patient had died. I feel that the information is less than actionable at this time.
Our early system had neglected to add a conditional flag ensuring that the patient was still alive at the time it sent the alert message. A small oversight, but one that had very large implications. Future studies would show that “false positive” alerts like this seriously degrade physician confidence in the system. And why wouldn’t they?
Not knowing the vital status of a patient can have major consequences.
Health systems send messages to their patients all the time: reminders of appointments, reminders for preventive care, reminders for vaccinations, and so on.
But what if the patient being reminded has died? It’s a waste of resources, of course, but more than that, it can be painful for their families and reflects poorly on the health care system. Of all the people who should know whether someone is alive or dead, shouldn’t their doctor be at the top of the list?
A new study in JAMA Internal Medicine quantifies this very phenomenon.
Researchers examined 11,658 primary care patients in their health system who met the criteria of being “seriously ill” and followed them for 2 years. During that period of time, 25% were recorded as deceased in the electronic health record. But 30.8% had died. That left 676 patients who had died, but were not known to have died, left in the system.
And those 676 were not left to rest in peace. They received 221 telephone and 338 health portal messages not related to death, and 920 letters reminding them about unmet primary care metrics like flu shots and cancer screening. Orders were entered into the health record for things like vaccines and routine screenings for 158 patients, and 310 future appointments — destined to be no-shows — were still on the books. One can only imagine the frustration of families checking their mail and finding yet another letter reminding their deceased loved one to get a mammogram.
How did the researchers figure out who had died? It turns out it’s not that hard. California keeps a record of all deaths in the state; they simply had to search it. Like all state death records, they tend to lag a bit so it’s not clinically terribly useful, but it works. California and most other states also have a very accurate and up-to-date death file which can only be used by law enforcement to investigate criminal activity and fraud; health care is left in the lurch.
Nationwide, there is the real-time fact of death service, supported by the National Association for Public Health Statistics and Information Systems. This allows employers to verify, in real time, whether the person applying for a job is alive. Healthcare systems are not allowed to use it.
Let’s also remember that very few people die in this country without some health care agency knowing about it and recording it. But sharing of medical information is so poor in the United States that your patient could die in a hospital one city away from you and you might not find out until you’re calling them to see why they missed a scheduled follow-up appointment.
These events — the embarrassing lack of knowledge about the very vital status of our patients — highlight a huge problem with health care in our country. The fragmented health care system is terrible at data sharing, in part because of poor protocols, in part because of unfounded concerns about patient privacy, and in part because of a tendency to hoard data that might be valuable in the future. It has to stop. We need to know how our patients are doing even when they are not sitting in front of us. When it comes to life and death, the knowledge is out there; we just can’t access it. Seems like a pretty easy fix.
Dr. Wilson is associate professor of medicine and public health and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Connecticut. He has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com .
This transcript has been edited for clarity.
Much of my research focuses on what is known as clinical decision support — prompts and messages to providers to help them make good decisions for their patients. I know that these things can be annoying, which is exactly why I study them — to figure out which ones actually help.
When I got started on this about 10 years ago, we were learning a lot about how best to message providers about their patients. My team had developed a simple alert for acute kidney injury (AKI). We knew that providers often missed the diagnosis, so maybe letting them know would improve patient outcomes.
As we tested the alert, we got feedback, and I have kept an email from an ICU doctor from those early days. It read:
Dear Dr. Wilson: Thank you for the automated alert informing me that my patient had AKI. Regrettably, the alert fired about an hour after the patient had died. I feel that the information is less than actionable at this time.
Our early system had neglected to add a conditional flag ensuring that the patient was still alive at the time it sent the alert message. A small oversight, but one that had very large implications. Future studies would show that “false positive” alerts like this seriously degrade physician confidence in the system. And why wouldn’t they?
Not knowing the vital status of a patient can have major consequences.
Health systems send messages to their patients all the time: reminders of appointments, reminders for preventive care, reminders for vaccinations, and so on.
But what if the patient being reminded has died? It’s a waste of resources, of course, but more than that, it can be painful for their families and reflects poorly on the health care system. Of all the people who should know whether someone is alive or dead, shouldn’t their doctor be at the top of the list?
