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Take precautions as cancer picture in MS remains hazy
NASHVILLE, TENN. – With much unknown about the risks of cancer and vaccination associated with immunosuppressants used in multiple sclerosis treatment, a neurologist advised colleagues to be aware of the potential dangers and take appropriate precautions.
For example, Eric Williamson, MD, of the University of Pennsylvania and Philadelphia Veterans Administration Hospital, said he goes a step further than recommending that adult female patients with MS who take ocrelizumab (Ocrevus) get regular mammograms. Per policy, he also double-checks to make sure that patients actually get screened.
“I know two women who were diagnosed with breast cancer before they began on their treatment because we asked about mammograms,” said Dr. Williamson, who spoke in a presentation about the risks of immunosuppressants in MS at the annual meeting of the Consortium of Multiple Sclerosis Centers.
In regard to cancer as a whole, he said, “it’s unclear if there is any true increased risk in MS patients.” But this doesn’t mean there is no danger, he said, since research into immunosuppressants in other contexts show that they can boost the risk of cancer by three times to as much as several hundred times.
In transplant patients, he said, immunosuppressants are linked to higher rates of lymphoproliferative tumors (such as those linked to Epstein-Barr virus), Kaposi sarcoma, and cutaneous, renal, hepatobiliary, and anogenital tumors.
Research is also hazy in regard to specific immunosuppressants used to treat MS. Two reports published about a decade ago raised the possibility that natalizumab (Tysabri) may have sparked a slightly higher risk cancer in patients taking the drug for Crohn’s disease and MS, respectively; the latter report hinted at a higher risk of melanoma specifically. However, Dr. Williamson said postmarketing surveillance has not detected any further sign of trouble (N Engl J Med. 2006;354:899‐910; N Engl J Med. 2008;358;647‐8).
Another drug, ocrelizumab (Ocrevus), has sparked questions about a possible breast cancer risk. As Genentech, its manufacturer, notes: “breast cancer occurred in 6 of 781 females treated with Ocrevus and none of 668 females treated with Rebif [interferon beta-1a] or placebo.”
However, a researcher reported ocrelizumab open-label extension study data at the 2017 CMSC annual meeting and said, “incidence rates of malignancies and breast cancer observed with ocrelizumab treatment in MS remain within the range of epidemiologic background data.”
For now, Dr. Williamson, said, it may take decades to understand if there’s actually an increased breast cancer risk with ocrelizumab.
Skin cancer is a concern for fingolimod (Gilenya), Dr. Williamson said, specifically basal cell carcinoma and melanoma. It’s debatable whether patients should be required to see a dermatologist or make annual visits, he said. Per policy, his VA employer requires these patients to visit a dermatologist.
Whatever the case, it’s important to keep in mind that skin cancer screenings are advisable in general, he said.
Guidance on vaccinations
On the vaccination front, Dr. Williamson said vaccines are a good idea for MS patients – as long as they’re “relatively safe” – because some infectious diseases appear to be more severe in this population.
Flu is a special danger, Dr. Williamson said. He recommends the flu vaccine to patients “because people with MS are at higher risk of influenza-related complications or hospitalizations.”
With guidance from a report led by Dr. Williamson, the National Multiple Sclerosis Society offers recommendations about whether patients with MS should use various vaccines (Curr Neurol Neurosci Rep. 2016;16:36).
Dr. Williamson cautioned that patients with MS who take dimethyl fumarate (Tecfidera), ocrelizumab (Ocrevus), and fingolimod (Gilenya) should not use live vaccines. The drugs can pose issues in regard to other vaccines, too, he said (Plos ONE 2013; 8:e78532; Neurol Res 2012;34:730-3; Neurology. 2013;81:552-8).
Autoimmune risk with alemtuzumab
Alemtuzumab (Lemtrada) has been linked to autoimmune thyroid disorders, especially Graves’ disease, Dr. Williamson said. It’s estimated to affect 17%-41% of patients (Front Endocrinol [Lausanne]. 2017;8:254).
Potentially life-threatening idiopathic thrombocytopenic purpura occurs in 2% of patients on Lemtrada, he said, and anti-GMB nephropathy/Goodpasture’s syndrome has been reported in 0.1%.
Dr. Williamson also noted case reports of autoimmune hemolytic anemia and hepatitis. Earlier this year, three reports in Neurology noted acute coronary syndrome in one patient, hemophagocytic lymphohistiocytosis (HLH) in two patients, and acute acalculous cholecystitis in eight patients (Neurology. 2018 Mar 30. doi: 10.1212/WNL.0000000000005422, doi: 10.1212/WNL.0000000000005420, doi: 10.1212/WNL.0000000000005417).
Dr. Williamson disclosed past consulting for Bayer, Biogen, Celgene, Genentech, EMD Serono, Teva, and Novartis, and current research support from Actelion and Alexion.
NASHVILLE, TENN. – With much unknown about the risks of cancer and vaccination associated with immunosuppressants used in multiple sclerosis treatment, a neurologist advised colleagues to be aware of the potential dangers and take appropriate precautions.
For example, Eric Williamson, MD, of the University of Pennsylvania and Philadelphia Veterans Administration Hospital, said he goes a step further than recommending that adult female patients with MS who take ocrelizumab (Ocrevus) get regular mammograms. Per policy, he also double-checks to make sure that patients actually get screened.
“I know two women who were diagnosed with breast cancer before they began on their treatment because we asked about mammograms,” said Dr. Williamson, who spoke in a presentation about the risks of immunosuppressants in MS at the annual meeting of the Consortium of Multiple Sclerosis Centers.
In regard to cancer as a whole, he said, “it’s unclear if there is any true increased risk in MS patients.” But this doesn’t mean there is no danger, he said, since research into immunosuppressants in other contexts show that they can boost the risk of cancer by three times to as much as several hundred times.
In transplant patients, he said, immunosuppressants are linked to higher rates of lymphoproliferative tumors (such as those linked to Epstein-Barr virus), Kaposi sarcoma, and cutaneous, renal, hepatobiliary, and anogenital tumors.
Research is also hazy in regard to specific immunosuppressants used to treat MS. Two reports published about a decade ago raised the possibility that natalizumab (Tysabri) may have sparked a slightly higher risk cancer in patients taking the drug for Crohn’s disease and MS, respectively; the latter report hinted at a higher risk of melanoma specifically. However, Dr. Williamson said postmarketing surveillance has not detected any further sign of trouble (N Engl J Med. 2006;354:899‐910; N Engl J Med. 2008;358;647‐8).
Another drug, ocrelizumab (Ocrevus), has sparked questions about a possible breast cancer risk. As Genentech, its manufacturer, notes: “breast cancer occurred in 6 of 781 females treated with Ocrevus and none of 668 females treated with Rebif [interferon beta-1a] or placebo.”
However, a researcher reported ocrelizumab open-label extension study data at the 2017 CMSC annual meeting and said, “incidence rates of malignancies and breast cancer observed with ocrelizumab treatment in MS remain within the range of epidemiologic background data.”
For now, Dr. Williamson, said, it may take decades to understand if there’s actually an increased breast cancer risk with ocrelizumab.
Skin cancer is a concern for fingolimod (Gilenya), Dr. Williamson said, specifically basal cell carcinoma and melanoma. It’s debatable whether patients should be required to see a dermatologist or make annual visits, he said. Per policy, his VA employer requires these patients to visit a dermatologist.
Whatever the case, it’s important to keep in mind that skin cancer screenings are advisable in general, he said.
Guidance on vaccinations
On the vaccination front, Dr. Williamson said vaccines are a good idea for MS patients – as long as they’re “relatively safe” – because some infectious diseases appear to be more severe in this population.
Flu is a special danger, Dr. Williamson said. He recommends the flu vaccine to patients “because people with MS are at higher risk of influenza-related complications or hospitalizations.”
With guidance from a report led by Dr. Williamson, the National Multiple Sclerosis Society offers recommendations about whether patients with MS should use various vaccines (Curr Neurol Neurosci Rep. 2016;16:36).
Dr. Williamson cautioned that patients with MS who take dimethyl fumarate (Tecfidera), ocrelizumab (Ocrevus), and fingolimod (Gilenya) should not use live vaccines. The drugs can pose issues in regard to other vaccines, too, he said (Plos ONE 2013; 8:e78532; Neurol Res 2012;34:730-3; Neurology. 2013;81:552-8).
Autoimmune risk with alemtuzumab
Alemtuzumab (Lemtrada) has been linked to autoimmune thyroid disorders, especially Graves’ disease, Dr. Williamson said. It’s estimated to affect 17%-41% of patients (Front Endocrinol [Lausanne]. 2017;8:254).
Potentially life-threatening idiopathic thrombocytopenic purpura occurs in 2% of patients on Lemtrada, he said, and anti-GMB nephropathy/Goodpasture’s syndrome has been reported in 0.1%.
Dr. Williamson also noted case reports of autoimmune hemolytic anemia and hepatitis. Earlier this year, three reports in Neurology noted acute coronary syndrome in one patient, hemophagocytic lymphohistiocytosis (HLH) in two patients, and acute acalculous cholecystitis in eight patients (Neurology. 2018 Mar 30. doi: 10.1212/WNL.0000000000005422, doi: 10.1212/WNL.0000000000005420, doi: 10.1212/WNL.0000000000005417).
Dr. Williamson disclosed past consulting for Bayer, Biogen, Celgene, Genentech, EMD Serono, Teva, and Novartis, and current research support from Actelion and Alexion.
NASHVILLE, TENN. – With much unknown about the risks of cancer and vaccination associated with immunosuppressants used in multiple sclerosis treatment, a neurologist advised colleagues to be aware of the potential dangers and take appropriate precautions.
For example, Eric Williamson, MD, of the University of Pennsylvania and Philadelphia Veterans Administration Hospital, said he goes a step further than recommending that adult female patients with MS who take ocrelizumab (Ocrevus) get regular mammograms. Per policy, he also double-checks to make sure that patients actually get screened.
“I know two women who were diagnosed with breast cancer before they began on their treatment because we asked about mammograms,” said Dr. Williamson, who spoke in a presentation about the risks of immunosuppressants in MS at the annual meeting of the Consortium of Multiple Sclerosis Centers.
In regard to cancer as a whole, he said, “it’s unclear if there is any true increased risk in MS patients.” But this doesn’t mean there is no danger, he said, since research into immunosuppressants in other contexts show that they can boost the risk of cancer by three times to as much as several hundred times.
In transplant patients, he said, immunosuppressants are linked to higher rates of lymphoproliferative tumors (such as those linked to Epstein-Barr virus), Kaposi sarcoma, and cutaneous, renal, hepatobiliary, and anogenital tumors.
Research is also hazy in regard to specific immunosuppressants used to treat MS. Two reports published about a decade ago raised the possibility that natalizumab (Tysabri) may have sparked a slightly higher risk cancer in patients taking the drug for Crohn’s disease and MS, respectively; the latter report hinted at a higher risk of melanoma specifically. However, Dr. Williamson said postmarketing surveillance has not detected any further sign of trouble (N Engl J Med. 2006;354:899‐910; N Engl J Med. 2008;358;647‐8).
