Sharon Worcester

CHARLESTON, S.C. – Women with pelvic organ prolapse symptoms are more likely to favor treatment that allows for uterine preservation than treatment involving hysterectomy, according to findings from a Fellow’s Pelvic Research Network study.

Of 213 women who participated in the multicenter cross-sectional study, 36% said they would prefer uterine preservation and 20% said they would prefer hysterectomy in a scenario in which outcomes were equal, Dr. Nicole. Korbly reported at the annual meeting of the Society of Gynecologic Surgeons.

The remaining 44% had no strong preference, said Dr. Korbly of the Women and Infants’ Hospital of Rhode Island and Brown University, both in Providence, R.I.

"In a scenario in which uterine preservation was superior, the proportion of women preferring uterine preservation increased from 36% to 44%; 11% preferred hysterectomy," she said.

In a scenario in which hysterectomy was superior, the proportion preferring hysterectomy increased from 20% to 36%. Of note, in this scenario, 21% of women still preferred uterine preservation, despite its inferior efficacy, she said.

Responses in some cases differed by geographic region. For example, in the scenarios in which outcomes would be equal and in which uterine preservation would be superior, those living in the West and Northeast regions of the United States were more likely than those in the South and Midwest regions to prefer uterine preservation. The responses did not differ significantly by region in the scenario in which hysterectomy was superior.

On logistic regression analysis, those living in the South had a lower odds of preferring uterine preservation compared with those living in the Northeast (odds ratio, 0.2), Dr. Korbly noted.

Also, women with at least some college education and those who said they considered the uterus important for a sense of self had increased odds of preferring uterine preservation (OR, 3.37 and 26.3, respectively). Age, race, and ethnicity, however, were not significant predictors.

Women included in the study were patients with a mean age of 59 years who presented with prolapse symptoms at one of nine participating centers between May 2011 and October 2012. They completed a 35-item questionnaire designed to assess uterine preservation and hysterectomy preference, as well as attitudes about the potential benefits and risks of uterine preservation and knowledge about pelvic organ prolapse.

The findings are timely, given a recent increased interest in prolapse treatment options that allow for uterine preservation, Dr. Korbly said, explaining that because long-term efficacy of these treatment methods remains unclear, patient preference remains a particularly important consideration when determining the best treatment approach.

Few studies have looked at patient preference regarding uterine preservation, she said at the meeting, jointly sponsored by the American College of Surgeons.

"Well-designed clinical trials comparing uterine-preserving versus hysterectomy-based techniques for prolapse are needed to improve the decision-making process and to balance patients’ values and preferences with evidence-based treatment outcomes data," she concluded.

Dr. Korbly reported having no relevant financial disclosures.

obnews@frontlinemedcom.com

CHARLESTON, S.C. – Women with pelvic organ prolapse symptoms are more likely to favor treatment that allows for uterine preservation than treatment involving hysterectomy, according to findings from a Fellow’s Pelvic Research Network study.

Of 213 women who participated in the multicenter cross-sectional study, 36% said they would prefer uterine preservation and 20% said they would prefer hysterectomy in a scenario in which outcomes were equal, Dr. Nicole. Korbly reported at the annual meeting of the Society of Gynecologic Surgeons.

The remaining 44% had no strong preference, said Dr. Korbly of the Women and Infants’ Hospital of Rhode Island and Brown University, both in Providence, R.I.

"In a scenario in which uterine preservation was superior, the proportion of women preferring uterine preservation increased from 36% to 44%; 11% preferred hysterectomy," she said.

In a scenario in which hysterectomy was superior, the proportion preferring hysterectomy increased from 20% to 36%. Of note, in this scenario, 21% of women still preferred uterine preservation, despite its inferior efficacy, she said.

Responses in some cases differed by geographic region. For example, in the scenarios in which outcomes would be equal and in which uterine preservation would be superior, those living in the West and Northeast regions of the United States were more likely than those in the South and Midwest regions to prefer uterine preservation. The responses did not differ significantly by region in the scenario in which hysterectomy was superior.

On logistic regression analysis, those living in the South had a lower odds of preferring uterine preservation compared with those living in the Northeast (odds ratio, 0.2), Dr. Korbly noted.

Also, women with at least some college education and those who said they considered the uterus important for a sense of self had increased odds of preferring uterine preservation (OR, 3.37 and 26.3, respectively). Age, race, and ethnicity, however, were not significant predictors.

Women included in the study were patients with a mean age of 59 years who presented with prolapse symptoms at one of nine participating centers between May 2011 and October 2012. They completed a 35-item questionnaire designed to assess uterine preservation and hysterectomy preference, as well as attitudes about the potential benefits and risks of uterine preservation and knowledge about pelvic organ prolapse.

The findings are timely, given a recent increased interest in prolapse treatment options that allow for uterine preservation, Dr. Korbly said, explaining that because long-term efficacy of these treatment methods remains unclear, patient preference remains a particularly important consideration when determining the best treatment approach.

Few studies have looked at patient preference regarding uterine preservation, she said at the meeting, jointly sponsored by the American College of Surgeons.

"Well-designed clinical trials comparing uterine-preserving versus hysterectomy-based techniques for prolapse are needed to improve the decision-making process and to balance patients’ values and preferences with evidence-based treatment outcomes data," she concluded.

Dr. Korbly reported having no relevant financial disclosures.

obnews@frontlinemedcom.com

CHARLESTON, S.C. – Women with pelvic organ prolapse symptoms are more likely to favor treatment that allows for uterine preservation than treatment involving hysterectomy, according to findings from a Fellow’s Pelvic Research Network study.

Of 213 women who participated in the multicenter cross-sectional study, 36% said they would prefer uterine preservation and 20% said they would prefer hysterectomy in a scenario in which outcomes were equal, Dr. Nicole. Korbly reported at the annual meeting of the Society of Gynecologic Surgeons.

The remaining 44% had no strong preference, said Dr. Korbly of the Women and Infants’ Hospital of Rhode Island and Brown University, both in Providence, R.I.

"In a scenario in which uterine preservation was superior, the proportion of women preferring uterine preservation increased from 36% to 44%; 11% preferred hysterectomy," she said.

In a scenario in which hysterectomy was superior, the proportion preferring hysterectomy increased from 20% to 36%. Of note, in this scenario, 21% of women still preferred uterine preservation, despite its inferior efficacy, she said.

Responses in some cases differed by geographic region. For example, in the scenarios in which outcomes would be equal and in which uterine preservation would be superior, those living in the West and Northeast regions of the United States were more likely than those in the South and Midwest regions to prefer uterine preservation. The responses did not differ significantly by region in the scenario in which hysterectomy was superior.

On logistic regression analysis, those living in the South had a lower odds of preferring uterine preservation compared with those living in the Northeast (odds ratio, 0.2), Dr. Korbly noted.

Also, women with at least some college education and those who said they considered the uterus important for a sense of self had increased odds of preferring uterine preservation (OR, 3.37 and 26.3, respectively). Age, race, and ethnicity, however, were not significant predictors.

Women included in the study were patients with a mean age of 59 years who presented with prolapse symptoms at one of nine participating centers between May 2011 and October 2012. They completed a 35-item questionnaire designed to assess uterine preservation and hysterectomy preference, as well as attitudes about the potential benefits and risks of uterine preservation and knowledge about pelvic organ prolapse.

The findings are timely, given a recent increased interest in prolapse treatment options that allow for uterine preservation, Dr. Korbly said, explaining that because long-term efficacy of these treatment methods remains unclear, patient preference remains a particularly important consideration when determining the best treatment approach.

Few studies have looked at patient preference regarding uterine preservation, she said at the meeting, jointly sponsored by the American College of Surgeons.

"Well-designed clinical trials comparing uterine-preserving versus hysterectomy-based techniques for prolapse are needed to improve the decision-making process and to balance patients’ values and preferences with evidence-based treatment outcomes data," she concluded.

Dr. Korbly reported having no relevant financial disclosures.

obnews@frontlinemedcom.com

CHARLESTON, S.C. – Native tissue, vaginal mesh, and abdominal mesh repairs may all be viable treatment options for repeat surgery after failed pelvic organ prolapse repair when used in appropriately selected patients, findings from a retrospective study of 63 cases has shown.

Of 20 patients with a failed initial vaginal mesh procedure, 1 underwent repeat vaginal mesh placement in a different compartment, 10 underwent sacrocolpopexy, and 9 had a native tissue procedure for their repeat surgery. Of 43 patients with a failed initial native tissue procedure, 2 underwent a vaginal mesh repair; 33, sacrocolpopexy; and 8, a repeat native tissue procedure for their repeat surgery, Dr. Lee A. Richter reported at the annual meeting of the Society of Gynecologic Surgeons.

All patients achieved objective success. Mean Pelvic Organ Prolapse Quantification (POP-Q) scores were significantly improved for all patients following their repeat surgery, regardless of the type of initial repair and the type of repeat surgery, and none of the patients required additional surgery or pessary use during follow-up, said Dr. Richter, a fourth-year urology resident at Medstar Washington (D.C.) Hospital Center.

At 1-year follow-up, mean POP-Q measurements at anterior point B improved by 2.18 and 2.25 points in the patients treated initially with native tissue and vaginal mesh, respectively (despite significantly worse preoperative anterior prolapse in the native tissue group). Measurements at posterior point B improved by 2.63 and 2.35 points in the groups, respectively; and measurements at the cervix or vaginal cuff were improved by 8.10 and 7.65 points in the groups.

No major perioperative or postoperative complications occurred.

Of note, the time to repeat surgery was 123 months for those who initially underwent native tissue repair, compared with 30 months for those who initially underwent vaginal mesh repair, Dr. Richter noted at the meeting, jointly sponsored by the American College of Surgeons.

Patients included in the study were treated between 2008 and 2011 for failed initial vaginal native tissue or vaginal mesh repair. Most (63%) were referred from outside institutions for the repeat surgery.

The findings are important because regardless of whether mesh or native tissue is used, surgery for pelvic organ prolapse is not always successful, Dr. Richter said, noting that 13% of patients require reoperation within 5 years, and 29% require reoperation at some point during their lifetime.

In this study, native tissue repair was associated with more anterior failures than vaginal mesh, but total reoperation rates were highest for vaginal mesh.

Although the majority of patients with failed initial procedures were treated with sacrocolpopexy, native tissue and vaginal mesh repairs were equally successful for reoperation.

Dr. Richter reported having no relevant financial disclosures.

CHARLESTON, S.C. – Native tissue, vaginal mesh, and abdominal mesh repairs may all be viable treatment options for repeat surgery after failed pelvic organ prolapse repair when used in appropriately selected patients, findings from a retrospective study of 63 cases has shown.

