Guideline-discordant androgen deprivation therapy (ADT) use in localized prostate cancer (CaP) and cost implications: A population-based study.

2012 ◽  
Vol 30 (15_suppl) ◽  
pp. 4647-4647 ◽  
Author(s):  
Adam Rea Kuykendal ◽  
Laura H Hendrix ◽  
Ramzi George Salloum ◽  
Paul Alphonso Godley ◽  
Ronald C. Chen
Keyword(s):  
Direct Cost ◽  
Clinical Stage ◽  
Population Based ◽  
Medicare Reimbursement ◽  
Nccn Guidelines ◽  
Risk Patients ◽  
Reimbursement Amount ◽  
Cost Implications ◽  
Cancer Network ◽  
Annual Direct Cost

4647 Background: ADT use in localized CaP has increased overall survival and is recommended by National Comprehensive Cancer Network (NCCN) guidelines in certain clinical situations. However, ADT may cause harm and is without benefit in other situations. Prior studies showed a decline in “inappropriate” ADT use coinciding with Medicare reimbursement changes in 2004-2005. This study examines recent trends in ADT use and quantifies the cost of guideline-discordant ADT. Methods: Patients in the Surveillance Epidemiology and End Results (SEER)-Medicare database diagnosed with non-metastatic CaP between 2004 and 2007, ages 66-80 were included for analysis. PSA, Gleason score and clinical stage were used to define D’Amico risk categories. Logistic regression was used to examine factors associated with guideline-discordant ADT use. Annual direct cost was estimated using the current Medicare reimbursement amount for ADT. Results: Of 24,280 men included, 13% received guideline-discordant ADT. Discordant use declined from 15% in 2004 to 11% in 2007. In low-risk patients, 15% received discordant ADT, mostly due to simultaneous ADT with radiation. Discordant use was seen in 7% of intermediate and 16% of high-risk patients, mostly from ADT monotherapy. African American (AA) (p<.001), older patients (p<.001) and those with more comorbidities (p<.001) were more likely to receive discordant ADT (Table). The estimated annual direct cost to Medicare from discordant ADT is $43,500,000. Conclusions: Approximately one in eight patients received ADT discordant with published guidelines, with AA and elderly patients disproportionately affected. Elimination of discordant use would result in substantial savings in healthcare costs. [Table: see text]

EAU and NCCN surveillance guidelines for bladder cancer: Do they effectively capture recurrences following cystectomy?

2014 ◽  
Vol 32 (4_suppl) ◽  
pp. 310-310
Author(s):  
Suzanne B. Stewart ◽  
Stephen A. Boorjian ◽  
Sarah P. Psutka ◽  
John C. Cheville ◽  
Prabin Thapa ◽  
...  
Keyword(s):  
Bladder Cancer ◽  
Surveillance Strategy ◽  
Site Specific ◽  
Nccn Guidelines ◽  
Kaplan Meier ◽  
Risk Patients ◽  
Recurrence Patterns ◽  
Cancer Network ◽  
Current Guidelines

310 Background: The European Association of Urology (EAU) and the National Comprehensive Cancer Network (NCCN) provide general guidelines for bladder cancer (BC) surveillance following radical cystectomy (RC). However, it is unclear how well these guidelines capture recurrences after surgery. Herein, we assess the ability of current guidelines to effectively capture BC recurrence following RC and propose a risk stratified and recurrence site-specific surveillance strategy. Methods: We reviewed our institutional database of 1,800 patients who underwent primary RC between 1980-2007. Guideline effectiveness was assessed by calculating the percentage of recurrences detected within the prescribed follow-up periods: EAU—5yrs; NCCN—2yrs. Patients were then stratified according to stage: < = pT1Nx-0, > = pT2Nx-0, pN+, and recurrence site: urothelium, abdomen, chest, other. Recurrence free survival estimates for stage groups and recurrence site were assessed with Kaplan Meier models. Results: Of the 1,800 patients, 634 (35.2%) were classified as > pT2Nx-0 and 234 (13%) as pN+ and overall 228 (12.7%) received perioperative chemotherapy. Median postoperative follow-up was 10.6yrs (IQR 6.8-15.2), during which 716 (39.8%) patients developed recurrence. Of these recurrences, 492 (68.7%) would have been detected using the NCCN guidelines and 644 (89.8%) by EAU recommendations. However, ending oncologic surveillance at 5 years would only capture 81.7% of all recurrences for < = pT1Nx-0 patients and 83% of urothelial specific recurrences across all stage groups. Capture of 90% of recurrences, by stage group, in the urothelium, abdomen and chest would require surveillance for 8yrs, 8yrs and 4yrs, respectively in < = pT1Nx-0, 6yrs, 4yrs and 3yrs in > = pT2Nx-0 and 3yrs, 3yrs and 2yrs for pN+ patients. Conclusions: Duration of surveillance recommended for BC following RC by the EAU and NCCN do not comprehensively capture recurrences seen, specifically, in low risk patients and in cases of urothelial recurrence. Guidelines using risk stratification and site-specific recurrence patterns to assign length of surveillance may allow providers to better individualize surveillance regimens.