Another drug, ocrelizumab (Ocrevus), has sparked questions about a possible breast cancer risk. As Genentech, its manufacturer, notes: “breast cancer occurred in 6 of 781 females treated with Ocrevus and none of 668 females treated with Rebif [interferon beta-1a] or placebo.”
However, a researcher reported ocrelizumab open-label extension study data at the 2017 CMSC annual meeting and said, “incidence rates of malignancies and breast cancer observed with ocrelizumab treatment in MS remain within the range of epidemiologic background data.”
For now, Dr. Williamson, said, it may take decades to understand if there’s actually an increased breast cancer risk with ocrelizumab.
Skin cancer is a concern for fingolimod (Gilenya), Dr. Williamson said, specifically basal cell carcinoma and melanoma. It’s debatable whether patients should be required to see a dermatologist or make annual visits, he said. Per policy, his VA employer requires these patients to visit a dermatologist.
Whatever the case, it’s important to keep in mind that skin cancer screenings are advisable in general, he said.
Guidance on vaccinations
On the vaccination front, Dr. Williamson said vaccines are a good idea for MS patients – as long as they’re “relatively safe” – because some infectious diseases appear to be more severe in this population.
Flu is a special danger, Dr. Williamson said. He recommends the flu vaccine to patients “because people with MS are at higher risk of influenza-related complications or hospitalizations.”
With guidance from a report led by Dr. Williamson, the National Multiple Sclerosis Society offers recommendations about whether patients with MS should use various vaccines (Curr Neurol Neurosci Rep. 2016;16:36).
Dr. Williamson cautioned that patients with MS who take dimethyl fumarate (Tecfidera), ocrelizumab (Ocrevus), and fingolimod (Gilenya) should not use live vaccines. The drugs can pose issues in regard to other vaccines, too, he said (Plos ONE 2013; 8:e78532; Neurol Res 2012;34:730-3; Neurology. 2013;81:552-8).
Autoimmune risk with alemtuzumab
Alemtuzumab (Lemtrada) has been linked to autoimmune thyroid disorders, especially Graves’ disease, Dr. Williamson said. It’s estimated to affect 17%-41% of patients (Front Endocrinol [Lausanne]. 2017;8:254).
Potentially life-threatening idiopathic thrombocytopenic purpura occurs in 2% of patients on Lemtrada, he said, and anti-GMB nephropathy/Goodpasture’s syndrome has been reported in 0.1%.
Dr. Williamson also noted case reports of autoimmune hemolytic anemia and hepatitis. Earlier this year, three reports in Neurology noted acute coronary syndrome in one patient, hemophagocytic lymphohistiocytosis (HLH) in two patients, and acute acalculous cholecystitis in eight patients (Neurology. 2018 Mar 30. doi: 10.1212/WNL.0000000000005422, doi: 10.1212/WNL.0000000000005420, doi: 10.1212/WNL.0000000000005417).
Dr. Williamson disclosed past consulting for Bayer, Biogen, Celgene, Genentech, EMD Serono, Teva, and Novartis, and current research support from Actelion and Alexion.
REPORTING FROM THE CMSC ANNUAL MEETING
Focus on preventing comorbidities in MS, physician urges
NASHVILLE, TENN. – Some patients use multiple sclerosis as an excuse to make poor health choices, but Allen C. Bowling, MD, PhD, of the Colorado Neurological Institute has seen another kind of story unfold. Fifteen to 20 years ago, Dr. Bowling said, he treated patients who took the development of MS in their 20s as a sign they needed to take better care of themselves. “They said MS was the best thing that happened to them ‘because it motivated me to make these healthy lifestyle changes I wouldn’t have made otherwise.’ ”
These patients have maintained their lifestyle changes, he said, lowering their risk of comorbidities and – perhaps – changing the course of their MS for the better.
“It’s all one machine, and sometimes we lose sight of that in our sub-sub-specialized world of treating MS ... You’re caring for a whole person. If you start thinking about that, it does make you think differently about how you treat the person, how you try to prevent disease in terms of certain pathways,” Dr. Bowling said in an interview at the annual meeting of the Consortium of Multiple Sclerosis Centers, where he spoke to colleagues about the importance of helping patients to adopt lifestyle changes.
According to Dr. Bowling, there’s evidence linking lifestyle-related comorbidities, poorer food quality, and tobacco use to higher levels of overall MS risk, relapses, disability, and symptoms.
Researchers have also linked other life factors to higher MS risks: obesity (linked to overall MS risk, disability, symptoms); lack of physical activity (linked to relapses, disability, symptoms); emotional factors (relapses, symptoms); and alcohol overuse (linked to overall risk, disability, symptoms).
“Data is mild to moderate to strong in all those areas for lifestyle approaches like diet, physical activity, emotional health, alcohol in moderation or less, and no tobacco smoking,” Dr. Bowling said.
He said he believes physical activity leads to “much higher and earlier success than diet” in MS patients, although there’s no confirmed “best exercise.”
As for nutrition, he said vitamins D and B12 are possibly beneficial. But he cautioned against the potential for harm from supplements and added that there’s no proven best diet for MS.
As for finding time to address these issues in clinic, Dr. Bowling recommended mentioning various lifestyle issues over multiple office visits.
“Some of the effort should be switched to the primary care doctor,” he said, “but you can use a strong collection of words to convey to the person with MS that this is serious: ‘It’s not MS, but it’s a serious issue, and you must see your primary care doctor.’ ”
He believes that this approach can have a significant impact, “especially for those aged 20-40, because the doctor they pay the most attention to may be their MS clinician.”
Dr. Bowling said that he receives royalties from a book he authored, “Optimal Health With Multiple Sclerosis.”
NASHVILLE, TENN. – Some patients use multiple sclerosis as an excuse to make poor health choices, but Allen C. Bowling, MD, PhD, of the Colorado Neurological Institute has seen another kind of story unfold. Fifteen to 20 years ago, Dr. Bowling said, he treated patients who took the development of MS in their 20s as a sign they needed to take better care of themselves. “They said MS was the best thing that happened to them ‘because it motivated me to make these healthy lifestyle changes I wouldn’t have made otherwise.’ ”
These patients have maintained their lifestyle changes, he said, lowering their risk of comorbidities and – perhaps – changing the course of their MS for the better.
“It’s all one machine, and sometimes we lose sight of that in our sub-sub-specialized world of treating MS ... You’re caring for a whole person. If you start thinking about that, it does make you think differently about how you treat the person, how you try to prevent disease in terms of certain pathways,” Dr. Bowling said in an interview at the annual meeting of the Consortium of Multiple Sclerosis Centers, where he spoke to colleagues about the importance of helping patients to adopt lifestyle changes.
According to Dr. Bowling, there’s evidence linking lifestyle-related comorbidities, poorer food quality, and tobacco use to higher levels of overall MS risk, relapses, disability, and symptoms.
Researchers have also linked other life factors to higher MS risks: obesity (linked to overall MS risk, disability, symptoms); lack of physical activity (linked to relapses, disability, symptoms); emotional factors (relapses, symptoms); and alcohol overuse (linked to overall risk, disability, symptoms).
“Data is mild to moderate to strong in all those areas for lifestyle approaches like diet, physical activity, emotional health, alcohol in moderation or less, and no tobacco smoking,” Dr. Bowling said.
He said he believes physical activity leads to “much higher and earlier success than diet” in MS patients, although there’s no confirmed “best exercise.”
As for nutrition, he said vitamins D and B12 are possibly beneficial. But he cautioned against the potential for harm from supplements and added that there’s no proven best diet for MS.
As for finding time to address these issues in clinic, Dr. Bowling recommended mentioning various lifestyle issues over multiple office visits.
“Some of the effort should be switched to the primary care doctor,” he said, “but you can use a strong collection of words to convey to the person with MS that this is serious: ‘It’s not MS, but it’s a serious issue, and you must see your primary care doctor.’ ”
He believes that this approach can have a significant impact, “especially for those aged 20-40, because the doctor they pay the most attention to may be their MS clinician.”
Dr. Bowling said that he receives royalties from a book he authored, “Optimal Health With Multiple Sclerosis.”
NASHVILLE, TENN. – Some patients use multiple sclerosis as an excuse to make poor health choices, but Allen C. Bowling, MD, PhD, of the Colorado Neurological Institute has seen another kind of story unfold. Fifteen to 20 years ago, Dr. Bowling said, he treated patients who took the development of MS in their 20s as a sign they needed to take better care of themselves. “They said MS was the best thing that happened to them ‘because it motivated me to make these healthy lifestyle changes I wouldn’t have made otherwise.’ ”
These patients have maintained their lifestyle changes, he said, lowering their risk of comorbidities and – perhaps – changing the course of their MS for the better.
“It’s all one machine, and sometimes we lose sight of that in our sub-sub-specialized world of treating MS ... You’re caring for a whole person. If you start thinking about that, it does make you think differently about how you treat the person, how you try to prevent disease in terms of certain pathways,” Dr. Bowling said in an interview at the annual meeting of the Consortium of Multiple Sclerosis Centers, where he spoke to colleagues about the importance of helping patients to adopt lifestyle changes.
According to Dr. Bowling, there’s evidence linking lifestyle-related comorbidities, poorer food quality, and tobacco use to higher levels of overall MS risk, relapses, disability, and symptoms.
Researchers have also linked other life factors to higher MS risks: obesity (linked to overall MS risk, disability, symptoms); lack of physical activity (linked to relapses, disability, symptoms); emotional factors (relapses, symptoms); and alcohol overuse (linked to overall risk, disability, symptoms).
“Data is mild to moderate to strong in all those areas for lifestyle approaches like diet, physical activity, emotional health, alcohol in moderation or less, and no tobacco smoking,” Dr. Bowling said.
He said he believes physical activity leads to “much higher and earlier success than diet” in MS patients, although there’s no confirmed “best exercise.”
As for nutrition, he said vitamins D and B12 are possibly beneficial. But he cautioned against the potential for harm from supplements and added that there’s no proven best diet for MS.
As for finding time to address these issues in clinic, Dr. Bowling recommended mentioning various lifestyle issues over multiple office visits.
“Some of the effort should be switched to the primary care doctor,” he said, “but you can use a strong collection of words to convey to the person with MS that this is serious: ‘It’s not MS, but it’s a serious issue, and you must see your primary care doctor.’ ”
He believes that this approach can have a significant impact, “especially for those aged 20-40, because the doctor they pay the most attention to may be their MS clinician.”
Dr. Bowling said that he receives royalties from a book he authored, “Optimal Health With Multiple Sclerosis.”
REPORTING FROM THE CMSC ANNUAL MEETING
Pregnancy may be ideal time to consider switching MS drugs
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
NASHVILLE, TENN – Women with multiple sclerosis who fare poorly on specific medications before pregnancy don’t tend to do any better afterward, a new study finds. This suggests that pregnancy – a period when many women with MS stop taking their medication – should trigger discussions about switching from drugs that aren’t doing the job, the study’s lead author said.