Of 20 patients with a failed initial vaginal mesh procedure, 1 underwent repeat vaginal mesh placement in a different compartment, 10 underwent sacrocolpopexy, and 9 had a native tissue procedure for their repeat surgery. Of 43 patients with a failed initial native tissue procedure, 2 underwent a vaginal mesh repair; 33, sacrocolpopexy; and 8, a repeat native tissue procedure for their repeat surgery, Dr. Lee A. Richter reported at the annual meeting of the Society of Gynecologic Surgeons.

All patients achieved objective success. Mean Pelvic Organ Prolapse Quantification (POP-Q) scores were significantly improved for all patients following their repeat surgery, regardless of the type of initial repair and the type of repeat surgery, and none of the patients required additional surgery or pessary use during follow-up, said Dr. Richter, a fourth-year urology resident at Medstar Washington (D.C.) Hospital Center.

At 1-year follow-up, mean POP-Q measurements at anterior point B improved by 2.18 and 2.25 points in the patients treated initially with native tissue and vaginal mesh, respectively (despite significantly worse preoperative anterior prolapse in the native tissue group). Measurements at posterior point B improved by 2.63 and 2.35 points in the groups, respectively; and measurements at the cervix or vaginal cuff were improved by 8.10 and 7.65 points in the groups.

No major perioperative or postoperative complications occurred.

Of note, the time to repeat surgery was 123 months for those who initially underwent native tissue repair, compared with 30 months for those who initially underwent vaginal mesh repair, Dr. Richter noted at the meeting, jointly sponsored by the American College of Surgeons.

Patients included in the study were treated between 2008 and 2011 for failed initial vaginal native tissue or vaginal mesh repair. Most (63%) were referred from outside institutions for the repeat surgery.

The findings are important because regardless of whether mesh or native tissue is used, surgery for pelvic organ prolapse is not always successful, Dr. Richter said, noting that 13% of patients require reoperation within 5 years, and 29% require reoperation at some point during their lifetime.

In this study, native tissue repair was associated with more anterior failures than vaginal mesh, but total reoperation rates were highest for vaginal mesh.

Although the majority of patients with failed initial procedures were treated with sacrocolpopexy, native tissue and vaginal mesh repairs were equally successful for reoperation.

Dr. Richter reported having no relevant financial disclosures.

CHARLESTON, S.C. – Native tissue, vaginal mesh, and abdominal mesh repairs may all be viable treatment options for repeat surgery after failed pelvic organ prolapse repair when used in appropriately selected patients, findings from a retrospective study of 63 cases has shown.

Of 20 patients with a failed initial vaginal mesh procedure, 1 underwent repeat vaginal mesh placement in a different compartment, 10 underwent sacrocolpopexy, and 9 had a native tissue procedure for their repeat surgery. Of 43 patients with a failed initial native tissue procedure, 2 underwent a vaginal mesh repair; 33, sacrocolpopexy; and 8, a repeat native tissue procedure for their repeat surgery, Dr. Lee A. Richter reported at the annual meeting of the Society of Gynecologic Surgeons.

All patients achieved objective success. Mean Pelvic Organ Prolapse Quantification (POP-Q) scores were significantly improved for all patients following their repeat surgery, regardless of the type of initial repair and the type of repeat surgery, and none of the patients required additional surgery or pessary use during follow-up, said Dr. Richter, a fourth-year urology resident at Medstar Washington (D.C.) Hospital Center.

At 1-year follow-up, mean POP-Q measurements at anterior point B improved by 2.18 and 2.25 points in the patients treated initially with native tissue and vaginal mesh, respectively (despite significantly worse preoperative anterior prolapse in the native tissue group). Measurements at posterior point B improved by 2.63 and 2.35 points in the groups, respectively; and measurements at the cervix or vaginal cuff were improved by 8.10 and 7.65 points in the groups.

No major perioperative or postoperative complications occurred.

Of note, the time to repeat surgery was 123 months for those who initially underwent native tissue repair, compared with 30 months for those who initially underwent vaginal mesh repair, Dr. Richter noted at the meeting, jointly sponsored by the American College of Surgeons.

Patients included in the study were treated between 2008 and 2011 for failed initial vaginal native tissue or vaginal mesh repair. Most (63%) were referred from outside institutions for the repeat surgery.

The findings are important because regardless of whether mesh or native tissue is used, surgery for pelvic organ prolapse is not always successful, Dr. Richter said, noting that 13% of patients require reoperation within 5 years, and 29% require reoperation at some point during their lifetime.

In this study, native tissue repair was associated with more anterior failures than vaginal mesh, but total reoperation rates were highest for vaginal mesh.

Although the majority of patients with failed initial procedures were treated with sacrocolpopexy, native tissue and vaginal mesh repairs were equally successful for reoperation.

Dr. Richter reported having no relevant financial disclosures.

CHARLESTON, S.C. – Women who desire pregnancy after undergoing robotic-assisted myomectomy – including those with known infertility prior to the procedure – may have a good chance of conceiving following the procedure, findings from a retrospective case series have shown.

Of 198 women who underwent robotic myomectomy between 2006 and 2011 and who were followed for between 1 and 6.5 years, 52% attempted pregnancy, and 71% of those had a total of 81 pregnancies. A subset of 39% of the participants had known infertility prior to myomectomy, and of those, 62% achieved a total of 52 pregnancies, Dr. Lauren Rascoff reported at the annual meeting of the Society of Gynecologic Surgeons.

Of the 81 pregnancies, 38 (47%) occurred spontaneously, including 14 in the group with preoperative infertility, and 43 (53%) were achieved using assisted reproductive technology, including 39 in the infertility group, said Dr. Rascoff of Mount Sinai Medical Center, New York.

Of 40 deliveries that had occurred by the time of Dr. Rascoff’s presentation, 31 (78%) were done at term, including 19 in the infertility group, and 9 (22%) were preterm, including 8 in the infertility group. Most (37, or 92.5%) of the women were delivered by cesarean section, including 26 in the infertility group, and 3 (7.5%) involved a normal spontaneous vaginal delivery, including 1 in the infertility group.

One pregnancy was complicated by cesarean hysterectomy secondary to a placenta accreta, but no cases of uterine rupture occurred.

Eighteen pregnancies were ongoing, and 18 resulted in spontaneous abortion, including 14 in the infertility group. The rest, except for one molar pregnancy, ended as a result of elective termination or intrauterine fetal demise.

Participants were interviewed by phone using a 27-item survey about pregnancy attempts and outcomes before and after myomectomy, and about preoperative and postoperative infertility treatments. They had a mean age of 37 years, had a mean body mass index of 24.75 kg/m², and were ethnically diverse. Parity ranged from 0 to 4.

On average, 3.3 fibroids with a mean weight of 332 g each were removed during the procedures. The mean operative time was 152 minutes.

The findings are important because the prevalence of fibroids in an unselected female population ranges from 5% to 25%, and fibroids account for 27% of uterine abnormalities in women attempting to become pregnant. The presence of fibroids is known to have adverse effects on implantation and pregnancy continuation, Dr. Rascoff said.

Although several studies have demonstrated the benefit of fibroid removal on fertility, few address pregnancy outcomes after robotic-assisted myomectomy, she noted.

The current findings are comparable to those of other series reported in the literature, she said.

Dr. Rascoff reported having no relevant financial disclosures.

obnews@frontlinemedcom.com

CHARLESTON, S.C. – Women who desire pregnancy after undergoing robotic-assisted myomectomy – including those with known infertility prior to the procedure – may have a good chance of conceiving following the procedure, findings from a retrospective case series have shown.

Of 198 women who underwent robotic myomectomy between 2006 and 2011 and who were followed for between 1 and 6.5 years, 52% attempted pregnancy, and 71% of those had a total of 81 pregnancies. A subset of 39% of the participants had known infertility prior to myomectomy, and of those, 62% achieved a total of 52 pregnancies, Dr. Lauren Rascoff reported at the annual meeting of the Society of Gynecologic Surgeons.

Of the 81 pregnancies, 38 (47%) occurred spontaneously, including 14 in the group with preoperative infertility, and 43 (53%) were achieved using assisted reproductive technology, including 39 in the infertility group, said Dr. Rascoff of Mount Sinai Medical Center, New York.

Of 40 deliveries that had occurred by the time of Dr. Rascoff’s presentation, 31 (78%) were done at term, including 19 in the infertility group, and 9 (22%) were preterm, including 8 in the infertility group. Most (37, or 92.5%) of the women were delivered by cesarean section, including 26 in the infertility group, and 3 (7.5%) involved a normal spontaneous vaginal delivery, including 1 in the infertility group.

One pregnancy was complicated by cesarean hysterectomy secondary to a placenta accreta, but no cases of uterine rupture occurred.

Eighteen pregnancies were ongoing, and 18 resulted in spontaneous abortion, including 14 in the infertility group. The rest, except for one molar pregnancy, ended as a result of elective termination or intrauterine fetal demise.

Participants were interviewed by phone using a 27-item survey about pregnancy attempts and outcomes before and after myomectomy, and about preoperative and postoperative infertility treatments. They had a mean age of 37 years, had a mean body mass index of 24.75 kg/m², and were ethnically diverse. Parity ranged from 0 to 4.

On average, 3.3 fibroids with a mean weight of 332 g each were removed during the procedures. The mean operative time was 152 minutes.

The findings are important because the prevalence of fibroids in an unselected female population ranges from 5% to 25%, and fibroids account for 27% of uterine abnormalities in women attempting to become pregnant. The presence of fibroids is known to have adverse effects on implantation and pregnancy continuation, Dr. Rascoff said.

Although several studies have demonstrated the benefit of fibroid removal on fertility, few address pregnancy outcomes after robotic-assisted myomectomy, she noted.

The current findings are comparable to those of other series reported in the literature, she said.

Dr. Rascoff reported having no relevant financial disclosures.

obnews@frontlinemedcom.com

CHARLESTON, S.C. – Women who desire pregnancy after undergoing robotic-assisted myomectomy – including those with known infertility prior to the procedure – may have a good chance of conceiving following the procedure, findings from a retrospective case series have shown.

Of 198 women who underwent robotic myomectomy between 2006 and 2011 and who were followed for between 1 and 6.5 years, 52% attempted pregnancy, and 71% of those had a total of 81 pregnancies. A subset of 39% of the participants had known infertility prior to myomectomy, and of those, 62% achieved a total of 52 pregnancies, Dr. Lauren Rascoff reported at the annual meeting of the Society of Gynecologic Surgeons.

Of the 81 pregnancies, 38 (47%) occurred spontaneously, including 14 in the group with preoperative infertility, and 43 (53%) were achieved using assisted reproductive technology, including 39 in the infertility group, said Dr. Rascoff of Mount Sinai Medical Center, New York.