Does thyroid-sparing total laryngectomy decrease the risk of hypothyroidism?

2020 ◽  
pp. 1-4
Author(s):  
G Viljoen ◽  
J K McGuire ◽  
A Alhadad ◽  
S Dalvie ◽  
J J Fagan
Keyword(s):  
South Africa ◽  
Retrospective Study ◽  
Laryngeal Carcinoma ◽  
Adjuvant Radiotherapy ◽  
Total Laryngectomy ◽  
Inclusion Criteria ◽  
Nccn Guidelines ◽  
Thyroid Lobectomy ◽  
Cancer Network ◽  
Advanced Laryngeal Carcinoma

Abstract Background Thyroid lobectomy is recommended with total laryngectomy for laryngeal cancer in the National Comprehensive Cancer Network (‘NCCN’) guidelines. However, it is associated with a 32–89 per cent risk of hypothyroidism, with or without adjuvant radiotherapy. Objective The study aimed to determine whether preserving the whole thyroid, compared to a single lobe, does indeed significantly lower the incidence of hypothyroidism in the setting of total laryngectomy. Method A retrospective study was conducted at Groote Schuur Hospital in Cape Town, South Africa. Results Eighty-four patients met the inclusion criteria. The overall incidence of hypothyroidism was 45.2 per cent. The incidence of hypothyroidism was significantly reduced in patients who underwent thyroid-sparing total laryngectomy compared to hemithyroidectomy (p = 0.037). Adjuvant radiotherapy was associated with a higher incidence of hypothyroidism (p = 0.001). Conclusion Thyroid-preserving laryngectomy should be advocated in carefully selected patients with advanced laryngeal carcinoma, as it reduces the incidence of hypothyroidism.

scholarly journals Clinical Predictors of Mortality in Prehospital Distress Calls by Emergency Medical Service Subscribers

2021 ◽  
Vol 10 (22) ◽  
pp. 5355
Author(s):  
Gabby Elbaz-Greener ◽  
Shemy Carasso ◽  
Elad Maor ◽  
Lior Gallimidi ◽  
Merav Yarkoni ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Population Based ◽  
Hospital Data ◽  
Clinical Predictors ◽  
Emergency Calls ◽  
Emergency Medical ◽  
Risk Patients ◽  
Early Decision ◽  
Risk Predictors

(1) Introduction: Most studies rely on in-hospital data to predict cardiovascular risk and do not include prehospital information that is substantially important for early decision making. The aim of the study was to define clinical parameters in the prehospital setting, which may affect clinical outcomes. (2) Methods: In this population-based study, we performed a retrospective analysis of emergency calls that were made by patients to the largest private emergency medical services (EMS) in Israel, SHL Telemedicine Ltd., who were treated on-site by the EMS team. Demographics, clinical characteristics, and clinical outcomes were analyzed. Mortality was evaluated at three time points: 1, 3, and 12 months’ follow-up. The first EMS prehospital measurements of the systolic blood pressure (SBP) were recorded and analyzed. Logistic regression analyses were performed. (3) Results: A total of 64,320 emergency calls were included with a follow-up of 12 months post index EMS call. Fifty-five percent of patients were men and the mean age was 70.2 ± 13.1 years. During follow-up of 12 months, 7.6% of patients died. Age above 80 years (OR 3.34; 95% CI 3.03–3.69, p < 0.005), first EMS SBP ≤ 130 mm Hg (OR 2.61; 95% CI 2.36–2.88, p < 0.005), dyspnea at presentation (OR 2.55; 95% CI 2.29–2.83, p < 0001), and chest pain with ischemic ECG changes (OR 1.95; 95% CI 1.71–2.23, p < 0.001) were the highest predictors of 1 month mortality and remained so for mortality at 3 and 12 months. In contrast, history of hypertension and first EMS prehospital SBP ≥ 160 mm Hg were significantly associated with decreased mortality at 1, 3 and 12 months. (4) Conclusions: We identified risk predictors for all-cause mortality in a large cohort of patients during prehospital EMS calls. Age over 80 years, first EMS-documented prehospital SBP < 130 mm Hg, and dyspnea at presentation were the most profound risk predictors for short- and long-term mortality. The current study demonstrates that in prehospital EMS call settings, several parameters can be used to improve prioritization and management of high-risk patients.