“It’s a good time to consider the therapy that the individual is on, whether it’s one that’s effective for them, and whether it’s one they should return to when they start up therapy post-partum. It’s likely it will affect them the same way” after pregnancy as before, Caila Vaughn, MPH, PhD, of the University of Buffalo, said in an interview at the 2018 annual meeting of the Consortium of Multiple Sclerosis Clinics.
From 2012-2017, the study authors sent surveys to 1,651 women in the New York State Multiple Sclerosis Consortium as part of an effort to understand how pregnancy affects women with MS, especially when relapses return in the post-partum period.
Of the 1,651 women, 635 (38% of the total) agreed to answer questions about their reproductive history.
Pregnancy data was available for 627 patients of whom 490 (78%) had been pregnant. Of those, 109 said they became pregnant after their MS diagnosis.
Fifty-three (49%) reported relapses in the 2 years prior to pregnancy and 46% reported them in the 2 subsequent years. Just 12% reported relapses during pregnancy, and 16% said they took disease-modifying drugs during pregnancy (60% had taken them before pregnancy).
Why does MS become less severe during pregnancy? “We believe the dormancy of the disease is related to an immune system that is naturally decreased and depressed during pregnancy,” Dr. Vaughn said. Afterward, she said, “the relapses are related to the recovery of the immune system post-partum.”
The researchers didn’t find any links between the use of disease-modifying drugs and relapses before, during, or after pregnancy.
Those who had relapses prior to pregnancy were more likely (P = 0.011) to have them afterward too. But researchers didn’t find a statistically significant link between relapses that occurred during and after pregnancy.
More than three-quarters of those who took disease-modifying drugs before pregnancy returned to using them afterward, in most cases within 3 months.
The study findings suggest that pregnancy is a helpful decision point when patients should take a closer look at the effects of their medications, Dr. Vaughn said. “In conjunction with a physician, they should decide if it’s a good one they should return to.”
Reflecting the findings of other research that suggests pregnancy is safe in women with MS, the study shows no sign that pregnancy – either before or after diagnosis of MS – boosts the risk that MS will get worse.
As for the possible effects of disease-modifying drugs on new mothers who breast-feed, the researchers found no evidence of adverse outcomes in 5 patients who took the medications while breast-feeding.
The study was funded by Teva. Dr. Vaughn reported no relevant disclosures. Several other study authors report various disclosures, including relationships with Teva.
SOURCE: Vaughn C. et al. Abstract FC04, 2018 annual meeting, Consortium of Multiple Sclerosis Centers.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
NASHVILLE, TENN – Women with multiple sclerosis who fare poorly on specific medications before pregnancy don’t tend to do any better afterward, a new study finds. This suggests that pregnancy – a period when many women with MS stop taking their medication – should trigger discussions about switching from drugs that aren’t doing the job, the study’s lead author said.
“It’s a good time to consider the therapy that the individual is on, whether it’s one that’s effective for them, and whether it’s one they should return to when they start up therapy post-partum. It’s likely it will affect them the same way” after pregnancy as before, Caila Vaughn, MPH, PhD, of the University of Buffalo, said in an interview at the 2018 annual meeting of the Consortium of Multiple Sclerosis Clinics.
From 2012-2017, the study authors sent surveys to 1,651 women in the New York State Multiple Sclerosis Consortium as part of an effort to understand how pregnancy affects women with MS, especially when relapses return in the post-partum period.
Of the 1,651 women, 635 (38% of the total) agreed to answer questions about their reproductive history.
Pregnancy data was available for 627 patients of whom 490 (78%) had been pregnant. Of those, 109 said they became pregnant after their MS diagnosis.
Fifty-three (49%) reported relapses in the 2 years prior to pregnancy and 46% reported them in the 2 subsequent years. Just 12% reported relapses during pregnancy, and 16% said they took disease-modifying drugs during pregnancy (60% had taken them before pregnancy).
Why does MS become less severe during pregnancy? “We believe the dormancy of the disease is related to an immune system that is naturally decreased and depressed during pregnancy,” Dr. Vaughn said. Afterward, she said, “the relapses are related to the recovery of the immune system post-partum.”
The researchers didn’t find any links between the use of disease-modifying drugs and relapses before, during, or after pregnancy.
Those who had relapses prior to pregnancy were more likely (P = 0.011) to have them afterward too. But researchers didn’t find a statistically significant link between relapses that occurred during and after pregnancy.
More than three-quarters of those who took disease-modifying drugs before pregnancy returned to using them afterward, in most cases within 3 months.
The study findings suggest that pregnancy is a helpful decision point when patients should take a closer look at the effects of their medications, Dr. Vaughn said. “In conjunction with a physician, they should decide if it’s a good one they should return to.”
Reflecting the findings of other research that suggests pregnancy is safe in women with MS, the study shows no sign that pregnancy – either before or after diagnosis of MS – boosts the risk that MS will get worse.
As for the possible effects of disease-modifying drugs on new mothers who breast-feed, the researchers found no evidence of adverse outcomes in 5 patients who took the medications while breast-feeding.
The study was funded by Teva. Dr. Vaughn reported no relevant disclosures. Several other study authors report various disclosures, including relationships with Teva.
SOURCE: Vaughn C. et al. Abstract FC04, 2018 annual meeting, Consortium of Multiple Sclerosis Centers.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
NASHVILLE, TENN – Women with multiple sclerosis who fare poorly on specific medications before pregnancy don’t tend to do any better afterward, a new study finds. This suggests that pregnancy – a period when many women with MS stop taking their medication – should trigger discussions about switching from drugs that aren’t doing the job, the study’s lead author said.
“It’s a good time to consider the therapy that the individual is on, whether it’s one that’s effective for them, and whether it’s one they should return to when they start up therapy post-partum. It’s likely it will affect them the same way” after pregnancy as before, Caila Vaughn, MPH, PhD, of the University of Buffalo, said in an interview at the 2018 annual meeting of the Consortium of Multiple Sclerosis Clinics.
From 2012-2017, the study authors sent surveys to 1,651 women in the New York State Multiple Sclerosis Consortium as part of an effort to understand how pregnancy affects women with MS, especially when relapses return in the post-partum period.
Of the 1,651 women, 635 (38% of the total) agreed to answer questions about their reproductive history.
Pregnancy data was available for 627 patients of whom 490 (78%) had been pregnant. Of those, 109 said they became pregnant after their MS diagnosis.
Fifty-three (49%) reported relapses in the 2 years prior to pregnancy and 46% reported them in the 2 subsequent years. Just 12% reported relapses during pregnancy, and 16% said they took disease-modifying drugs during pregnancy (60% had taken them before pregnancy).
Why does MS become less severe during pregnancy? “We believe the dormancy of the disease is related to an immune system that is naturally decreased and depressed during pregnancy,” Dr. Vaughn said. Afterward, she said, “the relapses are related to the recovery of the immune system post-partum.”
The researchers didn’t find any links between the use of disease-modifying drugs and relapses before, during, or after pregnancy.
Those who had relapses prior to pregnancy were more likely (P = 0.011) to have them afterward too. But researchers didn’t find a statistically significant link between relapses that occurred during and after pregnancy.
More than three-quarters of those who took disease-modifying drugs before pregnancy returned to using them afterward, in most cases within 3 months.
The study findings suggest that pregnancy is a helpful decision point when patients should take a closer look at the effects of their medications, Dr. Vaughn said. “In conjunction with a physician, they should decide if it’s a good one they should return to.”
Reflecting the findings of other research that suggests pregnancy is safe in women with MS, the study shows no sign that pregnancy – either before or after diagnosis of MS – boosts the risk that MS will get worse.
As for the possible effects of disease-modifying drugs on new mothers who breast-feed, the researchers found no evidence of adverse outcomes in 5 patients who took the medications while breast-feeding.
The study was funded by Teva. Dr. Vaughn reported no relevant disclosures. Several other study authors report various disclosures, including relationships with Teva.
SOURCE: Vaughn C. et al. Abstract FC04, 2018 annual meeting, Consortium of Multiple Sclerosis Centers.
REPORTING FROM THE CMSC ANNUAL MEETING
Key clinical point: Multiple sclerosis relapse rates are similar before and after pregnancy, suggesting it may be a good time to consider switching medications if feasible.
Major finding: 49% of women who were pregnant after MS diagnosis reported relapses in the 2 years prior to pregnancy and 46% reported them in the 2 subsequent years. Those who had relapses prior to pregnancy were more likely to have them afterward, too.
Study details: Survey of 109 women who became pregnant after MS diagnosis.
Disclosures: Teva funded the study. Several study authors report various disclosures, including relationships with Teva.
Source: Vaughn C. et al. Abstract FC04, 2018 annual meeting, Consortium of Multiple Sclerosis Centers.
MS clinic thrives by making regular care a ‘loss leader’
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
NASHVILLE, TENN. – Care for MS patients is expensive, and even non-profit treatment centers can’t survive on reimbursements alone. The solution, according to Terry Smith, CEO of the Multiple Sclerosis Center of Atlanta, is to transform regular care into a “loss leader” and embrace other revenue sources.
“The reimbursements for that 20- minute or 30-minute follow-up just really don’t cover all the resources necessary for comprehensive care,” Mr. Smith said in a video interview at the 2018 annual meeting of the Consortium of Multiple Sclerosis Clinics.
Mr. Smith said his involvement in the MS community was sparked about 2 decades ago when his wife developed the condition. “I have seen what the center gets reimbursed for her office visit, and then what her neurologist gets reimbursed.”
The reimbursement for an MS patient’s follow-up, 25-minute appointment with a physician is $104.25, according to Mr. Smith. Yet these MS visits are “the cornerstone of treatment ... set the tone for how successful the care is.”
To make make up for losses, the Atlanta center has begun offering its own ancillary services. “Our doctors are at the forefront of telling patients we have a group of neurologists that handle both emergent as well as non-emergent neurology,” he said. “That offers a revenue stream beyond the patient encounter.”
Other sources include imaging and an infusion clinic managed for a local hospital through a professional service agreement. The Atlanta center also has created its own specialty pharmacy focused on MS. “We buy disease-modifying drugs, develop personal contact with patients on a regular basis, then develop an ongoing compliance-monitoring program,” he said.
Mr. Smith discloses a consulting fee from Novartis.
Watch the interview to learn more about the center’s efforts.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
NASHVILLE, TENN. – Care for MS patients is expensive, and even non-profit treatment centers can’t survive on reimbursements alone. The solution, according to Terry Smith, CEO of the Multiple Sclerosis Center of Atlanta, is to transform regular care into a “loss leader” and embrace other revenue sources.
“The reimbursements for that 20- minute or 30-minute follow-up just really don’t cover all the resources necessary for comprehensive care,” Mr. Smith said in a video interview at the 2018 annual meeting of the Consortium of Multiple Sclerosis Clinics.