Of 40 deliveries that had occurred by the time of Dr. Rascoff’s presentation, 31 (78%) were done at term, including 19 in the infertility group, and 9 (22%) were preterm, including 8 in the infertility group. Most (37, or 92.5%) of the women were delivered by cesarean section, including 26 in the infertility group, and 3 (7.5%) involved a normal spontaneous vaginal delivery, including 1 in the infertility group.

One pregnancy was complicated by cesarean hysterectomy secondary to a placenta accreta, but no cases of uterine rupture occurred.

Eighteen pregnancies were ongoing, and 18 resulted in spontaneous abortion, including 14 in the infertility group. The rest, except for one molar pregnancy, ended as a result of elective termination or intrauterine fetal demise.

Participants were interviewed by phone using a 27-item survey about pregnancy attempts and outcomes before and after myomectomy, and about preoperative and postoperative infertility treatments. They had a mean age of 37 years, had a mean body mass index of 24.75 kg/m², and were ethnically diverse. Parity ranged from 0 to 4.

On average, 3.3 fibroids with a mean weight of 332 g each were removed during the procedures. The mean operative time was 152 minutes.

The findings are important because the prevalence of fibroids in an unselected female population ranges from 5% to 25%, and fibroids account for 27% of uterine abnormalities in women attempting to become pregnant. The presence of fibroids is known to have adverse effects on implantation and pregnancy continuation, Dr. Rascoff said.

Although several studies have demonstrated the benefit of fibroid removal on fertility, few address pregnancy outcomes after robotic-assisted myomectomy, she noted.

The current findings are comparable to those of other series reported in the literature, she said.

Dr. Rascoff reported having no relevant financial disclosures.

obnews@frontlinemedcom.com

LOS ANGELES – Antidepressant medications have a robust effect in older patients with a long duration of major depressive disorder that is at least moderately severe, according to findings from a meta-analysis of data from seven trials.

Since patients with a long duration of disease are also at increased risk for recurrence, and since the efficacy of antidepressant medications for relapse prevention is well established, antidepressant treatment should be considered in these patients, Dr. J. Craig Nelson said at the annual meeting of the American Association for Geriatric Psychiatry.

©Dundanim/shutterstock.com

Several prior studies have demonstrated that all classes of antidepressants generally are better than placebo for the treatment of depression in older adults, and that they have similar effectiveness, but the effects are modest, said Dr. Nelson, a professor of psychiatry at the University of California, San Francisco.

For example, in a 2008 meta-analysis of data from 10 studies that included adults aged 60 years and older with major depressive disorder, the response rates in the antidepressant and placebo groups were 44.4% vs. 34.7%, respectively (odds ratio, 1.40), and the remission rates were 34.6% vs. 26.5%, respectively (OR, 1.27), he said (Am. J. Geriatr. Psychiatry 2008;16:558-67).

The findings raised the question of whether moderators associated with a more robust response could be identified, he said, noting that several open studies have suggested that those with high levels of anxiety have lower responses to drug treatment, and several other moderators, such as disease severity and recurrent depression, appear to predict worse outcomes.

To look more closely at such moderators, Dr. Nelson and his colleagues revisited the 10 studies included in their 2008 meta-analysis, and obtained trial-level data from 8 of the studies for which complete information was available. They found no difference in outcomes between anxious and nonanxious depressed patients treated with antidepressants (Int. J. Geriatr. Psychiatry 2009;24:539-44).

The investigators decided to take an even closer look at possible moderators of response by performing a meta-analysis using patient-level data from seven of those trials for which complete information was available. These trials included 2,283 patients (mean age, 71.4 years), a mean duration of major depressive disorder of 11.8 years, and a mean baseline Hamilton Depression Rating Scale (HDRS) score of 21.5. About two-thirds (64.6%) were women, and nearly three-fourths (73.9%) had recurrent depression.

The findings, which were pending publication in the American Journal of Psychiatry at the time of Dr. Nelson’s presentation, showed significant linearity for the relationship between duration of illness and response in the placebo group, but not in the drug group (z scores, –3.81 and –0.92, respectively), and baseline depression severity was significantly associated with response in the drug group but not in the placebo group (z scores, 3.40 and –0.40, respectively).

On multivariate analysis, the strongest independent predictor of response was duration of illness, followed by severity of depression. An interaction between severity and duration also was noted.

"It turned out that among patients with longer duration of depression, severity did have a more significant relationship with drug-placebo difference. Among patients with a long duration of depression, patients with severity of at least moderate intensity – a Hamilton score of 21 or greater – showed the greatest drug effects," Dr. Nelson said.

Among patients with depression duration of less than 10 years and an HDRS score of less than 21, the response rates were 46.3% and 41.5% in the drug treatment vs. placebo groups, respectively, with a number needed to treat of 21; among patients with depression duration greater than 10 years and an HDRS score of 21 or greater, the response rates were 58% and 31.4% in the groups, respectively, with a number needed to treat of 4.

Of note, while disease duration and severity appear to identify patients who are more drug responsive, they also identify patients who have a pretty good response to placebo, he added.

That is, patients with a shorter duration of depression and less severe disease tend to have a good placebo response. Such a response is seen in 40%-50% of such patients.

"But of course, this is not just placebo. These are patients who are being seen, usually, on a weekly basis for the first month and then maybe every other week for the remainder of the trial," he explained, noting that the clinical management remains an important aspect of care.

Given that many trials include extensive clinical management along with drug treatment, it cannot be concluded that drug treatment without such management would lead to improvement, he said.

"So is it a mistake to give these patients an antidepressant? I think the mistake is not that you give an antidepressant; the mistake may be [thinking that is] all you need to do," he said. He added: "If clinical management is really accounting for most of the change, you can’t just give an antidepressant and walk away, and not do the clinical management."

A caveat, however, is that the about 50% of patients with short-duration and late-onset depression who do not respond to placebo with clinical management will need further treatment, he said.

Dr. Nelson disclosed that he has received honoraria from Korea Otsuka International Asia Arab Co. and has served as a paid consultant or advisory board member for Bristol-Myers Squibb, Cenestra Health, and other companies. He also has received research support from the National Institute of Mental Health and the Health Resources and Services Administration.

LOS ANGELES – Antidepressant medications have a robust effect in older patients with a long duration of major depressive disorder that is at least moderately severe, according to findings from a meta-analysis of data from seven trials.

Since patients with a long duration of disease are also at increased risk for recurrence, and since the efficacy of antidepressant medications for relapse prevention is well established, antidepressant treatment should be considered in these patients, Dr. J. Craig Nelson said at the annual meeting of the American Association for Geriatric Psychiatry.

©Dundanim/shutterstock.com

Several prior studies have demonstrated that all classes of antidepressants generally are better than placebo for the treatment of depression in older adults, and that they have similar effectiveness, but the effects are modest, said Dr. Nelson, a professor of psychiatry at the University of California, San Francisco.

For example, in a 2008 meta-analysis of data from 10 studies that included adults aged 60 years and older with major depressive disorder, the response rates in the antidepressant and placebo groups were 44.4% vs. 34.7%, respectively (odds ratio, 1.40), and the remission rates were 34.6% vs. 26.5%, respectively (OR, 1.27), he said (Am. J. Geriatr. Psychiatry 2008;16:558-67).

The findings raised the question of whether moderators associated with a more robust response could be identified, he said, noting that several open studies have suggested that those with high levels of anxiety have lower responses to drug treatment, and several other moderators, such as disease severity and recurrent depression, appear to predict worse outcomes.

To look more closely at such moderators, Dr. Nelson and his colleagues revisited the 10 studies included in their 2008 meta-analysis, and obtained trial-level data from 8 of the studies for which complete information was available. They found no difference in outcomes between anxious and nonanxious depressed patients treated with antidepressants (Int. J. Geriatr. Psychiatry 2009;24:539-44).

The investigators decided to take an even closer look at possible moderators of response by performing a meta-analysis using patient-level data from seven of those trials for which complete information was available. These trials included 2,283 patients (mean age, 71.4 years), a mean duration of major depressive disorder of 11.8 years, and a mean baseline Hamilton Depression Rating Scale (HDRS) score of 21.5. About two-thirds (64.6%) were women, and nearly three-fourths (73.9%) had recurrent depression.

The findings, which were pending publication in the American Journal of Psychiatry at the time of Dr. Nelson’s presentation, showed significant linearity for the relationship between duration of illness and response in the placebo group, but not in the drug group (z scores, –3.81 and –0.92, respectively), and baseline depression severity was significantly associated with response in the drug group but not in the placebo group (z scores, 3.40 and –0.40, respectively).

On multivariate analysis, the strongest independent predictor of response was duration of illness, followed by severity of depression. An interaction between severity and duration also was noted.

"It turned out that among patients with longer duration of depression, severity did have a more significant relationship with drug-placebo difference. Among patients with a long duration of depression, patients with severity of at least moderate intensity – a Hamilton score of 21 or greater – showed the greatest drug effects," Dr. Nelson said.

Among patients with depression duration of less than 10 years and an HDRS score of less than 21, the response rates were 46.3% and 41.5% in the drug treatment vs. placebo groups, respectively, with a number needed to treat of 21; among patients with depression duration greater than 10 years and an HDRS score of 21 or greater, the response rates were 58% and 31.4% in the groups, respectively, with a number needed to treat of 4.

Of note, while disease duration and severity appear to identify patients who are more drug responsive, they also identify patients who have a pretty good response to placebo, he added.

That is, patients with a shorter duration of depression and less severe disease tend to have a good placebo response. Such a response is seen in 40%-50% of such patients.

"But of course, this is not just placebo. These are patients who are being seen, usually, on a weekly basis for the first month and then maybe every other week for the remainder of the trial," he explained, noting that the clinical management remains an important aspect of care.

Given that many trials include extensive clinical management along with drug treatment, it cannot be concluded that drug treatment without such management would lead to improvement, he said.

"So is it a mistake to give these patients an antidepressant? I think the mistake is not that you give an antidepressant; the mistake may be [thinking that is] all you need to do," he said. He added: "If clinical management is really accounting for most of the change, you can’t just give an antidepressant and walk away, and not do the clinical management."

A caveat, however, is that the about 50% of patients with short-duration and late-onset depression who do not respond to placebo with clinical management will need further treatment, he said.

Dr. Nelson disclosed that he has received honoraria from Korea Otsuka International Asia Arab Co. and has served as a paid consultant or advisory board member for Bristol-Myers Squibb, Cenestra Health, and other companies. He also has received research support from the National Institute of Mental Health and the Health Resources and Services Administration.

LOS ANGELES – Antidepressant medications have a robust effect in older patients with a long duration of major depressive disorder that is at least moderately severe, according to findings from a meta-analysis of data from seven trials.