Role of partial cystectomy for muscle invasive bladder cancer: Impact on morbidity and overall survival, a population-based study, 2006-2017.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e16530-e16530
Author(s):  
Natasza Posielski ◽  
Hannah Koenig ◽  
Nathan Jung ◽  
On Ho ◽  
John Paul Flores ◽  
...  
Keyword(s):  
Overall Survival ◽  
Bladder Cancer ◽  
Population Based ◽  
Pelvic Lymphadenectomy ◽  
Partial Cystectomy ◽  
Invasive Bladder Cancer ◽  
Muscle Invasive Bladder Cancer ◽  
Full Cohort ◽  
Nccn Guidelines ◽  
Muscle Invasive

e16530 Background: National Comprehensive Cancer Network (NCCN) guidelines state partial cystectomy (PC) may be offered in select patients with clinical T2 (cT2) muscle invasive bladder cancer (MIBC) utilizing neoadjuvant chemotherapy (NAC) and pelvic lymphadenectomy (PLND). Our objective was to investigate utilization and survival outcomes of PC in a large contemporary cohort. Methods: Propensity matching was used to compare pathological and surgical outcomes in non-metastatic MIBC patients in the National Cancer Database undergoing PC or radical cystectomy (RC). Multivariate logistic regression was used to determine predictors of NAC, LND, peri-operative morbidity and mortality outcomes. This analysis was repeated in the subset with cT2 MIBC. Results: Of 31,306 T2-T4N0M0 patients, 1543 (4.9%) underwent PC. PC use was higher in older patients and most often (85%) performed for cT2 disease. The PC group was less likely to receive standard of care including NAC (11.4 vs 27.9%, p<0.001) and PLND (58.7 vs 92.5%, p<0.001) than the RC group. Pathological ≥T3 disease (pT3) was found in 39.4% and pos. nodes in 6.9% of PCs. Positive margins were higher in PC, 15.7 vs 10.6%, p<0.001. PC patients had shorter inpatient stay (4.2 vs 8.7 days, p<0.001), lower 30-day readmission (6.7 vs 9.6%, p<0.001), and decreased 30- and 90-day mortality (1.3 vs 1.8%, p<0.001 & 4.8 vs 4.9%, p=0.04). PC was an independent predictor of lack of NAC (OR 0.49, p<0.001) and PLND (OR 0.11, p<0.001), shorter LOS (b -4.66, <0.001), readmission rate (OR 0.72, p<0.001), and improved 30- and 90- day mortality (OR 0.55 & 0.75, p<0.001). In cT2 patients only: PLND and NAC were less utilized in PC (p<0.001), 32% were ≥pT3 and 6.6% node pos. In both full cohort and cT2 subset, PC was associated with slight improvement in time to mortality (Table) and overall survival (OS) (OR 1.44, p<0.001). Conclusions: PC is rarely used in treatment of MIBC. Despite guidelines, NAC and PLND are underutilized in PC. Care is required in selecting patients for PC as up to one third of cT2 patients have ≥pT3. In these likely highly selected patients, PC had lower peri-operative mortality and comparable OS to RC. Selection bias may play a role in these results and further investigation is needed to determine optimal candidates for PC.[Table: see text]

Level of Scientific Evidence Underlying Recommendations from the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines for Hematologic Malignancies: Are We Moving Forward?