Mr. Smith said his involvement in the MS community was sparked about 2 decades ago when his wife developed the condition. “I have seen what the center gets reimbursed for her office visit, and then what her neurologist gets reimbursed.”
The reimbursement for an MS patient’s follow-up, 25-minute appointment with a physician is $104.25, according to Mr. Smith. Yet these MS visits are “the cornerstone of treatment ... set the tone for how successful the care is.”
To make make up for losses, the Atlanta center has begun offering its own ancillary services. “Our doctors are at the forefront of telling patients we have a group of neurologists that handle both emergent as well as non-emergent neurology,” he said. “That offers a revenue stream beyond the patient encounter.”
Other sources include imaging and an infusion clinic managed for a local hospital through a professional service agreement. The Atlanta center also has created its own specialty pharmacy focused on MS. “We buy disease-modifying drugs, develop personal contact with patients on a regular basis, then develop an ongoing compliance-monitoring program,” he said.
Mr. Smith discloses a consulting fee from Novartis.
Watch the interview to learn more about the center’s efforts.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
NASHVILLE, TENN. – Care for MS patients is expensive, and even non-profit treatment centers can’t survive on reimbursements alone. The solution, according to Terry Smith, CEO of the Multiple Sclerosis Center of Atlanta, is to transform regular care into a “loss leader” and embrace other revenue sources.
“The reimbursements for that 20- minute or 30-minute follow-up just really don’t cover all the resources necessary for comprehensive care,” Mr. Smith said in a video interview at the 2018 annual meeting of the Consortium of Multiple Sclerosis Clinics.
Mr. Smith said his involvement in the MS community was sparked about 2 decades ago when his wife developed the condition. “I have seen what the center gets reimbursed for her office visit, and then what her neurologist gets reimbursed.”
The reimbursement for an MS patient’s follow-up, 25-minute appointment with a physician is $104.25, according to Mr. Smith. Yet these MS visits are “the cornerstone of treatment ... set the tone for how successful the care is.”
To make make up for losses, the Atlanta center has begun offering its own ancillary services. “Our doctors are at the forefront of telling patients we have a group of neurologists that handle both emergent as well as non-emergent neurology,” he said. “That offers a revenue stream beyond the patient encounter.”
Other sources include imaging and an infusion clinic managed for a local hospital through a professional service agreement. The Atlanta center also has created its own specialty pharmacy focused on MS. “We buy disease-modifying drugs, develop personal contact with patients on a regular basis, then develop an ongoing compliance-monitoring program,” he said.
Mr. Smith discloses a consulting fee from Novartis.
Watch the interview to learn more about the center’s efforts.
REPORTING FROM THE CMSC ANNUAL MEETING
VIDEO: PML prevention is possible, even when treating patients with aggressive MS
NASHVILLE, TENN. – Armed with new statistics, neurologist Joseph R. Berger, MD, has a message for colleagues about the widely feared risk of progressive multifocal leukoencephalopathy (PML) in multiple sclerosis: It’s not as inevitable as you might think.
“You can actually prevent this disease from occurring because we have risk-limiting strategies in many circumstances,” said Dr. Berger of the University of Pennsylvania, Philadelphia, in a presentation on PML at the annual meeting of the Consortium of Multiple Sclerosis Centers.
Unlike other conditions such as HIV, MS itself is not linked to a higher risk of PML, said Dr. Berger, a leading PML researcher. Instead, it’s the medications that spark the condition, he said, with at least three and possibly four drugs posing a risk to patients.
Natalizumab (Tysabri) is especially risky. “We know that the risk with natalizumab is incredibly high in the context of JC [John Cunningham] virus antibody positivity and prolonged therapy,” Dr. Berger said in an interview after his presentation.
Still, “you can safely give natalizumab for a short period of time when treating patients with aggressive MS,” he said. “I will frequently employ that strategy even in the context of JC virus antibody positivity.”
According to Dr. Berger, there’s no risk of PML when natalizumab is used for under 8 months (Mult Scler Relat Disord. 2017 Feb;12:59-63).
However, “if you leave people on the drug indefinitely, there is a substantial risk of developing PML,” he said. “Individuals who have been left on the drug for 2 years, who’ve seen prior immunosuppressant therapy, who are JC virus antibody positive – that group of individuals develops PML at rates of 1 in 50 to 1 in 100.”
These levels are “enormous,” he said, higher even than those in the HIV population before the rise of antiretroviral medications.
Overall, as of Nov. 30, 2017, 177,800 patients have received natalizumab in the postmarketing setting, and 756 cases of PML have been reported as of Dec. 7, 2017. All but three of those cases were in patients with MS, and the overall incidence was 4.19/1,000.
Dr. Berger recommends regular screening MRIs for PML in patients taking natalizumab, and he advised physicians to be on alert for signs of trouble like the appearance of new neurologic symptoms or a new or increasing JC virus antibody index.
Two other MS drugs, fingolimod (Gilenya) and dimethyl fumarate (Tecfidera), fall into the category of low risk, with just 19 and 5 reported cases, respectively, as of February 2018, Dr. Berger said. He added that two of the fingolimod patients had earlier exposure to natalizumab.
With dimethyl fumarate, the risk appears to disappear – although this isn’t confirmed – when JC antibody–positive patients are taken off the drug, and their lymphocyte counts fall below 500 per mcL, Dr. Berger said.
“Unfortunately for fingolimod, we don’t have a defined risk-mitigation strategy,” he said. However, researchers have noticed that the fingolimod cases have occurred more often in older people, possibly because of the aging of the immune system, he said.
Another three MS drugs – alemtuzumab (Lemtrada), ocrelizumab (Ocrevus; with rituximab as proxy), and teriflunomide (Aubagio; with leflunomide as proxy) have unknown risk, according to Dr. Berger. There have been three cases in ocrelizumab (rituximab as proxy) and one in teriflunomide (leflunomide as proxy), but all were carry-overs from natalizumab or fingolimod exposure or occurred after natalizumab exposure.
What can physicians do if a patient develops PML? Stopping the drug and restoring the immune system is crucial, he said.
While there’s evidence that plasma exchange clears natalizumab (Neurology. 2009 Feb 3;72[5]:402-9), “there’s no study that demonstrates it’s in the patient’s best interest,” Dr. Berger said during his presentation. He noted that a retrospective study found no improvement in morbidity or mortality (Neurology. 2017 Mar 21;88[12];1144-52).
Multiple strategies to treat PML – including immunizations and inhibitors of DNA replication – have failed to make an impact so far, Dr. Berger said. According to him, the reasons for the failure of PML treatment are a lack of hard evidence, apart from anecdotal, to support them, based on a history of failed clinical trials.
Dr. Berger disclosed serving as a consultant for numerous pharmaceutical companies.
NASHVILLE, TENN. – Armed with new statistics, neurologist Joseph R. Berger, MD, has a message for colleagues about the widely feared risk of progressive multifocal leukoencephalopathy (PML) in multiple sclerosis: It’s not as inevitable as you might think.
“You can actually prevent this disease from occurring because we have risk-limiting strategies in many circumstances,” said Dr. Berger of the University of Pennsylvania, Philadelphia, in a presentation on PML at the annual meeting of the Consortium of Multiple Sclerosis Centers.
Unlike other conditions such as HIV, MS itself is not linked to a higher risk of PML, said Dr. Berger, a leading PML researcher. Instead, it’s the medications that spark the condition, he said, with at least three and possibly four drugs posing a risk to patients.
Natalizumab (Tysabri) is especially risky. “We know that the risk with natalizumab is incredibly high in the context of JC [John Cunningham] virus antibody positivity and prolonged therapy,” Dr. Berger said in an interview after his presentation.
Still, “you can safely give natalizumab for a short period of time when treating patients with aggressive MS,” he said. “I will frequently employ that strategy even in the context of JC virus antibody positivity.”
According to Dr. Berger, there’s no risk of PML when natalizumab is used for under 8 months (Mult Scler Relat Disord. 2017 Feb;12:59-63).
However, “if you leave people on the drug indefinitely, there is a substantial risk of developing PML,” he said. “Individuals who have been left on the drug for 2 years, who’ve seen prior immunosuppressant therapy, who are JC virus antibody positive – that group of individuals develops PML at rates of 1 in 50 to 1 in 100.”
These levels are “enormous,” he said, higher even than those in the HIV population before the rise of antiretroviral medications.
Overall, as of Nov. 30, 2017, 177,800 patients have received natalizumab in the postmarketing setting, and 756 cases of PML have been reported as of Dec. 7, 2017. All but three of those cases were in patients with MS, and the overall incidence was 4.19/1,000.
Dr. Berger recommends regular screening MRIs for PML in patients taking natalizumab, and he advised physicians to be on alert for signs of trouble like the appearance of new neurologic symptoms or a new or increasing JC virus antibody index.
Two other MS drugs, fingolimod (Gilenya) and dimethyl fumarate (Tecfidera), fall into the category of low risk, with just 19 and 5 reported cases, respectively, as of February 2018, Dr. Berger said. He added that two of the fingolimod patients had earlier exposure to natalizumab.
With dimethyl fumarate, the risk appears to disappear – although this isn’t confirmed – when JC antibody–positive patients are taken off the drug, and their lymphocyte counts fall below 500 per mcL, Dr. Berger said.
“Unfortunately for fingolimod, we don’t have a defined risk-mitigation strategy,” he said. However, researchers have noticed that the fingolimod cases have occurred more often in older people, possibly because of the aging of the immune system, he said.
Another three MS drugs – alemtuzumab (Lemtrada), ocrelizumab (Ocrevus; with rituximab as proxy), and teriflunomide (Aubagio; with leflunomide as proxy) have unknown risk, according to Dr. Berger. There have been three cases in ocrelizumab (rituximab as proxy) and one in teriflunomide (leflunomide as proxy), but all were carry-overs from natalizumab or fingolimod exposure or occurred after natalizumab exposure.
What can physicians do if a patient develops PML? Stopping the drug and restoring the immune system is crucial, he said.
While there’s evidence that plasma exchange clears natalizumab (Neurology. 2009 Feb 3;72[5]:402-9), “there’s no study that demonstrates it’s in the patient’s best interest,” Dr. Berger said during his presentation. He noted that a retrospective study found no improvement in morbidity or mortality (Neurology. 2017 Mar 21;88[12];1144-52).
Multiple strategies to treat PML – including immunizations and inhibitors of DNA replication – have failed to make an impact so far, Dr. Berger said. According to him, the reasons for the failure of PML treatment are a lack of hard evidence, apart from anecdotal, to support them, based on a history of failed clinical trials.
Dr. Berger disclosed serving as a consultant for numerous pharmaceutical companies.
NASHVILLE, TENN. – Armed with new statistics, neurologist Joseph R. Berger, MD, has a message for colleagues about the widely feared risk of progressive multifocal leukoencephalopathy (PML) in multiple sclerosis: It’s not as inevitable as you might think.