Since patients with a long duration of disease are also at increased risk for recurrence, and since the efficacy of antidepressant medications for relapse prevention is well established, antidepressant treatment should be considered in these patients, Dr. J. Craig Nelson said at the annual meeting of the American Association for Geriatric Psychiatry.

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Several prior studies have demonstrated that all classes of antidepressants generally are better than placebo for the treatment of depression in older adults, and that they have similar effectiveness, but the effects are modest, said Dr. Nelson, a professor of psychiatry at the University of California, San Francisco.

For example, in a 2008 meta-analysis of data from 10 studies that included adults aged 60 years and older with major depressive disorder, the response rates in the antidepressant and placebo groups were 44.4% vs. 34.7%, respectively (odds ratio, 1.40), and the remission rates were 34.6% vs. 26.5%, respectively (OR, 1.27), he said (Am. J. Geriatr. Psychiatry 2008;16:558-67).

The findings raised the question of whether moderators associated with a more robust response could be identified, he said, noting that several open studies have suggested that those with high levels of anxiety have lower responses to drug treatment, and several other moderators, such as disease severity and recurrent depression, appear to predict worse outcomes.

To look more closely at such moderators, Dr. Nelson and his colleagues revisited the 10 studies included in their 2008 meta-analysis, and obtained trial-level data from 8 of the studies for which complete information was available. They found no difference in outcomes between anxious and nonanxious depressed patients treated with antidepressants (Int. J. Geriatr. Psychiatry 2009;24:539-44).

The investigators decided to take an even closer look at possible moderators of response by performing a meta-analysis using patient-level data from seven of those trials for which complete information was available. These trials included 2,283 patients (mean age, 71.4 years), a mean duration of major depressive disorder of 11.8 years, and a mean baseline Hamilton Depression Rating Scale (HDRS) score of 21.5. About two-thirds (64.6%) were women, and nearly three-fourths (73.9%) had recurrent depression.

The findings, which were pending publication in the American Journal of Psychiatry at the time of Dr. Nelson’s presentation, showed significant linearity for the relationship between duration of illness and response in the placebo group, but not in the drug group (z scores, –3.81 and –0.92, respectively), and baseline depression severity was significantly associated with response in the drug group but not in the placebo group (z scores, 3.40 and –0.40, respectively).

On multivariate analysis, the strongest independent predictor of response was duration of illness, followed by severity of depression. An interaction between severity and duration also was noted.

"It turned out that among patients with longer duration of depression, severity did have a more significant relationship with drug-placebo difference. Among patients with a long duration of depression, patients with severity of at least moderate intensity – a Hamilton score of 21 or greater – showed the greatest drug effects," Dr. Nelson said.

Among patients with depression duration of less than 10 years and an HDRS score of less than 21, the response rates were 46.3% and 41.5% in the drug treatment vs. placebo groups, respectively, with a number needed to treat of 21; among patients with depression duration greater than 10 years and an HDRS score of 21 or greater, the response rates were 58% and 31.4% in the groups, respectively, with a number needed to treat of 4.

Of note, while disease duration and severity appear to identify patients who are more drug responsive, they also identify patients who have a pretty good response to placebo, he added.

That is, patients with a shorter duration of depression and less severe disease tend to have a good placebo response. Such a response is seen in 40%-50% of such patients.

"But of course, this is not just placebo. These are patients who are being seen, usually, on a weekly basis for the first month and then maybe every other week for the remainder of the trial," he explained, noting that the clinical management remains an important aspect of care.

Given that many trials include extensive clinical management along with drug treatment, it cannot be concluded that drug treatment without such management would lead to improvement, he said.

"So is it a mistake to give these patients an antidepressant? I think the mistake is not that you give an antidepressant; the mistake may be [thinking that is] all you need to do," he said. He added: "If clinical management is really accounting for most of the change, you can’t just give an antidepressant and walk away, and not do the clinical management."

A caveat, however, is that the about 50% of patients with short-duration and late-onset depression who do not respond to placebo with clinical management will need further treatment, he said.

Dr. Nelson disclosed that he has received honoraria from Korea Otsuka International Asia Arab Co. and has served as a paid consultant or advisory board member for Bristol-Myers Squibb, Cenestra Health, and other companies. He also has received research support from the National Institute of Mental Health and the Health Resources and Services Administration.

CHARLESTON, S.C. – Most simple vesicovaginal fistulae are initially managed by surgery, which is successful in the majority of cases, according to a multicenter review from the Fellows’ Pelvic Research Network.

Conversely, most of those initially managed conservatively by catheter drainage fail to resolve.

Of 226 patients with vesicovaginal fistulae (VVF) included in the review, 166 were managed surgically at the outset, and 77.5% of these resolved with one surgery. Of 37 who did not resolve after initial surgery, 32 underwent a second surgery; 56% of these resolved, Dr. Susan H. Oakley reported at the annual meeting of the Society of Gynecologic Surgeons.

Of the 60 patients who were managed conservatively, only 12% resolved during a median duration of catheterization of 35 days. The 53 who did not resolve went on to have surgery; the majority of these patients resolved. The overall success rate in the study was 83% in the 219 who underwent surgery, said Dr. Oakley of Good Samaritan Hospital, Cincinnati.

The patients (mean age, 49.5 years) were treated for VVF at 1 of 12 participating academic medical centers between July 2006 and June 2011. Most patients were postmenopausal (53%), nonsmokers (59.5%) and white (71%).

Of those initially managed surgically, 41% underwent vaginal repair, 23% underwent abdominal repair, and the remaining patients underwent other types of repair such as electrocautery. Of those initially managed conservatively who underwent subsequent surgery, 41% underwent vaginal repair, 53% underwent abdominal repair, and the remaining patients underwent other types of repair.

"VVF are the most common acquired fistulae of the urinary tract, and in the United States, gynecologic surgery is often the cause. Regardless of the etiology, the physical and emotional effects on patients are profound," Dr. Oakley said, adding that because a standardized algorithm for the management of VVS is lacking, the purpose of this study was to describe practice patterns and treatment outcomes for VVF.

While conservative management is often suggested as first-line therapy, it has been unclear how often this strategy is successful, she said at the meeting, jointly sponsored by the American College of Surgeons.

Although limited by its retrospective nature and by missing data that prevented complete analysis of all of the variables of interest, the study does have several strengths, including the multicenter design and a large number of cases. The findings thus support a recommendation that early surgical management should be considered as the preferred approach to treating simple VVF, Dr. Oakley concluded.

She reported having no relevant financial disclosures.

CHARLESTON, S.C. – Most simple vesicovaginal fistulae are initially managed by surgery, which is successful in the majority of cases, according to a multicenter review from the Fellows’ Pelvic Research Network.

Conversely, most of those initially managed conservatively by catheter drainage fail to resolve.

Of 226 patients with vesicovaginal fistulae (VVF) included in the review, 166 were managed surgically at the outset, and 77.5% of these resolved with one surgery. Of 37 who did not resolve after initial surgery, 32 underwent a second surgery; 56% of these resolved, Dr. Susan H. Oakley reported at the annual meeting of the Society of Gynecologic Surgeons.

Of the 60 patients who were managed conservatively, only 12% resolved during a median duration of catheterization of 35 days. The 53 who did not resolve went on to have surgery; the majority of these patients resolved. The overall success rate in the study was 83% in the 219 who underwent surgery, said Dr. Oakley of Good Samaritan Hospital, Cincinnati.

The patients (mean age, 49.5 years) were treated for VVF at 1 of 12 participating academic medical centers between July 2006 and June 2011. Most patients were postmenopausal (53%), nonsmokers (59.5%) and white (71%).

Of those initially managed surgically, 41% underwent vaginal repair, 23% underwent abdominal repair, and the remaining patients underwent other types of repair such as electrocautery. Of those initially managed conservatively who underwent subsequent surgery, 41% underwent vaginal repair, 53% underwent abdominal repair, and the remaining patients underwent other types of repair.

"VVF are the most common acquired fistulae of the urinary tract, and in the United States, gynecologic surgery is often the cause. Regardless of the etiology, the physical and emotional effects on patients are profound," Dr. Oakley said, adding that because a standardized algorithm for the management of VVS is lacking, the purpose of this study was to describe practice patterns and treatment outcomes for VVF.

While conservative management is often suggested as first-line therapy, it has been unclear how often this strategy is successful, she said at the meeting, jointly sponsored by the American College of Surgeons.

Although limited by its retrospective nature and by missing data that prevented complete analysis of all of the variables of interest, the study does have several strengths, including the multicenter design and a large number of cases. The findings thus support a recommendation that early surgical management should be considered as the preferred approach to treating simple VVF, Dr. Oakley concluded.

She reported having no relevant financial disclosures.

CHARLESTON, S.C. – Most simple vesicovaginal fistulae are initially managed by surgery, which is successful in the majority of cases, according to a multicenter review from the Fellows’ Pelvic Research Network.

Conversely, most of those initially managed conservatively by catheter drainage fail to resolve.

Of 226 patients with vesicovaginal fistulae (VVF) included in the review, 166 were managed surgically at the outset, and 77.5% of these resolved with one surgery. Of 37 who did not resolve after initial surgery, 32 underwent a second surgery; 56% of these resolved, Dr. Susan H. Oakley reported at the annual meeting of the Society of Gynecologic Surgeons.

Of the 60 patients who were managed conservatively, only 12% resolved during a median duration of catheterization of 35 days. The 53 who did not resolve went on to have surgery; the majority of these patients resolved. The overall success rate in the study was 83% in the 219 who underwent surgery, said Dr. Oakley of Good Samaritan Hospital, Cincinnati.

The patients (mean age, 49.5 years) were treated for VVF at 1 of 12 participating academic medical centers between July 2006 and June 2011. Most patients were postmenopausal (53%), nonsmokers (59.5%) and white (71%).

Of those initially managed surgically, 41% underwent vaginal repair, 23% underwent abdominal repair, and the remaining patients underwent other types of repair such as electrocautery. Of those initially managed conservatively who underwent subsequent surgery, 41% underwent vaginal repair, 53% underwent abdominal repair, and the remaining patients underwent other types of repair.

"VVF are the most common acquired fistulae of the urinary tract, and in the United States, gynecologic surgery is often the cause. Regardless of the etiology, the physical and emotional effects on patients are profound," Dr. Oakley said, adding that because a standardized algorithm for the management of VVS is lacking, the purpose of this study was to describe practice patterns and treatment outcomes for VVF.

While conservative management is often suggested as first-line therapy, it has been unclear how often this strategy is successful, she said at the meeting, jointly sponsored by the American College of Surgeons.

Although limited by its retrospective nature and by missing data that prevented complete analysis of all of the variables of interest, the study does have several strengths, including the multicenter design and a large number of cases. The findings thus support a recommendation that early surgical management should be considered as the preferred approach to treating simple VVF, Dr. Oakley concluded.