A new study in JAMA Internal Medicine quantifies this very phenomenon.
Researchers examined 11,658 primary care patients in their health system who met the criteria of being “seriously ill” and followed them for 2 years. During that period of time, 25% were recorded as deceased in the electronic health record. But 30.8% had died. That left 676 patients who had died, but were not known to have died, left in the system.
And those 676 were not left to rest in peace. They received 221 telephone and 338 health portal messages not related to death, and 920 letters reminding them about unmet primary care metrics like flu shots and cancer screening. Orders were entered into the health record for things like vaccines and routine screenings for 158 patients, and 310 future appointments — destined to be no-shows — were still on the books. One can only imagine the frustration of families checking their mail and finding yet another letter reminding their deceased loved one to get a mammogram.
How did the researchers figure out who had died? It turns out it’s not that hard. California keeps a record of all deaths in the state; they simply had to search it. Like all state death records, they tend to lag a bit so it’s not clinically terribly useful, but it works. California and most other states also have a very accurate and up-to-date death file which can only be used by law enforcement to investigate criminal activity and fraud; health care is left in the lurch.
Nationwide, there is the real-time fact of death service, supported by the National Association for Public Health Statistics and Information Systems. This allows employers to verify, in real time, whether the person applying for a job is alive. Healthcare systems are not allowed to use it.
Let’s also remember that very few people die in this country without some health care agency knowing about it and recording it. But sharing of medical information is so poor in the United States that your patient could die in a hospital one city away from you and you might not find out until you’re calling them to see why they missed a scheduled follow-up appointment.
These events — the embarrassing lack of knowledge about the very vital status of our patients — highlight a huge problem with health care in our country. The fragmented health care system is terrible at data sharing, in part because of poor protocols, in part because of unfounded concerns about patient privacy, and in part because of a tendency to hoard data that might be valuable in the future. It has to stop. We need to know how our patients are doing even when they are not sitting in front of us. When it comes to life and death, the knowledge is out there; we just can’t access it. Seems like a pretty easy fix.
Dr. Wilson is associate professor of medicine and public health and director of the Clinical and Translational Research Accelerator at Yale University, New Haven, Connecticut. He has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com .
Even with insurance, cancer out-of-pocket costs can be punishing
TOPLINE:
METHODOLOGY:
- Out-of-pocket costs contribute to financial toxicity in cancer, but little is known about how they vary across various tumor types and stages over time.
- To find out, investigators reviewed claims data for 7494 US patients diagnosed with stage I-IV breast, cervical, colorectal, lung, ovarian, or prostate cancer from 2016 to 2020.
- They assessed cumulative out-of-pocket (OOP) costs — defined as copayments, deductibles, and coinsurance — in the first 3 years following diagnosis.
- Subjects had private, commercial health insurance through United Healthcare.
TAKEAWAY:
- By the end of 3 years, average cumulative OOP costs ranged from $16,673 for stage I prostate cancer to $35,253 for stage IV lung cancer.
- Across all cancer types, average OOP costs in the first year ranged from $2,754 for stage I anal cancer to $25,876 for stage IV vaginal cancer.
- However, the upper limits of OOP costs exceeded $100,000 across many tumors and stages in the first year, reaching a high of $450,374 for stage I breast cancer and far exceeding $200,000 for stage II-IV colorectal and lung cancer.
- OOP costs were generally highest during the first year of treatment and for cancers diagnosed at later stages.
IN PRACTICE:
“OOP costs may present an extreme economic stressor on patients diagnosed with cancer,” leading to emotional distress, reduced treatment adherence, and poor outcomes. “Even cancer patients with insurance coverage [are] not protected.” Future research is “needed to help clarify the type of patient most burdened by OOP costs” as well as ways to reduce them, including promoting “diagnosis at an earlier stage and increas[ing] access to health plans that minimize patient cost sharing.”
SOURCE:
The work was led by November McGarvey of BluePath Solutions, Los Angeles, and published in the Journal of Medical Economics.
LIMITATIONS:
The study did not include additional OOP costs, such as transportation. It also did not assess the long-term impacts of cancer-related out-of-pocket spending. Details on health plan types and features were limited, and the results are limited to patients with commercial health insurance.