“You can actually prevent this disease from occurring because we have risk-limiting strategies in many circumstances,” said Dr. Berger of the University of Pennsylvania, Philadelphia, in a presentation on PML at the annual meeting of the Consortium of Multiple Sclerosis Centers.
Unlike other conditions such as HIV, MS itself is not linked to a higher risk of PML, said Dr. Berger, a leading PML researcher. Instead, it’s the medications that spark the condition, he said, with at least three and possibly four drugs posing a risk to patients.
Natalizumab (Tysabri) is especially risky. “We know that the risk with natalizumab is incredibly high in the context of JC [John Cunningham] virus antibody positivity and prolonged therapy,” Dr. Berger said in an interview after his presentation.
Still, “you can safely give natalizumab for a short period of time when treating patients with aggressive MS,” he said. “I will frequently employ that strategy even in the context of JC virus antibody positivity.”
According to Dr. Berger, there’s no risk of PML when natalizumab is used for under 8 months (Mult Scler Relat Disord. 2017 Feb;12:59-63).
However, “if you leave people on the drug indefinitely, there is a substantial risk of developing PML,” he said. “Individuals who have been left on the drug for 2 years, who’ve seen prior immunosuppressant therapy, who are JC virus antibody positive – that group of individuals develops PML at rates of 1 in 50 to 1 in 100.”
These levels are “enormous,” he said, higher even than those in the HIV population before the rise of antiretroviral medications.
Overall, as of Nov. 30, 2017, 177,800 patients have received natalizumab in the postmarketing setting, and 756 cases of PML have been reported as of Dec. 7, 2017. All but three of those cases were in patients with MS, and the overall incidence was 4.19/1,000.
Dr. Berger recommends regular screening MRIs for PML in patients taking natalizumab, and he advised physicians to be on alert for signs of trouble like the appearance of new neurologic symptoms or a new or increasing JC virus antibody index.
Two other MS drugs, fingolimod (Gilenya) and dimethyl fumarate (Tecfidera), fall into the category of low risk, with just 19 and 5 reported cases, respectively, as of February 2018, Dr. Berger said. He added that two of the fingolimod patients had earlier exposure to natalizumab.
With dimethyl fumarate, the risk appears to disappear – although this isn’t confirmed – when JC antibody–positive patients are taken off the drug, and their lymphocyte counts fall below 500 per mcL, Dr. Berger said.
“Unfortunately for fingolimod, we don’t have a defined risk-mitigation strategy,” he said. However, researchers have noticed that the fingolimod cases have occurred more often in older people, possibly because of the aging of the immune system, he said.
Another three MS drugs – alemtuzumab (Lemtrada), ocrelizumab (Ocrevus; with rituximab as proxy), and teriflunomide (Aubagio; with leflunomide as proxy) have unknown risk, according to Dr. Berger. There have been three cases in ocrelizumab (rituximab as proxy) and one in teriflunomide (leflunomide as proxy), but all were carry-overs from natalizumab or fingolimod exposure or occurred after natalizumab exposure.
What can physicians do if a patient develops PML? Stopping the drug and restoring the immune system is crucial, he said.
While there’s evidence that plasma exchange clears natalizumab (Neurology. 2009 Feb 3;72[5]:402-9), “there’s no study that demonstrates it’s in the patient’s best interest,” Dr. Berger said during his presentation. He noted that a retrospective study found no improvement in morbidity or mortality (Neurology. 2017 Mar 21;88[12];1144-52).
Multiple strategies to treat PML – including immunizations and inhibitors of DNA replication – have failed to make an impact so far, Dr. Berger said. According to him, the reasons for the failure of PML treatment are a lack of hard evidence, apart from anecdotal, to support them, based on a history of failed clinical trials.
Dr. Berger disclosed serving as a consultant for numerous pharmaceutical companies.
REPORTING FROM THE CMSC ANNUAL MEETING
Inside the complex, surprising world of MS comorbidities
NASHVILLE, Tenn. – Recent research into comorbidities in multiple sclerosis – including head-scratching findings about lower cancer rates – is shedding light on the links between the disease and other illnesses, according to an epidemiologist specializing in MS.
“People should be mindful that if they look at having a positive impact on those comorbidities, they may have the ability to benefit patients in context of their MS,” Helen Tremlett, PhD, said in a video interview at the annual meeting of the Consortium of Multiple Sclerosis Centers. She is the Canada Research Chair in Neuroepidemiology and Multiple Sclerosis at the University of British Columbia, Vancouver.
In recent years, research into comorbidities in MS has risen dramatically. Dr. Tremlett found that the number of papers per year in PubMed that address MS and comorbidity has risen from roughly 30 in 2007 to about 80 in 2015, although the numbers dipped to about 50 and 60, respectively, in 2016 and 2017.
A 2015 systematic review of research into MS and comorbidities reported that while “findings were inconsistent overall,” studies suggested that “meningiomas and possibly urinary system cancers, inflammatory bowel disease, irritable bowel syndrome, epilepsy, depression, anxiety, bipolar disorder, early cataracts, and restless legs syndrome were more common than expected in the MS population.” (Mult Scler. 2015 Mar;21[3]:263-81).
Notably, most cancers are missing from this list. In fact, Dr. Tremlett cowrote a 2012 study that found lower risks of all cancers and several specific types of cancer – breast, lung, colorectal, prostate, and melanoma – in MS patients, compared with age- and gender-matched controls (Brain. 2012 Oct;135[Pt 10]:2973-9).
According to Dr. Tremlett, there are several theories about the apparent lower cancer risk in patients with MS. Perhaps their immune systems are hypervigilant, or maybe MS diagnoses inspire healthier lifestyles.
Researchers have been intrigued by another possibility – that cancer diagnoses are being delayed in patients with MS. Indeed, the 2012 study found that tumor sizes at diagnosis in patients with MS were larger than expected in breast, prostate, lung, and colorectal cancer (P = .04).
“We couldn’t record why that’s the case, but there may be some so-called ‘diagnostic neglect,’ ” she said. “You could imagine a scenario where a typical person with MS goes to see their physician and says, ‘I’m tired. I have fatigue,’ and the physician says, ‘Yes, you have MS, that’s what you should expect.’ Someone in the general population might get additional investigation, get blood work done, and their cancer might be found earlier.”
It’s also possible, she said, that cancer isn’t picked up earlier because it can be difficult to screen people with disabilities. “It’s only recently that physicians can offer the Pap smear to women in a wheelchair.”
On another front, there’s evidence linking comorbidities to worsening MS. A 2018 study coauthored by Dr. Tremlett found that patients with more comorbidities had more disability. Specifically, ischemic heart disease and epilepsy were associated with greater Expanded Disability Status Scale scores (Neurology. 2018 Jan 3. doi: 10.1212/WNL.0000000000004885).
Other research coauthored by Dr. Tremlett has linked comorbidities in MS – specifically, hyperlipidemia, migraine, and three or more comorbidities – to higher risk of MS relapse (Neurology. 2017 Dec 12;89[24]:2455-61).
Dr. Tremlett reported having no relevant disclosures.
NASHVILLE, Tenn. – Recent research into comorbidities in multiple sclerosis – including head-scratching findings about lower cancer rates – is shedding light on the links between the disease and other illnesses, according to an epidemiologist specializing in MS.
“People should be mindful that if they look at having a positive impact on those comorbidities, they may have the ability to benefit patients in context of their MS,” Helen Tremlett, PhD, said in a video interview at the annual meeting of the Consortium of Multiple Sclerosis Centers. She is the Canada Research Chair in Neuroepidemiology and Multiple Sclerosis at the University of British Columbia, Vancouver.
In recent years, research into comorbidities in MS has risen dramatically. Dr. Tremlett found that the number of papers per year in PubMed that address MS and comorbidity has risen from roughly 30 in 2007 to about 80 in 2015, although the numbers dipped to about 50 and 60, respectively, in 2016 and 2017.
A 2015 systematic review of research into MS and comorbidities reported that while “findings were inconsistent overall,” studies suggested that “meningiomas and possibly urinary system cancers, inflammatory bowel disease, irritable bowel syndrome, epilepsy, depression, anxiety, bipolar disorder, early cataracts, and restless legs syndrome were more common than expected in the MS population.” (Mult Scler. 2015 Mar;21[3]:263-81).
Notably, most cancers are missing from this list. In fact, Dr. Tremlett cowrote a 2012 study that found lower risks of all cancers and several specific types of cancer – breast, lung, colorectal, prostate, and melanoma – in MS patients, compared with age- and gender-matched controls (Brain. 2012 Oct;135[Pt 10]:2973-9).
According to Dr. Tremlett, there are several theories about the apparent lower cancer risk in patients with MS. Perhaps their immune systems are hypervigilant, or maybe MS diagnoses inspire healthier lifestyles.
Researchers have been intrigued by another possibility – that cancer diagnoses are being delayed in patients with MS. Indeed, the 2012 study found that tumor sizes at diagnosis in patients with MS were larger than expected in breast, prostate, lung, and colorectal cancer (P = .04).
“We couldn’t record why that’s the case, but there may be some so-called ‘diagnostic neglect,’ ” she said. “You could imagine a scenario where a typical person with MS goes to see their physician and says, ‘I’m tired. I have fatigue,’ and the physician says, ‘Yes, you have MS, that’s what you should expect.’ Someone in the general population might get additional investigation, get blood work done, and their cancer might be found earlier.”
It’s also possible, she said, that cancer isn’t picked up earlier because it can be difficult to screen people with disabilities. “It’s only recently that physicians can offer the Pap smear to women in a wheelchair.”
On another front, there’s evidence linking comorbidities to worsening MS. A 2018 study coauthored by Dr. Tremlett found that patients with more comorbidities had more disability. Specifically, ischemic heart disease and epilepsy were associated with greater Expanded Disability Status Scale scores (Neurology. 2018 Jan 3. doi: 10.1212/WNL.0000000000004885).
Other research coauthored by Dr. Tremlett has linked comorbidities in MS – specifically, hyperlipidemia, migraine, and three or more comorbidities – to higher risk of MS relapse (Neurology. 2017 Dec 12;89[24]:2455-61).
Dr. Tremlett reported having no relevant disclosures.
NASHVILLE, Tenn. – Recent research into comorbidities in multiple sclerosis – including head-scratching findings about lower cancer rates – is shedding light on the links between the disease and other illnesses, according to an epidemiologist specializing in MS.
“People should be mindful that if they look at having a positive impact on those comorbidities, they may have the ability to benefit patients in context of their MS,” Helen Tremlett, PhD, said in a video interview at the annual meeting of the Consortium of Multiple Sclerosis Centers. She is the Canada Research Chair in Neuroepidemiology and Multiple Sclerosis at the University of British Columbia, Vancouver.
In recent years, research into comorbidities in MS has risen dramatically. Dr. Tremlett found that the number of papers per year in PubMed that address MS and comorbidity has risen from roughly 30 in 2007 to about 80 in 2015, although the numbers dipped to about 50 and 60, respectively, in 2016 and 2017.