She reported having no relevant financial disclosures.

LOS ANGELES – Several types of psychotherapy are effective for late-life depression, studies show. However, the type of control used in those studies plays an important role in the magnitude of the effect size, findings from a systematic review and meta-analysis suggest.

The findings underscore the value of the supportive aspects of care and the importance of good clinical management in late-life depression, regardless of whether medication is used as part of treatment, Dr. Alice X. Huang said at the annual meeting of the American Association for Geriatric Psychiatry.

Several prior reviews have examined the efficacy of psychotherapy for late-life depression. In a 2005 review that included prior reviews and 17 trials, the investigators concluded that cognitive-behavioral therapy, reminiscence therapy, brief dynamic therapy, and combined medication and interpersonal therapy all are "acutely efficacious" for the treatment of major depression in ambulatory adults (Psychiatr. Clin. N. Am. 2005;28:805-20).

Authors of a 2006 review and meta-analysis that included 25 studies concluded, based on the comparable effect size of various types of psychological treatments, that all types of treatment are equally effective (Int. J. Geriatr. Psychiatry 2006;21:1139-49). Meanwhile, authors of a 2009 Cochrane Review and meta-analysis concluded that their findings were constrained by the heterogeneity of trials and the diversity of control conditions used in the various studies (Cochrane Database Syst. Rev. 2008 Jan 23;(1):CD004853).

Taken together, these studies support the use of various types of psychotherapy for late-life depression. But interestingly, no review has looked at the impact of the type of control group used in clinical trials of psychotherapy, which vary widely, including waitlist, treatment as usual, attention control, supportive therapy, and placebo, said Dr. Huang, a third-year psychiatry resident at the University of California, San Francisco.

In their own review and meta-analysis of 27 trials, including 37 psychotherapy vs. control contrasts, Dr. Huang and her colleagues found that the type of control group used in trials of psychotherapy was related to the effect size of the psychotherapy being tested. The standard mean differences (SMDs) were statistically significant between psychotherapy and waitlist control, treatment-as-usual control, attention control, and supportive therapy control, but not placebo control; the SMDs were lower for the supportive therapy, placebo control, and treatment-as-usual groups, compared with the waitlist control and attention control groups.

The findings are in line with the hypothesis that effect sizes would be larger when psychotherapy is compared with less active treatments, and smaller when it is compared with a control that includes significant clinical management, she explained.

Supportive therapy as a control, and placebo, which included extensive clinical management in the studies that were reviewed, both captured many of the elements of psychotherapy that are effective, she noted.

Studies included in the current review and meta-analysis were conducted between 1981 and 2011, and involved a total of 2,229 patients (mean age, 66-81 years). The studies included lasted anywhere from 4 to 28 weeks (median, 8 weeks). Psychotherapies included in the studies were cognitive-behavioral therapy, cognitive therapy, behavioral therapy, problem solving therapy, interpersonal therapy, brief dynamic therapy, bibliotherapy, reminiscence therapy, and variants of these treatments, she said.

The findings suggest that many nonspecific elements of psychotherapy, which are estimated to account for a large percentage of the effect of psychotherapy in older adults according to prior psychotherapy research, are captured by supportive psychotherapy, and this provides evidence for improved clinical management and supportive care in this population, regardless of whether a specific psychotherapy is indicated, she concluded.

Dr. Huang reported having no financial disclosures.

LOS ANGELES – Several types of psychotherapy are effective for late-life depression, studies show. However, the type of control used in those studies plays an important role in the magnitude of the effect size, findings from a systematic review and meta-analysis suggest.

The findings underscore the value of the supportive aspects of care and the importance of good clinical management in late-life depression, regardless of whether medication is used as part of treatment, Dr. Alice X. Huang said at the annual meeting of the American Association for Geriatric Psychiatry.

Several prior reviews have examined the efficacy of psychotherapy for late-life depression. In a 2005 review that included prior reviews and 17 trials, the investigators concluded that cognitive-behavioral therapy, reminiscence therapy, brief dynamic therapy, and combined medication and interpersonal therapy all are "acutely efficacious" for the treatment of major depression in ambulatory adults (Psychiatr. Clin. N. Am. 2005;28:805-20).

Authors of a 2006 review and meta-analysis that included 25 studies concluded, based on the comparable effect size of various types of psychological treatments, that all types of treatment are equally effective (Int. J. Geriatr. Psychiatry 2006;21:1139-49). Meanwhile, authors of a 2009 Cochrane Review and meta-analysis concluded that their findings were constrained by the heterogeneity of trials and the diversity of control conditions used in the various studies (Cochrane Database Syst. Rev. 2008 Jan 23;(1):CD004853).

Taken together, these studies support the use of various types of psychotherapy for late-life depression. But interestingly, no review has looked at the impact of the type of control group used in clinical trials of psychotherapy, which vary widely, including waitlist, treatment as usual, attention control, supportive therapy, and placebo, said Dr. Huang, a third-year psychiatry resident at the University of California, San Francisco.

In their own review and meta-analysis of 27 trials, including 37 psychotherapy vs. control contrasts, Dr. Huang and her colleagues found that the type of control group used in trials of psychotherapy was related to the effect size of the psychotherapy being tested. The standard mean differences (SMDs) were statistically significant between psychotherapy and waitlist control, treatment-as-usual control, attention control, and supportive therapy control, but not placebo control; the SMDs were lower for the supportive therapy, placebo control, and treatment-as-usual groups, compared with the waitlist control and attention control groups.

The findings are in line with the hypothesis that effect sizes would be larger when psychotherapy is compared with less active treatments, and smaller when it is compared with a control that includes significant clinical management, she explained.

Supportive therapy as a control, and placebo, which included extensive clinical management in the studies that were reviewed, both captured many of the elements of psychotherapy that are effective, she noted.

Studies included in the current review and meta-analysis were conducted between 1981 and 2011, and involved a total of 2,229 patients (mean age, 66-81 years). The studies included lasted anywhere from 4 to 28 weeks (median, 8 weeks). Psychotherapies included in the studies were cognitive-behavioral therapy, cognitive therapy, behavioral therapy, problem solving therapy, interpersonal therapy, brief dynamic therapy, bibliotherapy, reminiscence therapy, and variants of these treatments, she said.

The findings suggest that many nonspecific elements of psychotherapy, which are estimated to account for a large percentage of the effect of psychotherapy in older adults according to prior psychotherapy research, are captured by supportive psychotherapy, and this provides evidence for improved clinical management and supportive care in this population, regardless of whether a specific psychotherapy is indicated, she concluded.

Dr. Huang reported having no financial disclosures.

LOS ANGELES – Several types of psychotherapy are effective for late-life depression, studies show. However, the type of control used in those studies plays an important role in the magnitude of the effect size, findings from a systematic review and meta-analysis suggest.

The findings underscore the value of the supportive aspects of care and the importance of good clinical management in late-life depression, regardless of whether medication is used as part of treatment, Dr. Alice X. Huang said at the annual meeting of the American Association for Geriatric Psychiatry.

Several prior reviews have examined the efficacy of psychotherapy for late-life depression. In a 2005 review that included prior reviews and 17 trials, the investigators concluded that cognitive-behavioral therapy, reminiscence therapy, brief dynamic therapy, and combined medication and interpersonal therapy all are "acutely efficacious" for the treatment of major depression in ambulatory adults (Psychiatr. Clin. N. Am. 2005;28:805-20).

Authors of a 2006 review and meta-analysis that included 25 studies concluded, based on the comparable effect size of various types of psychological treatments, that all types of treatment are equally effective (Int. J. Geriatr. Psychiatry 2006;21:1139-49). Meanwhile, authors of a 2009 Cochrane Review and meta-analysis concluded that their findings were constrained by the heterogeneity of trials and the diversity of control conditions used in the various studies (Cochrane Database Syst. Rev. 2008 Jan 23;(1):CD004853).

Taken together, these studies support the use of various types of psychotherapy for late-life depression. But interestingly, no review has looked at the impact of the type of control group used in clinical trials of psychotherapy, which vary widely, including waitlist, treatment as usual, attention control, supportive therapy, and placebo, said Dr. Huang, a third-year psychiatry resident at the University of California, San Francisco.

In their own review and meta-analysis of 27 trials, including 37 psychotherapy vs. control contrasts, Dr. Huang and her colleagues found that the type of control group used in trials of psychotherapy was related to the effect size of the psychotherapy being tested. The standard mean differences (SMDs) were statistically significant between psychotherapy and waitlist control, treatment-as-usual control, attention control, and supportive therapy control, but not placebo control; the SMDs were lower for the supportive therapy, placebo control, and treatment-as-usual groups, compared with the waitlist control and attention control groups.

The findings are in line with the hypothesis that effect sizes would be larger when psychotherapy is compared with less active treatments, and smaller when it is compared with a control that includes significant clinical management, she explained.

Supportive therapy as a control, and placebo, which included extensive clinical management in the studies that were reviewed, both captured many of the elements of psychotherapy that are effective, she noted.

Studies included in the current review and meta-analysis were conducted between 1981 and 2011, and involved a total of 2,229 patients (mean age, 66-81 years). The studies included lasted anywhere from 4 to 28 weeks (median, 8 weeks). Psychotherapies included in the studies were cognitive-behavioral therapy, cognitive therapy, behavioral therapy, problem solving therapy, interpersonal therapy, brief dynamic therapy, bibliotherapy, reminiscence therapy, and variants of these treatments, she said.

The findings suggest that many nonspecific elements of psychotherapy, which are estimated to account for a large percentage of the effect of psychotherapy in older adults according to prior psychotherapy research, are captured by supportive psychotherapy, and this provides evidence for improved clinical management and supportive care in this population, regardless of whether a specific psychotherapy is indicated, she concluded.

Dr. Huang reported having no financial disclosures.

MIAMI BEACH – Virgin coconut oil is superior to mineral oil for lessening both the signs and symptoms of mild to moderate atopic dermatitis in children and senile xerosis in elderly adults, according to findings from separate randomized controlled studies.

In the pediatric atopic dermatitis study, 117 children were randomized to receive 8 weeks of twice-daily topical application of either virgin coconut oil (VCO) or mineral oil. Of those treated with VCO, 93% experienced improvement on the Scoring Atopic Dermatitis (SCORAD) index, compared with 53% of those treated with mineral oil. An excellent response, defined as 75% or greater improvement on SCORAD, occurred in 46% and 19% of the patients in the VCO and mineral oil groups, respectively, Dr. Mara Therese P. Evangelista reported at the annual meeting of the American Contact Dermatitis Society.