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 32-32
Author(s):  
Aakash Desai ◽  
Harry E Fuentes ◽  
Sri Harsha Tella ◽  
Caleb J Scheckel ◽  
Thejaswi Poonacha ◽  
...  
Keyword(s):  
Clinical Practice ◽  
National Comprehensive Cancer Network ◽  
Clinical Practice Guidelines ◽  
Practice Guidelines ◽  
Scientific Evidence ◽  
Hematologic Malignancies ◽  
Level Of Evidence ◽  
Nccn Guidelines ◽  
Therapeutic Recommendations ◽  
Cancer Network

Background: National Comprehensive Cancer Network (NCCN) guidelines are the most comprehensive and widely used standard for clinical care in malignant hematology by clinicians and payers in the US. The level of scientific evidence in NCCN guidelines for malignant hematological conditions has not been recently investigated. We describe the distribution of categories of evidence and consensus (EC) among the 10 most common hematologic malignancies with regard to recommendations for staging, initial and salvage therapy, and surveillance. Methods: NCCN uses a system of guideline development distinct from other major professional organizations. The NCCN definitions for EC are: category I, high level of evidence such as randomized controlled trials with uniform consensus; category IIA, lower level of evidence with uniform consensus; category IIB, lower level of evidence without a uniform consensus but with no major disagreement; and category III, any level of evidence but with major disagreement. We compared our results with previously published results from 2011 guidelines. Results: Total recommendations increased by 16.6% from 1160 (2011) to 1353 (2020). Of the 1353 recommendations, Category 1, 2A, 2B and 3 EC were 5%, 91%, 4%, 1% while in 2011 they were 3%, 93%, 4% and 0% respectively. Recommendations with category 1 EC were found in all guidelines, except for Burkitt's Lymphoma. 6.3% of therapeutic recommendations were category 1 EC with the majority (56.4%) pertaining to initial therapy. Guidelines with highest proportions of therapeutic recommendations with category 1 EC were Multiple Myeloma (12.4%), CLL/SLL (6.9%) and AML (5.6%). Between 2011 and 2020, the proportion of category I recommendations increased significantly only in Follicular lymphoma and CLL/SLL. No category 1 EC recommendations existed in staging or surveillance. Conclusion: Recommendations issued in the 2020 NCCN guidelines are largely developed from lower levels of evidence but with uniform expert opinion. Despite the major advances in hematology in the past decade, this is largely unchanged. Our study underscores the urgent need and available opportunities to expand the current evidence base in malignant hematological disorders which forms the platform for clinical practice guidelines. Figure Disclosures No relevant conflicts of interest to declare.

Statin dose titration patterns and subsequent major cardiovascular events in very high-risk patients: estimates from Swedish population-based registry data

2020 ◽  
Vol 6 (4) ◽  
pp. 323-331
Author(s):  
Jonas Banefelt ◽  
Maria Lindh ◽  
Maria K Svensson ◽  
Björn Eliasson ◽  
Ming-Hui Tai
Keyword(s):  
High Risk ◽  
Statin Therapy ◽  
High Intensity ◽  
Lower Risk ◽  
Cardiovascular Events ◽  
Population Based ◽  
Moderate Intensity ◽  
Risk Patients ◽  
Population Based Registry ◽  
Very High

Abstract Aims Clinical studies have demonstrated the efficacy of intensive statin therapy in lowering low-density lipoprotein cholesterol and cardiovascular (CV) events. Our objective was to examine statin titration patterns and the association between titration patterns and subsequent CV events in very high-risk patients. Methods and results Using Swedish national population-based registry data, we identified 192 435 patients with very high risk of atherosclerotic CV disease initiated on moderate-intensity statin therapy between 2006 and 2013. Outcomes of interest were titration to high-intensity therapy and the major adverse cardiovascular events (MACE) composite (myocardial infarction, ischaemic stroke, and CV death) outcome. Cumulative incidence of MACE was assessed by titration status 1-year post-treatment initiation in patients adherent to treatment during the first year, using a 12-week cut-off from initiation to define early, delayed and no up-titration to high-intensity statins. Cox regression analysis was used to estimate adjusted hazard ratios (HRs). In 144 498 eligible patients, early titration was associated with significantly lower risk of MACE in the subsequent 2 years compared to no up-titration (HR 0.76, P &lt; 0.01]. Delayed up-titration was associated with a smaller reduction (HR 0.88, P = 0.08). The majority of patients did not up-titrate. Conclusion Early up-titration to high-intensity statins was independently associated with lower risk of subsequent CV events compared to no up-titration. Delayed up-titration was not associated with the same benefit. Despite the higher risk associated with no up-titration, few patients at very high CV risk who started treatment on moderate-intensity up-titrated to high intensity, indicating a potential need for more aggressive lipid management of these patients in clinical practice.