A 2015 systematic review of research into MS and comorbidities reported that while “findings were inconsistent overall,” studies suggested that “meningiomas and possibly urinary system cancers, inflammatory bowel disease, irritable bowel syndrome, epilepsy, depression, anxiety, bipolar disorder, early cataracts, and restless legs syndrome were more common than expected in the MS population.” (Mult Scler. 2015 Mar;21[3]:263-81).
Notably, most cancers are missing from this list. In fact, Dr. Tremlett cowrote a 2012 study that found lower risks of all cancers and several specific types of cancer – breast, lung, colorectal, prostate, and melanoma – in MS patients, compared with age- and gender-matched controls (Brain. 2012 Oct;135[Pt 10]:2973-9).
According to Dr. Tremlett, there are several theories about the apparent lower cancer risk in patients with MS. Perhaps their immune systems are hypervigilant, or maybe MS diagnoses inspire healthier lifestyles.
Researchers have been intrigued by another possibility – that cancer diagnoses are being delayed in patients with MS. Indeed, the 2012 study found that tumor sizes at diagnosis in patients with MS were larger than expected in breast, prostate, lung, and colorectal cancer (P = .04).
“We couldn’t record why that’s the case, but there may be some so-called ‘diagnostic neglect,’ ” she said. “You could imagine a scenario where a typical person with MS goes to see their physician and says, ‘I’m tired. I have fatigue,’ and the physician says, ‘Yes, you have MS, that’s what you should expect.’ Someone in the general population might get additional investigation, get blood work done, and their cancer might be found earlier.”
It’s also possible, she said, that cancer isn’t picked up earlier because it can be difficult to screen people with disabilities. “It’s only recently that physicians can offer the Pap smear to women in a wheelchair.”
On another front, there’s evidence linking comorbidities to worsening MS. A 2018 study coauthored by Dr. Tremlett found that patients with more comorbidities had more disability. Specifically, ischemic heart disease and epilepsy were associated with greater Expanded Disability Status Scale scores (Neurology. 2018 Jan 3. doi: 10.1212/WNL.0000000000004885).
Other research coauthored by Dr. Tremlett has linked comorbidities in MS – specifically, hyperlipidemia, migraine, and three or more comorbidities – to higher risk of MS relapse (Neurology. 2017 Dec 12;89[24]:2455-61).
Dr. Tremlett reported having no relevant disclosures.
EXPERT ANALYSIS FROM THE CMSC ANNUAL MEETING
Value-based care spawns new challenges for MS physicians
NASHVILLE, TENN. – Jeffrey B. English, MD, of the MS Center of Atlanta, knows which quality measures physicians and their patients with multiple sclerosis think are important. After all, he and his colleagues have surveyed them about that very topic.
But he has little time to monitor these measures since he’s too busy with a more overwhelming task: keeping track of unrelated quality measures as required by the federal government.
“When they developed quality measures under the MACRA law, they were not thinking about MS people in general. They were very primary care based,” Dr. English said in an interview at the annual meeting of the Consortium of Multiple Sclerosis Centers.
In terms of MS, he said, “no one really knows what the correct outcome measures are.”
Dr. English knows more than most about quality measures preferred by neurologists and patients. At the annual CMSC meeting last year, he presented results from a survey of 11 physicians and 423 patients about the measures of care they consider most important. The patient survey asked about several measures recommended by the American Academy of Neurology plus other measures recommended by the physicians.
The two groups – physicians and patients – agreed on the top four measures: change observed via MRI, change observed via exam, quality of life, and fatigue. However, they disagreed on the ranking within the top four spots.
The least important measures for patients were exercise levels, depression, medication compliance, and relapses.
Dr. English wants to “be able to follow what the patients want me to follow.” However, he hasn’t been able to do so since “25% of my time with patients, in between patients and after hours, is spent trying to comply with outcome measures from the new health care system that are of no benefit to the patient,” he said.
He’s referring to the quality measures that many physicians are tracking to get reimbursed by Medicare and Medicaid.
Value-based care posts other challenges for MS physicians, he said, since MS care is especially expensive. Accountable Care Organizations are looking at cost savings in closed systems, he said, and that could spell trouble because patients with MS cost more.
As a 2015 report noted, first-generation disease-modifying therapies (DMTs) for MS cost about $60,000, and “costs for these agents have increased annually at rates 5 to 7 times higher than prescription drug inflation. Newer DMTs commonly entered the market with a cost 25%-60% higher than existing DMTs” (Neurology. 2015 May 26;84[21]:2185-92).
“If I’m in an ACO, and I’m taking care of a lot of MS patients, I’ll already lose money for the accountable care system,” Dr. English said. “They may not necessarily want an MS center inside an ACO.”
What can doctors do? “Advocacy efforts are pretty difficult for physicians,” Dr. English said. “Our hope is that the CMSC will be a clearinghouse for doctors who have ideas and efforts and advocacy, and somehow channel that into the actual provision of care. You have people advocating for medications and for research and for patients, but there’s nobody advocating for the actual care that’s going on, the boots-on-the-ground care. That’s where CMSC should play a big role.”
Dr. English disclosed that he has served as a consultant for multiple pharmaceutical companies.
NASHVILLE, TENN. – Jeffrey B. English, MD, of the MS Center of Atlanta, knows which quality measures physicians and their patients with multiple sclerosis think are important. After all, he and his colleagues have surveyed them about that very topic.
But he has little time to monitor these measures since he’s too busy with a more overwhelming task: keeping track of unrelated quality measures as required by the federal government.
“When they developed quality measures under the MACRA law, they were not thinking about MS people in general. They were very primary care based,” Dr. English said in an interview at the annual meeting of the Consortium of Multiple Sclerosis Centers.
In terms of MS, he said, “no one really knows what the correct outcome measures are.”
Dr. English knows more than most about quality measures preferred by neurologists and patients. At the annual CMSC meeting last year, he presented results from a survey of 11 physicians and 423 patients about the measures of care they consider most important. The patient survey asked about several measures recommended by the American Academy of Neurology plus other measures recommended by the physicians.
The two groups – physicians and patients – agreed on the top four measures: change observed via MRI, change observed via exam, quality of life, and fatigue. However, they disagreed on the ranking within the top four spots.
The least important measures for patients were exercise levels, depression, medication compliance, and relapses.
Dr. English wants to “be able to follow what the patients want me to follow.” However, he hasn’t been able to do so since “25% of my time with patients, in between patients and after hours, is spent trying to comply with outcome measures from the new health care system that are of no benefit to the patient,” he said.
He’s referring to the quality measures that many physicians are tracking to get reimbursed by Medicare and Medicaid.
Value-based care posts other challenges for MS physicians, he said, since MS care is especially expensive. Accountable Care Organizations are looking at cost savings in closed systems, he said, and that could spell trouble because patients with MS cost more.
As a 2015 report noted, first-generation disease-modifying therapies (DMTs) for MS cost about $60,000, and “costs for these agents have increased annually at rates 5 to 7 times higher than prescription drug inflation. Newer DMTs commonly entered the market with a cost 25%-60% higher than existing DMTs” (Neurology. 2015 May 26;84[21]:2185-92).
“If I’m in an ACO, and I’m taking care of a lot of MS patients, I’ll already lose money for the accountable care system,” Dr. English said. “They may not necessarily want an MS center inside an ACO.”
What can doctors do? “Advocacy efforts are pretty difficult for physicians,” Dr. English said. “Our hope is that the CMSC will be a clearinghouse for doctors who have ideas and efforts and advocacy, and somehow channel that into the actual provision of care. You have people advocating for medications and for research and for patients, but there’s nobody advocating for the actual care that’s going on, the boots-on-the-ground care. That’s where CMSC should play a big role.”
Dr. English disclosed that he has served as a consultant for multiple pharmaceutical companies.
NASHVILLE, TENN. – Jeffrey B. English, MD, of the MS Center of Atlanta, knows which quality measures physicians and their patients with multiple sclerosis think are important. After all, he and his colleagues have surveyed them about that very topic.
But he has little time to monitor these measures since he’s too busy with a more overwhelming task: keeping track of unrelated quality measures as required by the federal government.
“When they developed quality measures under the MACRA law, they were not thinking about MS people in general. They were very primary care based,” Dr. English said in an interview at the annual meeting of the Consortium of Multiple Sclerosis Centers.
In terms of MS, he said, “no one really knows what the correct outcome measures are.”
Dr. English knows more than most about quality measures preferred by neurologists and patients. At the annual CMSC meeting last year, he presented results from a survey of 11 physicians and 423 patients about the measures of care they consider most important. The patient survey asked about several measures recommended by the American Academy of Neurology plus other measures recommended by the physicians.
The two groups – physicians and patients – agreed on the top four measures: change observed via MRI, change observed via exam, quality of life, and fatigue. However, they disagreed on the ranking within the top four spots.
The least important measures for patients were exercise levels, depression, medication compliance, and relapses.
Dr. English wants to “be able to follow what the patients want me to follow.” However, he hasn’t been able to do so since “25% of my time with patients, in between patients and after hours, is spent trying to comply with outcome measures from the new health care system that are of no benefit to the patient,” he said.
He’s referring to the quality measures that many physicians are tracking to get reimbursed by Medicare and Medicaid.
Value-based care posts other challenges for MS physicians, he said, since MS care is especially expensive. Accountable Care Organizations are looking at cost savings in closed systems, he said, and that could spell trouble because patients with MS cost more.
As a 2015 report noted, first-generation disease-modifying therapies (DMTs) for MS cost about $60,000, and “costs for these agents have increased annually at rates 5 to 7 times higher than prescription drug inflation. Newer DMTs commonly entered the market with a cost 25%-60% higher than existing DMTs” (Neurology. 2015 May 26;84[21]:2185-92).
“If I’m in an ACO, and I’m taking care of a lot of MS patients, I’ll already lose money for the accountable care system,” Dr. English said. “They may not necessarily want an MS center inside an ACO.”
What can doctors do? “Advocacy efforts are pretty difficult for physicians,” Dr. English said. “Our hope is that the CMSC will be a clearinghouse for doctors who have ideas and efforts and advocacy, and somehow channel that into the actual provision of care. You have people advocating for medications and for research and for patients, but there’s nobody advocating for the actual care that’s going on, the boots-on-the-ground care. That’s where CMSC should play a big role.”
Dr. English disclosed that he has served as a consultant for multiple pharmaceutical companies.
REPORTING FROM THE CMSC ANNUAL MEETING
Teaching opportunities of live surgery broadcasts debated
SAN DIEGO – Two thoracic societies are being challenged to review their rejection of at medical meetings.
The American Association for Thoracic Surgery and Society of Thoracic Surgeons “should modify their stance on live surgery as an educational tool like almost all of their sister organizations,” said Joseph E. Bavaria, MD, FACS, of the University of Pennsylvania, Philadelphia. “Presently, it is effectively a ban on the practice. But there are no data to suggest that it does harm to patients if done with proper constraints.”