The children treated with topical VCO were 85% more likely to experience treatment success than those treated with mineral oil, said Dr. Evangelista, a resident at Jose R. Reyes Memorial Medical Center, Manila, Philippines.

Like mineral oil, VCO has both occlusive and emollient properties. But unlike mineral oil, it is believed to have both anti-inflammatory and antibacterial properties, Dr. Evangelista said.

In this double-blind study, the VCO was significantly more effective than mineral oil on all subjective and objective measures, including SCORAD, transepidermal water loss, and skin capacitance, she noted.

Treatment was safe and well tolerated; no differences were noted between the groups with respect to adverse effects.

VCO, which is readily available in health food stores and in many Asian food markets, represents an effective and inexpensive alternative to other commercially available moisturizers for the treatment of atopic dermatitis in children, Dr. Evangelista concluded.

Similarly, in the senile xerosis study, 148 patients with mild to moderate leg xerosis were randomized to receive 2 weeks of twice-daily application of either VCO or mineral oil. The therapeutic response rate was 32.1% in those treated with VCO, compared with 8.9% for those treated with mineral oil, Dr. Mariecon Escuadro reported in a poster at the meeting.

VCO treatment was associated with significant improvement on most subjective and objective measures used in this assessor-blinded study, including the Overall Disability Sum Score (ODSS), patient-assessed efficacy, corneometer reading, and sebumeter reading (relative risk reductions of 60.5%, 27.6%, 51.75%, and 55.5%, respectively), said Dr. Escuadro of the University of the Philippines, Manila.

Scores on the Filipino Dermatology Life Quality Index did not differ significantly between the two groups, nor did adverse events.

VCO in this study was associated with effective and immediate improvement in senile xerosis of the legs in elderly patients, Dr. Escuadro said.

The ACDS Annual Meeting Review Committee reported resolving any real or apparent conflicts of interest prior to presentations being made at the annual meeting.

MIAMI BEACH – Virgin coconut oil is superior to mineral oil for lessening both the signs and symptoms of mild to moderate atopic dermatitis in children and senile xerosis in elderly adults, according to findings from separate randomized controlled studies.

In the pediatric atopic dermatitis study, 117 children were randomized to receive 8 weeks of twice-daily topical application of either virgin coconut oil (VCO) or mineral oil. Of those treated with VCO, 93% experienced improvement on the Scoring Atopic Dermatitis (SCORAD) index, compared with 53% of those treated with mineral oil. An excellent response, defined as 75% or greater improvement on SCORAD, occurred in 46% and 19% of the patients in the VCO and mineral oil groups, respectively, Dr. Mara Therese P. Evangelista reported at the annual meeting of the American Contact Dermatitis Society.

The children treated with topical VCO were 85% more likely to experience treatment success than those treated with mineral oil, said Dr. Evangelista, a resident at Jose R. Reyes Memorial Medical Center, Manila, Philippines.

Like mineral oil, VCO has both occlusive and emollient properties. But unlike mineral oil, it is believed to have both anti-inflammatory and antibacterial properties, Dr. Evangelista said.

In this double-blind study, the VCO was significantly more effective than mineral oil on all subjective and objective measures, including SCORAD, transepidermal water loss, and skin capacitance, she noted.

Treatment was safe and well tolerated; no differences were noted between the groups with respect to adverse effects.

VCO, which is readily available in health food stores and in many Asian food markets, represents an effective and inexpensive alternative to other commercially available moisturizers for the treatment of atopic dermatitis in children, Dr. Evangelista concluded.

Similarly, in the senile xerosis study, 148 patients with mild to moderate leg xerosis were randomized to receive 2 weeks of twice-daily application of either VCO or mineral oil. The therapeutic response rate was 32.1% in those treated with VCO, compared with 8.9% for those treated with mineral oil, Dr. Mariecon Escuadro reported in a poster at the meeting.

VCO treatment was associated with significant improvement on most subjective and objective measures used in this assessor-blinded study, including the Overall Disability Sum Score (ODSS), patient-assessed efficacy, corneometer reading, and sebumeter reading (relative risk reductions of 60.5%, 27.6%, 51.75%, and 55.5%, respectively), said Dr. Escuadro of the University of the Philippines, Manila.

Scores on the Filipino Dermatology Life Quality Index did not differ significantly between the two groups, nor did adverse events.

VCO in this study was associated with effective and immediate improvement in senile xerosis of the legs in elderly patients, Dr. Escuadro said.

The ACDS Annual Meeting Review Committee reported resolving any real or apparent conflicts of interest prior to presentations being made at the annual meeting.

MIAMI BEACH – Virgin coconut oil is superior to mineral oil for lessening both the signs and symptoms of mild to moderate atopic dermatitis in children and senile xerosis in elderly adults, according to findings from separate randomized controlled studies.

In the pediatric atopic dermatitis study, 117 children were randomized to receive 8 weeks of twice-daily topical application of either virgin coconut oil (VCO) or mineral oil. Of those treated with VCO, 93% experienced improvement on the Scoring Atopic Dermatitis (SCORAD) index, compared with 53% of those treated with mineral oil. An excellent response, defined as 75% or greater improvement on SCORAD, occurred in 46% and 19% of the patients in the VCO and mineral oil groups, respectively, Dr. Mara Therese P. Evangelista reported at the annual meeting of the American Contact Dermatitis Society.

The children treated with topical VCO were 85% more likely to experience treatment success than those treated with mineral oil, said Dr. Evangelista, a resident at Jose R. Reyes Memorial Medical Center, Manila, Philippines.

Like mineral oil, VCO has both occlusive and emollient properties. But unlike mineral oil, it is believed to have both anti-inflammatory and antibacterial properties, Dr. Evangelista said.

In this double-blind study, the VCO was significantly more effective than mineral oil on all subjective and objective measures, including SCORAD, transepidermal water loss, and skin capacitance, she noted.

Treatment was safe and well tolerated; no differences were noted between the groups with respect to adverse effects.

VCO, which is readily available in health food stores and in many Asian food markets, represents an effective and inexpensive alternative to other commercially available moisturizers for the treatment of atopic dermatitis in children, Dr. Evangelista concluded.

Similarly, in the senile xerosis study, 148 patients with mild to moderate leg xerosis were randomized to receive 2 weeks of twice-daily application of either VCO or mineral oil. The therapeutic response rate was 32.1% in those treated with VCO, compared with 8.9% for those treated with mineral oil, Dr. Mariecon Escuadro reported in a poster at the meeting.

VCO treatment was associated with significant improvement on most subjective and objective measures used in this assessor-blinded study, including the Overall Disability Sum Score (ODSS), patient-assessed efficacy, corneometer reading, and sebumeter reading (relative risk reductions of 60.5%, 27.6%, 51.75%, and 55.5%, respectively), said Dr. Escuadro of the University of the Philippines, Manila.

Scores on the Filipino Dermatology Life Quality Index did not differ significantly between the two groups, nor did adverse events.

VCO in this study was associated with effective and immediate improvement in senile xerosis of the legs in elderly patients, Dr. Escuadro said.

The ACDS Annual Meeting Review Committee reported resolving any real or apparent conflicts of interest prior to presentations being made at the annual meeting.

MIAMI BEACH – The risk of nickel and cobalt sensitivity increases in tandem with the number of body piercings, according to findings from a study involving nearly 9,400 patch-tested patients.

Overall, 3,907 (41.6%) of the 9,388 subjects had no piercings, 131 (1.3%) had one piercing, 3,987 (42.5%) had two piercings, 934 (9.9%) had three to four piercings, and 429 (4.6%) had five or more piercings, Jaime L. Loso reported at the annual meeting of the American Contact Dermatitis Society.

Nickel and cobalt sensitivity both were significantly associated with piercing (relative risks of 2.52 and 1.63, respectively); chromate sensitivity had an inverse relationship with piercing (relative risk, 0.60), said Ms. Loso, a third-year medical student at the University of Minnesota, Minneapolis.

Overall, 1,651 patients (17.7%) had nickel sensitivity and 685 (7.3%) had cobalt sensitivity. The sensitivity rates increased with the number of piercings. The rates of sensitivity among those with zero, one, two, three to four, and five or more piercings were 9.4%, 16%, 22.6%, 25.1%, and 32.4%, respectively, for nickel and 5.3%, 7.6%, 8.2%, 9.5%, and 11.7% for cobalt.

Chromate sensitivity was less common, occurring in only 306 patients (3.26%). Less than 4.3% of patients in all piercing groups had chromate sensitivity, Ms. Loso noted.

"Nickel is the most common allergen for patch-tested patients, and body piercing has been directly correlated with the development of nickel allergy," she said, adding that cobalt content is often associated with nickel content in consumer products, although recent studies suggest that only a small amount of jewelry – mainly earrings – releases cobalt.

In the current study, which involved patients identified using North American Contact Dermatitis Group data from 2007 to 2010, younger patients were affected more often than older patients, females were affected more often than males, and – surprisingly – piercing was associated with allergy in males more often than in females, she reported.

The findings, though limited by the fact that the referral population may not be representative of the general population and by a lack of information regarding age at the time of piercing and the body sites pierced, help characterize metal allergy associated with body piercing, Ms. Loso said.

She noted that nickel allergy has been well studied in Europe – resulting in regulation of the nickel content in consumer goods and a subsequent significant decline in nickel sensitivity among young females there. The same is not true for the United States, where nickel sensitivity remains an important problem.

Ms. Loso reported having no disclosures.

MIAMI BEACH – The risk of nickel and cobalt sensitivity increases in tandem with the number of body piercings, according to findings from a study involving nearly 9,400 patch-tested patients.

Overall, 3,907 (41.6%) of the 9,388 subjects had no piercings, 131 (1.3%) had one piercing, 3,987 (42.5%) had two piercings, 934 (9.9%) had three to four piercings, and 429 (4.6%) had five or more piercings, Jaime L. Loso reported at the annual meeting of the American Contact Dermatitis Society.

Nickel and cobalt sensitivity both were significantly associated with piercing (relative risks of 2.52 and 1.63, respectively); chromate sensitivity had an inverse relationship with piercing (relative risk, 0.60), said Ms. Loso, a third-year medical student at the University of Minnesota, Minneapolis.

Overall, 1,651 patients (17.7%) had nickel sensitivity and 685 (7.3%) had cobalt sensitivity. The sensitivity rates increased with the number of piercings. The rates of sensitivity among those with zero, one, two, three to four, and five or more piercings were 9.4%, 16%, 22.6%, 25.1%, and 32.4%, respectively, for nickel and 5.3%, 7.6%, 8.2%, 9.5%, and 11.7% for cobalt.

Chromate sensitivity was less common, occurring in only 306 patients (3.26%). Less than 4.3% of patients in all piercing groups had chromate sensitivity, Ms. Loso noted.