DISCLOSURES:
The work was funded by Grail. The investigators are employees of Grail or BluePath Solutions.
TOPLINE:
METHODOLOGY:
- Out-of-pocket costs contribute to financial toxicity in cancer, but little is known about how they vary across various tumor types and stages over time.
- To find out, investigators reviewed claims data for 7494 US patients diagnosed with stage I-IV breast, cervical, colorectal, lung, ovarian, or prostate cancer from 2016 to 2020.
- They assessed cumulative out-of-pocket (OOP) costs — defined as copayments, deductibles, and coinsurance — in the first 3 years following diagnosis.
- Subjects had private, commercial health insurance through United Healthcare.
TAKEAWAY:
- By the end of 3 years, average cumulative OOP costs ranged from $16,673 for stage I prostate cancer to $35,253 for stage IV lung cancer.
- Across all cancer types, average OOP costs in the first year ranged from $2,754 for stage I anal cancer to $25,876 for stage IV vaginal cancer.
- However, the upper limits of OOP costs exceeded $100,000 across many tumors and stages in the first year, reaching a high of $450,374 for stage I breast cancer and far exceeding $200,000 for stage II-IV colorectal and lung cancer.
- OOP costs were generally highest during the first year of treatment and for cancers diagnosed at later stages.
IN PRACTICE:
“OOP costs may present an extreme economic stressor on patients diagnosed with cancer,” leading to emotional distress, reduced treatment adherence, and poor outcomes. “Even cancer patients with insurance coverage [are] not protected.” Future research is “needed to help clarify the type of patient most burdened by OOP costs” as well as ways to reduce them, including promoting “diagnosis at an earlier stage and increas[ing] access to health plans that minimize patient cost sharing.”
SOURCE:
The work was led by November McGarvey of BluePath Solutions, Los Angeles, and published in the Journal of Medical Economics.
LIMITATIONS:
The study did not include additional OOP costs, such as transportation. It also did not assess the long-term impacts of cancer-related out-of-pocket spending. Details on health plan types and features were limited, and the results are limited to patients with commercial health insurance.
DISCLOSURES:
The work was funded by Grail. The investigators are employees of Grail or BluePath Solutions.
TOPLINE:
METHODOLOGY:
- Out-of-pocket costs contribute to financial toxicity in cancer, but little is known about how they vary across various tumor types and stages over time.
- To find out, investigators reviewed claims data for 7494 US patients diagnosed with stage I-IV breast, cervical, colorectal, lung, ovarian, or prostate cancer from 2016 to 2020.
- They assessed cumulative out-of-pocket (OOP) costs — defined as copayments, deductibles, and coinsurance — in the first 3 years following diagnosis.
- Subjects had private, commercial health insurance through United Healthcare.
TAKEAWAY:
- By the end of 3 years, average cumulative OOP costs ranged from $16,673 for stage I prostate cancer to $35,253 for stage IV lung cancer.
- Across all cancer types, average OOP costs in the first year ranged from $2,754 for stage I anal cancer to $25,876 for stage IV vaginal cancer.
- However, the upper limits of OOP costs exceeded $100,000 across many tumors and stages in the first year, reaching a high of $450,374 for stage I breast cancer and far exceeding $200,000 for stage II-IV colorectal and lung cancer.
- OOP costs were generally highest during the first year of treatment and for cancers diagnosed at later stages.
IN PRACTICE:
“OOP costs may present an extreme economic stressor on patients diagnosed with cancer,” leading to emotional distress, reduced treatment adherence, and poor outcomes. “Even cancer patients with insurance coverage [are] not protected.” Future research is “needed to help clarify the type of patient most burdened by OOP costs” as well as ways to reduce them, including promoting “diagnosis at an earlier stage and increas[ing] access to health plans that minimize patient cost sharing.”
SOURCE:
The work was led by November McGarvey of BluePath Solutions, Los Angeles, and published in the Journal of Medical Economics.
LIMITATIONS:
The study did not include additional OOP costs, such as transportation. It also did not assess the long-term impacts of cancer-related out-of-pocket spending. Details on health plan types and features were limited, and the results are limited to patients with commercial health insurance.
DISCLOSURES:
The work was funded by Grail. The investigators are employees of Grail or BluePath Solutions.