Live broadcasts of surgeries at medical meetings are both common and controversial. Dr. Bavaria listed numerous recent thoracic meetings in Europe and Canada that featured live broadcasts. But, he noted, the AATS and STS are not supportive of the trend.
In a policy amended in 2017, the AATS states, among other things, that “national and international cardiothoracic societies should consider prohibiting live surgery broadcasts to large audiences at their annual meetings.” The STS policy, amended in 2016, is nearly identical. However, it adds language specifying that “violation of these guidelines may lead to disciplinary action by the Society.”
Both the AATS and STS policies state that surgeons should not take part in live broadcasts of operations that are intended for the public. And both policies say “generally, recorded broadcasts, either edited or unedited, are preferable to live surgery broadcasts because recordings intended for later broadcast pose fewer risks of harm to patients.”
The policies don’t elaborate on how a live broadcast of an operation might be more harmful than one aired at a later time. “Where are the data to support this statement?” Dr. Bavaria asked. “Is this what we call the expert opinion of a few people with gray hair? Our European and Canadian colleagues certainly don’t agree with [the policies] and might take issue with our sanctimonious lecturing that’s not supported by any data whatsoever.”
He pointed to a 2011 study that examined 250 cardiac procedures that were broadcast live to 32 scientific meetings. Researchers found that “there is no evidence for an excess perioperative risk for patients operated under the conditions of live broadcasting” (Eur J Cardiothorac Surg. 2011;40[2]:367-71).
A member of the audience at the AATS session pointed out that the study may be misleading because only top surgeons may be willing to perform procedures live on television. Dr. Bavaria responded by noting that the outcomes of surgeries performed on live video were not worse.
Skeptics have also expressed concern about the potential for sensationalism in live broadcasts and the drive for participants to make a splash: “the demands of ‘the performance,’ including questions and discussion with the audience, may divert the surgeon’s attention and produce an inferior outcome,” wrote three physicians in 2011 (J Surg Educ. 2011 Jan-Feb; 68[1]:58-61).
The trio also expressed worry about safety risks posed by extra equipment and extra people in the operating room during a live broadcast. However, Dr. Bavaria said the crowded conditions of an operation observed in person – instead of via video – could be worse: “You don’t have a sterile environment, you have people hanging around all over. A moderated live session could be better for the surgeon and the patient, rather than having a bunch of people in the room.”
Dr. Bavaria was also asked why surgeries couldn’t be recorded for airing later instead of being broadcast live, as this approach “takes you out of the nexus of having two masters, the patient and the audience.” In response, Dr. Bavaria said editing takes extra time in order to capture the nuances of the live procedure.
Dr. Bavaria reports no relevant disclosures.
Peter Angelos, MD, FACS, is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago. Dr. Angelos has no disclosures.
Peter Angelos, MD, FACS, is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago. Dr. Angelos has no disclosures.
Peter Angelos, MD, FACS, is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, chief of endocrine surgery, and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago. Dr. Angelos has no disclosures.
SAN DIEGO – Two thoracic societies are being challenged to review their rejection of at medical meetings.
The American Association for Thoracic Surgery and Society of Thoracic Surgeons “should modify their stance on live surgery as an educational tool like almost all of their sister organizations,” said Joseph E. Bavaria, MD, FACS, of the University of Pennsylvania, Philadelphia. “Presently, it is effectively a ban on the practice. But there are no data to suggest that it does harm to patients if done with proper constraints.”
Live broadcasts of surgeries at medical meetings are both common and controversial. Dr. Bavaria listed numerous recent thoracic meetings in Europe and Canada that featured live broadcasts. But, he noted, the AATS and STS are not supportive of the trend.
In a policy amended in 2017, the AATS states, among other things, that “national and international cardiothoracic societies should consider prohibiting live surgery broadcasts to large audiences at their annual meetings.” The STS policy, amended in 2016, is nearly identical. However, it adds language specifying that “violation of these guidelines may lead to disciplinary action by the Society.”
Both the AATS and STS policies state that surgeons should not take part in live broadcasts of operations that are intended for the public. And both policies say “generally, recorded broadcasts, either edited or unedited, are preferable to live surgery broadcasts because recordings intended for later broadcast pose fewer risks of harm to patients.”
The policies don’t elaborate on how a live broadcast of an operation might be more harmful than one aired at a later time. “Where are the data to support this statement?” Dr. Bavaria asked. “Is this what we call the expert opinion of a few people with gray hair? Our European and Canadian colleagues certainly don’t agree with [the policies] and might take issue with our sanctimonious lecturing that’s not supported by any data whatsoever.”
He pointed to a 2011 study that examined 250 cardiac procedures that were broadcast live to 32 scientific meetings. Researchers found that “there is no evidence for an excess perioperative risk for patients operated under the conditions of live broadcasting” (Eur J Cardiothorac Surg. 2011;40[2]:367-71).
A member of the audience at the AATS session pointed out that the study may be misleading because only top surgeons may be willing to perform procedures live on television. Dr. Bavaria responded by noting that the outcomes of surgeries performed on live video were not worse.
Skeptics have also expressed concern about the potential for sensationalism in live broadcasts and the drive for participants to make a splash: “the demands of ‘the performance,’ including questions and discussion with the audience, may divert the surgeon’s attention and produce an inferior outcome,” wrote three physicians in 2011 (J Surg Educ. 2011 Jan-Feb; 68[1]:58-61).
The trio also expressed worry about safety risks posed by extra equipment and extra people in the operating room during a live broadcast. However, Dr. Bavaria said the crowded conditions of an operation observed in person – instead of via video – could be worse: “You don’t have a sterile environment, you have people hanging around all over. A moderated live session could be better for the surgeon and the patient, rather than having a bunch of people in the room.”
Dr. Bavaria was also asked why surgeries couldn’t be recorded for airing later instead of being broadcast live, as this approach “takes you out of the nexus of having two masters, the patient and the audience.” In response, Dr. Bavaria said editing takes extra time in order to capture the nuances of the live procedure.
Dr. Bavaria reports no relevant disclosures.
SAN DIEGO – Two thoracic societies are being challenged to review their rejection of at medical meetings.
The American Association for Thoracic Surgery and Society of Thoracic Surgeons “should modify their stance on live surgery as an educational tool like almost all of their sister organizations,” said Joseph E. Bavaria, MD, FACS, of the University of Pennsylvania, Philadelphia. “Presently, it is effectively a ban on the practice. But there are no data to suggest that it does harm to patients if done with proper constraints.”
Live broadcasts of surgeries at medical meetings are both common and controversial. Dr. Bavaria listed numerous recent thoracic meetings in Europe and Canada that featured live broadcasts. But, he noted, the AATS and STS are not supportive of the trend.
In a policy amended in 2017, the AATS states, among other things, that “national and international cardiothoracic societies should consider prohibiting live surgery broadcasts to large audiences at their annual meetings.” The STS policy, amended in 2016, is nearly identical. However, it adds language specifying that “violation of these guidelines may lead to disciplinary action by the Society.”
Both the AATS and STS policies state that surgeons should not take part in live broadcasts of operations that are intended for the public. And both policies say “generally, recorded broadcasts, either edited or unedited, are preferable to live surgery broadcasts because recordings intended for later broadcast pose fewer risks of harm to patients.”
The policies don’t elaborate on how a live broadcast of an operation might be more harmful than one aired at a later time. “Where are the data to support this statement?” Dr. Bavaria asked. “Is this what we call the expert opinion of a few people with gray hair? Our European and Canadian colleagues certainly don’t agree with [the policies] and might take issue with our sanctimonious lecturing that’s not supported by any data whatsoever.”
He pointed to a 2011 study that examined 250 cardiac procedures that were broadcast live to 32 scientific meetings. Researchers found that “there is no evidence for an excess perioperative risk for patients operated under the conditions of live broadcasting” (Eur J Cardiothorac Surg. 2011;40[2]:367-71).
A member of the audience at the AATS session pointed out that the study may be misleading because only top surgeons may be willing to perform procedures live on television. Dr. Bavaria responded by noting that the outcomes of surgeries performed on live video were not worse.
Skeptics have also expressed concern about the potential for sensationalism in live broadcasts and the drive for participants to make a splash: “the demands of ‘the performance,’ including questions and discussion with the audience, may divert the surgeon’s attention and produce an inferior outcome,” wrote three physicians in 2011 (J Surg Educ. 2011 Jan-Feb; 68[1]:58-61).
The trio also expressed worry about safety risks posed by extra equipment and extra people in the operating room during a live broadcast. However, Dr. Bavaria said the crowded conditions of an operation observed in person – instead of via video – could be worse: “You don’t have a sterile environment, you have people hanging around all over. A moderated live session could be better for the surgeon and the patient, rather than having a bunch of people in the room.”
Dr. Bavaria was also asked why surgeries couldn’t be recorded for airing later instead of being broadcast live, as this approach “takes you out of the nexus of having two masters, the patient and the audience.” In response, Dr. Bavaria said editing takes extra time in order to capture the nuances of the live procedure.
Dr. Bavaria reports no relevant disclosures.
REPORTING FROM AATS
CMSC looks to increase advocacy efforts to address looming concerns
As patients with multiple sclerosis and their caregivers face various challenges in the American health care system, the Consortium of Multiple Sclerosis Centers (CMSC) is re-energizing its focus on advocacy. The 2018 annual meeting in Nashville, Tenn., will feature programming designed to teach MS professionals and researchers how to speak up and let their voices be heard.
“CMSC has re-engaged in advocacy, in a more focused and energized way, because of mounting concerns that there is inadequate advocacy pressure on some of the critical issues negatively impacting the quality and comprehensive nature of MS care required of people living with MS,” said Lisa Taylor Skutnik, a physical therapist and chief operating officer of the CMSC. “Both people living with MS and the clinicians dedicated to treating them are increasingly frustrated and powerless in attempts to facilitate the right care and resources for people living with MS. Our members are facing significant barriers and obstacles to ensure timely and seamless comprehensive care.”
The development of quality measures in MS is also a “huge concern,” she said, referring to the federal government’s efforts to develop new ways to measure whether health professionals are providing high-quality care. Physicians have expressed widespread concern about the measures, which are being linked to reimbursement from Medicare and Medicaid.
Among the highlights of the CMSC meeting will be an educational session that “will focus on the available resources within the MS community for MS professionals and researchers to access advocacy efforts and get involved,” Ms. Skutnik said.
Another educational session “will focus on helping MS clinicians and researchers to understand all of the various stakeholders and their respective perspectives related to access to comprehensive care services for those living with MS,” such as pharmacy benefit managers and insurers, she said.
As patients with multiple sclerosis and their caregivers face various challenges in the American health care system, the Consortium of Multiple Sclerosis Centers (CMSC) is re-energizing its focus on advocacy. The 2018 annual meeting in Nashville, Tenn., will feature programming designed to teach MS professionals and researchers how to speak up and let their voices be heard.