"Nickel is the most common allergen for patch-tested patients, and body piercing has been directly correlated with the development of nickel allergy," she said, adding that cobalt content is often associated with nickel content in consumer products, although recent studies suggest that only a small amount of jewelry – mainly earrings – releases cobalt.

In the current study, which involved patients identified using North American Contact Dermatitis Group data from 2007 to 2010, younger patients were affected more often than older patients, females were affected more often than males, and – surprisingly – piercing was associated with allergy in males more often than in females, she reported.

The findings, though limited by the fact that the referral population may not be representative of the general population and by a lack of information regarding age at the time of piercing and the body sites pierced, help characterize metal allergy associated with body piercing, Ms. Loso said.

She noted that nickel allergy has been well studied in Europe – resulting in regulation of the nickel content in consumer goods and a subsequent significant decline in nickel sensitivity among young females there. The same is not true for the United States, where nickel sensitivity remains an important problem.

Ms. Loso reported having no disclosures.

MIAMI BEACH – The risk of nickel and cobalt sensitivity increases in tandem with the number of body piercings, according to findings from a study involving nearly 9,400 patch-tested patients.

Overall, 3,907 (41.6%) of the 9,388 subjects had no piercings, 131 (1.3%) had one piercing, 3,987 (42.5%) had two piercings, 934 (9.9%) had three to four piercings, and 429 (4.6%) had five or more piercings, Jaime L. Loso reported at the annual meeting of the American Contact Dermatitis Society.

Nickel and cobalt sensitivity both were significantly associated with piercing (relative risks of 2.52 and 1.63, respectively); chromate sensitivity had an inverse relationship with piercing (relative risk, 0.60), said Ms. Loso, a third-year medical student at the University of Minnesota, Minneapolis.

Overall, 1,651 patients (17.7%) had nickel sensitivity and 685 (7.3%) had cobalt sensitivity. The sensitivity rates increased with the number of piercings. The rates of sensitivity among those with zero, one, two, three to four, and five or more piercings were 9.4%, 16%, 22.6%, 25.1%, and 32.4%, respectively, for nickel and 5.3%, 7.6%, 8.2%, 9.5%, and 11.7% for cobalt.

Chromate sensitivity was less common, occurring in only 306 patients (3.26%). Less than 4.3% of patients in all piercing groups had chromate sensitivity, Ms. Loso noted.

"Nickel is the most common allergen for patch-tested patients, and body piercing has been directly correlated with the development of nickel allergy," she said, adding that cobalt content is often associated with nickel content in consumer products, although recent studies suggest that only a small amount of jewelry – mainly earrings – releases cobalt.

In the current study, which involved patients identified using North American Contact Dermatitis Group data from 2007 to 2010, younger patients were affected more often than older patients, females were affected more often than males, and – surprisingly – piercing was associated with allergy in males more often than in females, she reported.

The findings, though limited by the fact that the referral population may not be representative of the general population and by a lack of information regarding age at the time of piercing and the body sites pierced, help characterize metal allergy associated with body piercing, Ms. Loso said.

She noted that nickel allergy has been well studied in Europe – resulting in regulation of the nickel content in consumer goods and a subsequent significant decline in nickel sensitivity among young females there. The same is not true for the United States, where nickel sensitivity remains an important problem.

Ms. Loso reported having no disclosures.

MIAMI BEACH – Calls for a ban on the use of tanning beds by minors in the United States have thus far gone unheeded, but medical organizations are increasingly supporting such a ban – and with good reason, according to Alan Geller of the Harvard School of Public Health, Boston.

The data linking tanning bed use and melanoma are consistent and convincing. A 2010 University of Minnesota case-control study, for example, demonstrated that melanoma risk was significantly increased among users, compared with nonusers, of UVB-enhanced tanning devices (adjusted odds ratio, 2.86) and primarily UVA-emitting devices (AOR, 4.44), Mr. Geller said at the annual meeting of the American Academy of Dermatology.

©Vidmantas Goldbergas/iStockphoto.com

The risk increased as tanning bed use increased (Cancer Epidemiol. Biomarkers Prev. 2010;19:1557-68).

A more recent study demonstrated that with every visit to a tanning bed, the risk of melanoma increased by 1.8% – and the risk was even greater among those who started tanning at a younger age (BMJ 2012;345:e4757).

"We are clearly in the throes of a modern-day epidemic, particularly among teenage white girls and young women between the ages of 18 and 25," Mr. Geller said, noting that study after study shows that about a third of white teenage girls and about 20% of all teenage girls use a tanning bed by the age of 17.

And yet only five states restrict the use of tanning beds by those under age 18. Others have parental consent restrictions, but these have been shown to have no effect on tanning bed use by minors. That means that in 45 states, children aged 15 years and younger are free to visit tanning salons with no restrictions, he said, noting that a Washington University in St. Louis survey released in February showed that 65% of Missouri tanning salon owners would allow preteens aged 10-12 years to use their tanning beds – and that 43% of tanning salon employees believe indoor tanning poses no health risks.

Data show that 7% of girls use tanning beds by age 14 years. This doubles from age 14 to 15, and doubles again from age 15 to 17, he said, noting that girls are about five to six times more likely than boys to use tanning beds.

Of particular concern, not only are girls using tanning beds early, but they are using them more often.

A Centers for Disease Control and Prevention survey showed that while the rate of use (20% among all girls) has remained constant in recent years, the "prom phenomenon" – the occasional use of tanning beds before a special event – is no longer the norm; the average yearly number of uses of tanning beds among those surveyed was 28.

"We’re way past the prom phenomenon," Mr. Geller said, noting that one reason for this is that tanning salons "do a wonderful job of selling giant packages of use for very little money."

"When people are beginning to think of some kind of restrictions on the tanning bed industry, that would be one we could surely consider," he said, noting that based on the data showing a 1.8% increase in melanoma risk with each tanning bed use, the risk would be 54%-90% in a teen who starts tanning at age 18 and quits at age 19.

That’s a conservative estimate, because most teens start before age 18 and don’t stop at age 19, he said.

Surveillance, Epidemiology, and End Results (SEER) data from the National Cancer Institute show that the risk of melanoma has doubled among women aged 20-24 years since the 1980s, while the risk in men has declined in some age groups, and remained the same in others.

"You have to ask what’s happened during that time," Mr. Geller said, adding that there is concern about the late effects of tanning bed use, especially given that sun exposure time hasn’t changed in that age group over time.

As for what can be done from a public health perspective to reduce tanning bed use, Mr. Geller said a number of research, legislative, and public health campaigns are underway.

"We know from doing qualitative work, that indoor tanning is largely socially driven. "When [girls] are not tanning, they talk about tanning, they blog about tanning," he said, explaining that "the tanning culture involves some kind of socially driven bonds."

The key is to figure out how to break up those bonds.

"If one girl in a social group quits tanning, will this have an effect on the others? We don’t know," he said, adding that this is among the areas that require further research.

Researchers are also studying the effects of antitanning campaigns and legislation in other countries, a number of which have restricted access to tanning beds for minors. A recent web-based advertising campaign in Denmark targeted teens, and, along with legislation restricting access, resulted in a substantial drop in tanning bed use there, he said.

The results of campaigns and legislative efforts like these are being closely monitored so that the lessons learned about if and how they work can be incorporated into efforts here.

Lessons from the campaign against smoking launched three decades ago also are being incorporated into the current effort to reduce tanning, he said.

Although the link between tanning and melanoma isn’t quite as strong as the link between smoking and lung cancer, the seven key principles that made the antismoking campaign a success can be adapted for this purpose. These are surveillance, taxation, legal strategies, public health advertising campaigns, educational programs, legislation, and "some move to mandate enforcement," he said.

Some progress has been made with respect to these principles. For example, state-by-state surveillance and scoring of states’ level of compliance with existing regulations are underway, a 10% tax has been imposed on tanning salons, cost-efficacy studies are being planned, and lawsuits have been filed in multiple states. However, most of these efforts are in their infancy, Mr. Geller said.

For now, what exists across the United States is a "patchwork quilt of pretty crummy regulations," he said.

While intense pressure is on the Food and Drug Administration to ban tanning bed use by those under age 18 – including pressure from the American Academy of Dermatology – and while the agency is cognizant of the risks and has acknowledged a need for more regulations, "politics have prevailed, and at this point we don’t have the ban," he said.

The FDA website does, however, indicate plans for revising regulations and strengthening warning labels to make consumers more aware of the risks, he noted.

"This is good, but I think it’s a really faulty response to everything that we know about the link between tanning beds and melanoma," he said.

Despite the slow progress toward a ban for those under age 18, there have been some successes in the antitanning campaign. For one, numerous organizations have taken up the cause, including the World Health Organization, the American Academy of Pediatrics, the American Medical Association, the Society of Surgical Oncology, and the Canadian Pediatric Society.

Also, thanks to a Federal Trade Commission crackdown in 2010, the tanning industry is no longer allowed to claim that tanning has certain health benefits, such as reducing the risks of some types of cancers. And in 2012, the U.S. Preventive Services Task Force issued its first guidelines on tanning, stating that the evidence is strong enough to recommend that women aged 10-24 years who have fair skin should avoid prime-time sun exposure and tanning beds.

Additionally, a wellness provision of the Patient Protection and Affordable Care Act that will go into effect in May provides for full reimbursement to health care providers for counseling about skin cancer prevention and tanning bed reduction.

"We want to study this because we think this will have a huge effect on increasing the rate of counseling," he said.

Mr. Geller reported having no disclosures.

MIAMI BEACH – Calls for a ban on the use of tanning beds by minors in the United States have thus far gone unheeded, but medical organizations are increasingly supporting such a ban – and with good reason, according to Alan Geller of the Harvard School of Public Health, Boston.

The data linking tanning bed use and melanoma are consistent and convincing. A 2010 University of Minnesota case-control study, for example, demonstrated that melanoma risk was significantly increased among users, compared with nonusers, of UVB-enhanced tanning devices (adjusted odds ratio, 2.86) and primarily UVA-emitting devices (AOR, 4.44), Mr. Geller said at the annual meeting of the American Academy of Dermatology.

©Vidmantas Goldbergas/iStockphoto.com

The risk increased as tanning bed use increased (Cancer Epidemiol. Biomarkers Prev. 2010;19:1557-68).

A more recent study demonstrated that with every visit to a tanning bed, the risk of melanoma increased by 1.8% – and the risk was even greater among those who started tanning at a younger age (BMJ 2012;345:e4757).

"We are clearly in the throes of a modern-day epidemic, particularly among teenage white girls and young women between the ages of 18 and 25," Mr. Geller said, noting that study after study shows that about a third of white teenage girls and about 20% of all teenage girls use a tanning bed by the age of 17.