scholarly journals Serious complications and risk of re-operation after Dupuytren’s disease surgery: a population-based cohort study of 121,488 patients in England

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Osaid Alser ◽  
Richard S. Craig ◽  
Jennifer C. E. Lane ◽  
Albert Prats-Uribe ◽  
Danielle E. Robinson ◽  
...  
Keyword(s):  
Cohort Study ◽  
High Risk ◽  
Case Series ◽  
Population Based ◽  
Dupuytren’S Disease ◽  
Dupuytren's Disease ◽  
Systemic Complications ◽  
Increased Risk ◽  
Risk Patients ◽  
Limited Fasciectomy

Abstract Dupuytren’s disease (DD) is a common fibro-proliferative disorder of the palm. We estimated the risk of serious local and systemic complications and re-operation after DD surgery. We queried England’s Hospital Episode Statistics database and included all adult DD patients who were surgically treated. A longitudinal cohort study and self-controlled case series were conducted. Between 1 April 2007 and 31 March 2017, 121,488 adults underwent 158,119 operations for DD. The cumulative incidence of 90-day serious local complications was low at 1.2% (95% CI 1.1–1.2). However, the amputation rate for re-operation by limited fasciectomy following dermofasciectomy was 8%. 90-day systemic complications were also uncommon at 0.78% (95% CI 0.74–0.83), however operations routinely performed under general or regional anaesthesia carried an increased risk of serious systemic complications such as myocardial infarction. Re-operation was lower than previous reports (33.7% for percutaneous needle fasciotomy, 19.5% for limited fasciectomy, and 18.2% for dermofasciectomy). Overall, DD surgery performed in England was safe; however, re-operation by after dermofasciectomy carries a high risk of amputation. Furthermore, whilst serious systemic complications were unusual, the data suggest that high-risk patients should undergo treatment under local anaesthesia. These data will inform better shared decision-making regarding this common condition.

scholarly journals Molecular Features and Clinical Management of Hereditary Gynecological Cancers

2020 ◽  
Vol 21 (24) ◽  
pp. 9504
Author(s):  
Arisa Ueki ◽  
Akira Hirasawa
Keyword(s):  
Clinical Management ◽  
Therapeutic Targets ◽  
Treatment Strategies ◽  
Gynecological Cancers ◽  
Hereditary Cancers ◽  
Nccn Guidelines ◽  
Molecular Features ◽  
Methods Of Evaluation ◽  
Cancer Network ◽  
Tumor Profiling

Hereditary gynecological cancers are caused by several inherited genes. Tumors that arise in the female reproductive system, such as ovaries and the uterus, overlap with hereditary cancers. Several hereditary cancer-related genes are important because they might lead to therapeutic targets. Treatment of hereditary cancers should be updated in line with the advent of various new methods of evaluation. Next-generation sequencing has led to rapid, economical genetic analyses that have prompted a concomitant and significant paradigm shift with respect to hereditary cancers. Molecular tumor profiling is an epochal method for determining therapeutic targets. Clinical treatment strategies are now being designed based on biomarkers based on tumor profiling. Furthermore, the National Comprehensive Cancer Network (NCCN) guidelines significantly changed the genetic testing process in 2020 to initially consider multi-gene panel (MGP) evaluation. Here, we reviewed the molecular features and clinical management of hereditary gynecological malignancies, such as hereditary breast and ovarian cancer (HBOC), and Lynch, Li–Fraumeni, Cowden, and Peutz–Jeghers syndromes. We also reviewed cancer-susceptible genes revealed by MGP tests.

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