“CMSC has re-engaged in advocacy, in a more focused and energized way, because of mounting concerns that there is inadequate advocacy pressure on some of the critical issues negatively impacting the quality and comprehensive nature of MS care required of people living with MS,” said Lisa Taylor Skutnik, a physical therapist and chief operating officer of the CMSC. “Both people living with MS and the clinicians dedicated to treating them are increasingly frustrated and powerless in attempts to facilitate the right care and resources for people living with MS. Our members are facing significant barriers and obstacles to ensure timely and seamless comprehensive care.”
The development of quality measures in MS is also a “huge concern,” she said, referring to the federal government’s efforts to develop new ways to measure whether health professionals are providing high-quality care. Physicians have expressed widespread concern about the measures, which are being linked to reimbursement from Medicare and Medicaid.
Among the highlights of the CMSC meeting will be an educational session that “will focus on the available resources within the MS community for MS professionals and researchers to access advocacy efforts and get involved,” Ms. Skutnik said.
Another educational session “will focus on helping MS clinicians and researchers to understand all of the various stakeholders and their respective perspectives related to access to comprehensive care services for those living with MS,” such as pharmacy benefit managers and insurers, she said.
As patients with multiple sclerosis and their caregivers face various challenges in the American health care system, the Consortium of Multiple Sclerosis Centers (CMSC) is re-energizing its focus on advocacy. The 2018 annual meeting in Nashville, Tenn., will feature programming designed to teach MS professionals and researchers how to speak up and let their voices be heard.
“CMSC has re-engaged in advocacy, in a more focused and energized way, because of mounting concerns that there is inadequate advocacy pressure on some of the critical issues negatively impacting the quality and comprehensive nature of MS care required of people living with MS,” said Lisa Taylor Skutnik, a physical therapist and chief operating officer of the CMSC. “Both people living with MS and the clinicians dedicated to treating them are increasingly frustrated and powerless in attempts to facilitate the right care and resources for people living with MS. Our members are facing significant barriers and obstacles to ensure timely and seamless comprehensive care.”
The development of quality measures in MS is also a “huge concern,” she said, referring to the federal government’s efforts to develop new ways to measure whether health professionals are providing high-quality care. Physicians have expressed widespread concern about the measures, which are being linked to reimbursement from Medicare and Medicaid.
Among the highlights of the CMSC meeting will be an educational session that “will focus on the available resources within the MS community for MS professionals and researchers to access advocacy efforts and get involved,” Ms. Skutnik said.
Another educational session “will focus on helping MS clinicians and researchers to understand all of the various stakeholders and their respective perspectives related to access to comprehensive care services for those living with MS,” such as pharmacy benefit managers and insurers, she said.
Rehabilitation in MS is hot topic at CMSC 2018
This year’s annual meeting of the Consortium of Multiple Sclerosis Centers in Nashville, Tenn., will feature an intense focus on rehabilitation in MS. The topic is often a priority for patients but not necessarily at top of mind for health care providers, said rehabilitation therapist Patty Bobryk, secretary of the CMSC.
“This year, some of the Rehab Track topics include addressing respiratory issues in MS, exploring the impact of visual impairments on rehab, and recommending the proper orthotics, as well as discussing treatments that focus on mind-body understanding,” said Ms. Bobryk of MS Comprehensive Care Center of Central Florida, Orlando. She serves as cochair of the International Organization of MS Rehabilitation Therapists.
Rehabilitation in MS is a controversial topic. Two years ago, the CMSC endorsed a statement criticizing a 2015 report by the American Academy of Neurology that found limited evidence supporting MS rehabilitation (Neurology. 2015 Nov 24;85[21]:1896-903). The statement, also supported by the International Organization of MS Nurses and International Organization of MS Rehabilitation Therapists, declared that the AAN report “presents an incomplete review of the evidence published” (Neurol Clin Pract. 2016 Dec;6[6]:475-9).
However, the statement acknowledged that “larger studies with better research methodologies and higher-quality evidence are needed in rehabilitation.”
More recently, a 2017 systematic review of systematic reviews of rehabilitation in MS found that “strong” evidence only exists “for physical therapy for improved activity and participation, and for exercise-based educational programs for the reduction of patient-reported fatigue.” The review of reviews also found there’s “ ‘moderate’ evidence for multidisciplinary rehabilitation for longer-term gains at the levels of activity (disability) and participation, for cognitive-behavior therapy for the treatment of depression, and for information-provision interventions for improved patient knowledge” (Arch Phys Med Rehabil. 2017 Feb;98[2]:353-67).
In an interview, Ms. Bobryk said the MS rehabilitation community is evolving toward “a better understanding of neuroplasticity and the impact that rehab can have on maintaining and improving functional skills.”
In addition, she said, “more emphasis is being placed on early intervention and preventing the secondary effects of the disease versus providing only compensatory strategies.”
Highlights of this year’s rehab sessions at the CMSC conference include a 3-hour course on imbalance in MS that will “provide an intensive review of the anatomy of the balance system and educate the audience on evaluation and treatment interventions specific to retraining the balance system,” Ms. Bobryk said.
Another highlight: A half-day course that will “provide the rationale for including rehabilitation in a comprehensive model of care for people with severe MS,” she said. “Unique interventions such as the use of functional electrical stimulation cycling and body weight-supported treadmill training will be discussed.”
In the big picture, “clinicians who are working in the field of MS realize the benefits of rehab, but more education is needed to spread the word to the broader scope of health care providers,” Ms. Bobryk said. “Patients are often the ones that bring up rehab to their physicians to initiate a referral.”
This year’s annual meeting of the Consortium of Multiple Sclerosis Centers in Nashville, Tenn., will feature an intense focus on rehabilitation in MS. The topic is often a priority for patients but not necessarily at top of mind for health care providers, said rehabilitation therapist Patty Bobryk, secretary of the CMSC.
“This year, some of the Rehab Track topics include addressing respiratory issues in MS, exploring the impact of visual impairments on rehab, and recommending the proper orthotics, as well as discussing treatments that focus on mind-body understanding,” said Ms. Bobryk of MS Comprehensive Care Center of Central Florida, Orlando. She serves as cochair of the International Organization of MS Rehabilitation Therapists.
Rehabilitation in MS is a controversial topic. Two years ago, the CMSC endorsed a statement criticizing a 2015 report by the American Academy of Neurology that found limited evidence supporting MS rehabilitation (Neurology. 2015 Nov 24;85[21]:1896-903). The statement, also supported by the International Organization of MS Nurses and International Organization of MS Rehabilitation Therapists, declared that the AAN report “presents an incomplete review of the evidence published” (Neurol Clin Pract. 2016 Dec;6[6]:475-9).
However, the statement acknowledged that “larger studies with better research methodologies and higher-quality evidence are needed in rehabilitation.”
More recently, a 2017 systematic review of systematic reviews of rehabilitation in MS found that “strong” evidence only exists “for physical therapy for improved activity and participation, and for exercise-based educational programs for the reduction of patient-reported fatigue.” The review of reviews also found there’s “ ‘moderate’ evidence for multidisciplinary rehabilitation for longer-term gains at the levels of activity (disability) and participation, for cognitive-behavior therapy for the treatment of depression, and for information-provision interventions for improved patient knowledge” (Arch Phys Med Rehabil. 2017 Feb;98[2]:353-67).
In an interview, Ms. Bobryk said the MS rehabilitation community is evolving toward “a better understanding of neuroplasticity and the impact that rehab can have on maintaining and improving functional skills.”
In addition, she said, “more emphasis is being placed on early intervention and preventing the secondary effects of the disease versus providing only compensatory strategies.”
Highlights of this year’s rehab sessions at the CMSC conference include a 3-hour course on imbalance in MS that will “provide an intensive review of the anatomy of the balance system and educate the audience on evaluation and treatment interventions specific to retraining the balance system,” Ms. Bobryk said.
Another highlight: A half-day course that will “provide the rationale for including rehabilitation in a comprehensive model of care for people with severe MS,” she said. “Unique interventions such as the use of functional electrical stimulation cycling and body weight-supported treadmill training will be discussed.”
In the big picture, “clinicians who are working in the field of MS realize the benefits of rehab, but more education is needed to spread the word to the broader scope of health care providers,” Ms. Bobryk said. “Patients are often the ones that bring up rehab to their physicians to initiate a referral.”
This year’s annual meeting of the Consortium of Multiple Sclerosis Centers in Nashville, Tenn., will feature an intense focus on rehabilitation in MS. The topic is often a priority for patients but not necessarily at top of mind for health care providers, said rehabilitation therapist Patty Bobryk, secretary of the CMSC.
“This year, some of the Rehab Track topics include addressing respiratory issues in MS, exploring the impact of visual impairments on rehab, and recommending the proper orthotics, as well as discussing treatments that focus on mind-body understanding,” said Ms. Bobryk of MS Comprehensive Care Center of Central Florida, Orlando. She serves as cochair of the International Organization of MS Rehabilitation Therapists.
Rehabilitation in MS is a controversial topic. Two years ago, the CMSC endorsed a statement criticizing a 2015 report by the American Academy of Neurology that found limited evidence supporting MS rehabilitation (Neurology. 2015 Nov 24;85[21]:1896-903). The statement, also supported by the International Organization of MS Nurses and International Organization of MS Rehabilitation Therapists, declared that the AAN report “presents an incomplete review of the evidence published” (Neurol Clin Pract. 2016 Dec;6[6]:475-9).
However, the statement acknowledged that “larger studies with better research methodologies and higher-quality evidence are needed in rehabilitation.”
More recently, a 2017 systematic review of systematic reviews of rehabilitation in MS found that “strong” evidence only exists “for physical therapy for improved activity and participation, and for exercise-based educational programs for the reduction of patient-reported fatigue.” The review of reviews also found there’s “ ‘moderate’ evidence for multidisciplinary rehabilitation for longer-term gains at the levels of activity (disability) and participation, for cognitive-behavior therapy for the treatment of depression, and for information-provision interventions for improved patient knowledge” (Arch Phys Med Rehabil. 2017 Feb;98[2]:353-67).
In an interview, Ms. Bobryk said the MS rehabilitation community is evolving toward “a better understanding of neuroplasticity and the impact that rehab can have on maintaining and improving functional skills.”
In addition, she said, “more emphasis is being placed on early intervention and preventing the secondary effects of the disease versus providing only compensatory strategies.”
Highlights of this year’s rehab sessions at the CMSC conference include a 3-hour course on imbalance in MS that will “provide an intensive review of the anatomy of the balance system and educate the audience on evaluation and treatment interventions specific to retraining the balance system,” Ms. Bobryk said.
Another highlight: A half-day course that will “provide the rationale for including rehabilitation in a comprehensive model of care for people with severe MS,” she said. “Unique interventions such as the use of functional electrical stimulation cycling and body weight-supported treadmill training will be discussed.”
In the big picture, “clinicians who are working in the field of MS realize the benefits of rehab, but more education is needed to spread the word to the broader scope of health care providers,” Ms. Bobryk said. “Patients are often the ones that bring up rehab to their physicians to initiate a referral.”