And yet only five states restrict the use of tanning beds by those under age 18. Others have parental consent restrictions, but these have been shown to have no effect on tanning bed use by minors. That means that in 45 states, children aged 15 years and younger are free to visit tanning salons with no restrictions, he said, noting that a Washington University in St. Louis survey released in February showed that 65% of Missouri tanning salon owners would allow preteens aged 10-12 years to use their tanning beds – and that 43% of tanning salon employees believe indoor tanning poses no health risks.

Data show that 7% of girls use tanning beds by age 14 years. This doubles from age 14 to 15, and doubles again from age 15 to 17, he said, noting that girls are about five to six times more likely than boys to use tanning beds.

Of particular concern, not only are girls using tanning beds early, but they are using them more often.

A Centers for Disease Control and Prevention survey showed that while the rate of use (20% among all girls) has remained constant in recent years, the "prom phenomenon" – the occasional use of tanning beds before a special event – is no longer the norm; the average yearly number of uses of tanning beds among those surveyed was 28.

"We’re way past the prom phenomenon," Mr. Geller said, noting that one reason for this is that tanning salons "do a wonderful job of selling giant packages of use for very little money."

"When people are beginning to think of some kind of restrictions on the tanning bed industry, that would be one we could surely consider," he said, noting that based on the data showing a 1.8% increase in melanoma risk with each tanning bed use, the risk would be 54%-90% in a teen who starts tanning at age 18 and quits at age 19.

That’s a conservative estimate, because most teens start before age 18 and don’t stop at age 19, he said.

Surveillance, Epidemiology, and End Results (SEER) data from the National Cancer Institute show that the risk of melanoma has doubled among women aged 20-24 years since the 1980s, while the risk in men has declined in some age groups, and remained the same in others.

"You have to ask what’s happened during that time," Mr. Geller said, adding that there is concern about the late effects of tanning bed use, especially given that sun exposure time hasn’t changed in that age group over time.

As for what can be done from a public health perspective to reduce tanning bed use, Mr. Geller said a number of research, legislative, and public health campaigns are underway.

"We know from doing qualitative work, that indoor tanning is largely socially driven. "When [girls] are not tanning, they talk about tanning, they blog about tanning," he said, explaining that "the tanning culture involves some kind of socially driven bonds."

The key is to figure out how to break up those bonds.

"If one girl in a social group quits tanning, will this have an effect on the others? We don’t know," he said, adding that this is among the areas that require further research.

Researchers are also studying the effects of antitanning campaigns and legislation in other countries, a number of which have restricted access to tanning beds for minors. A recent web-based advertising campaign in Denmark targeted teens, and, along with legislation restricting access, resulted in a substantial drop in tanning bed use there, he said.

The results of campaigns and legislative efforts like these are being closely monitored so that the lessons learned about if and how they work can be incorporated into efforts here.

Lessons from the campaign against smoking launched three decades ago also are being incorporated into the current effort to reduce tanning, he said.

Although the link between tanning and melanoma isn’t quite as strong as the link between smoking and lung cancer, the seven key principles that made the antismoking campaign a success can be adapted for this purpose. These are surveillance, taxation, legal strategies, public health advertising campaigns, educational programs, legislation, and "some move to mandate enforcement," he said.

Some progress has been made with respect to these principles. For example, state-by-state surveillance and scoring of states’ level of compliance with existing regulations are underway, a 10% tax has been imposed on tanning salons, cost-efficacy studies are being planned, and lawsuits have been filed in multiple states. However, most of these efforts are in their infancy, Mr. Geller said.

For now, what exists across the United States is a "patchwork quilt of pretty crummy regulations," he said.

While intense pressure is on the Food and Drug Administration to ban tanning bed use by those under age 18 – including pressure from the American Academy of Dermatology – and while the agency is cognizant of the risks and has acknowledged a need for more regulations, "politics have prevailed, and at this point we don’t have the ban," he said.

The FDA website does, however, indicate plans for revising regulations and strengthening warning labels to make consumers more aware of the risks, he noted.

"This is good, but I think it’s a really faulty response to everything that we know about the link between tanning beds and melanoma," he said.

Despite the slow progress toward a ban for those under age 18, there have been some successes in the antitanning campaign. For one, numerous organizations have taken up the cause, including the World Health Organization, the American Academy of Pediatrics, the American Medical Association, the Society of Surgical Oncology, and the Canadian Pediatric Society.

Also, thanks to a Federal Trade Commission crackdown in 2010, the tanning industry is no longer allowed to claim that tanning has certain health benefits, such as reducing the risks of some types of cancers. And in 2012, the U.S. Preventive Services Task Force issued its first guidelines on tanning, stating that the evidence is strong enough to recommend that women aged 10-24 years who have fair skin should avoid prime-time sun exposure and tanning beds.

Additionally, a wellness provision of the Patient Protection and Affordable Care Act that will go into effect in May provides for full reimbursement to health care providers for counseling about skin cancer prevention and tanning bed reduction.

"We want to study this because we think this will have a huge effect on increasing the rate of counseling," he said.

Mr. Geller reported having no disclosures.

MIAMI BEACH – Calls for a ban on the use of tanning beds by minors in the United States have thus far gone unheeded, but medical organizations are increasingly supporting such a ban – and with good reason, according to Alan Geller of the Harvard School of Public Health, Boston.

The data linking tanning bed use and melanoma are consistent and convincing. A 2010 University of Minnesota case-control study, for example, demonstrated that melanoma risk was significantly increased among users, compared with nonusers, of UVB-enhanced tanning devices (adjusted odds ratio, 2.86) and primarily UVA-emitting devices (AOR, 4.44), Mr. Geller said at the annual meeting of the American Academy of Dermatology.

©Vidmantas Goldbergas/iStockphoto.com

The risk increased as tanning bed use increased (Cancer Epidemiol. Biomarkers Prev. 2010;19:1557-68).

A more recent study demonstrated that with every visit to a tanning bed, the risk of melanoma increased by 1.8% – and the risk was even greater among those who started tanning at a younger age (BMJ 2012;345:e4757).

"We are clearly in the throes of a modern-day epidemic, particularly among teenage white girls and young women between the ages of 18 and 25," Mr. Geller said, noting that study after study shows that about a third of white teenage girls and about 20% of all teenage girls use a tanning bed by the age of 17.

And yet only five states restrict the use of tanning beds by those under age 18. Others have parental consent restrictions, but these have been shown to have no effect on tanning bed use by minors. That means that in 45 states, children aged 15 years and younger are free to visit tanning salons with no restrictions, he said, noting that a Washington University in St. Louis survey released in February showed that 65% of Missouri tanning salon owners would allow preteens aged 10-12 years to use their tanning beds – and that 43% of tanning salon employees believe indoor tanning poses no health risks.

Data show that 7% of girls use tanning beds by age 14 years. This doubles from age 14 to 15, and doubles again from age 15 to 17, he said, noting that girls are about five to six times more likely than boys to use tanning beds.

Of particular concern, not only are girls using tanning beds early, but they are using them more often.

A Centers for Disease Control and Prevention survey showed that while the rate of use (20% among all girls) has remained constant in recent years, the "prom phenomenon" – the occasional use of tanning beds before a special event – is no longer the norm; the average yearly number of uses of tanning beds among those surveyed was 28.

"We’re way past the prom phenomenon," Mr. Geller said, noting that one reason for this is that tanning salons "do a wonderful job of selling giant packages of use for very little money."

"When people are beginning to think of some kind of restrictions on the tanning bed industry, that would be one we could surely consider," he said, noting that based on the data showing a 1.8% increase in melanoma risk with each tanning bed use, the risk would be 54%-90% in a teen who starts tanning at age 18 and quits at age 19.

That’s a conservative estimate, because most teens start before age 18 and don’t stop at age 19, he said.

Surveillance, Epidemiology, and End Results (SEER) data from the National Cancer Institute show that the risk of melanoma has doubled among women aged 20-24 years since the 1980s, while the risk in men has declined in some age groups, and remained the same in others.

"You have to ask what’s happened during that time," Mr. Geller said, adding that there is concern about the late effects of tanning bed use, especially given that sun exposure time hasn’t changed in that age group over time.

As for what can be done from a public health perspective to reduce tanning bed use, Mr. Geller said a number of research, legislative, and public health campaigns are underway.

"We know from doing qualitative work, that indoor tanning is largely socially driven. "When [girls] are not tanning, they talk about tanning, they blog about tanning," he said, explaining that "the tanning culture involves some kind of socially driven bonds."

The key is to figure out how to break up those bonds.

"If one girl in a social group quits tanning, will this have an effect on the others? We don’t know," he said, adding that this is among the areas that require further research.

Researchers are also studying the effects of antitanning campaigns and legislation in other countries, a number of which have restricted access to tanning beds for minors. A recent web-based advertising campaign in Denmark targeted teens, and, along with legislation restricting access, resulted in a substantial drop in tanning bed use there, he said.

The results of campaigns and legislative efforts like these are being closely monitored so that the lessons learned about if and how they work can be incorporated into efforts here.

Lessons from the campaign against smoking launched three decades ago also are being incorporated into the current effort to reduce tanning, he said.

Although the link between tanning and melanoma isn’t quite as strong as the link between smoking and lung cancer, the seven key principles that made the antismoking campaign a success can be adapted for this purpose. These are surveillance, taxation, legal strategies, public health advertising campaigns, educational programs, legislation, and "some move to mandate enforcement," he said.

Some progress has been made with respect to these principles. For example, state-by-state surveillance and scoring of states’ level of compliance with existing regulations are underway, a 10% tax has been imposed on tanning salons, cost-efficacy studies are being planned, and lawsuits have been filed in multiple states. However, most of these efforts are in their infancy, Mr. Geller said.

For now, what exists across the United States is a "patchwork quilt of pretty crummy regulations," he said.

While intense pressure is on the Food and Drug Administration to ban tanning bed use by those under age 18 – including pressure from the American Academy of Dermatology – and while the agency is cognizant of the risks and has acknowledged a need for more regulations, "politics have prevailed, and at this point we don’t have the ban," he said.

The FDA website does, however, indicate plans for revising regulations and strengthening warning labels to make consumers more aware of the risks, he noted.

"This is good, but I think it’s a really faulty response to everything that we know about the link between tanning beds and melanoma," he said.

Despite the slow progress toward a ban for those under age 18, there have been some successes in the antitanning campaign. For one, numerous organizations have taken up the cause, including the World Health Organization, the American Academy of Pediatrics, the American Medical Association, the Society of Surgical Oncology, and the Canadian Pediatric Society.

Also, thanks to a Federal Trade Commission crackdown in 2010, the tanning industry is no longer allowed to claim that tanning has certain health benefits, such as reducing the risks of some types of cancers. And in 2012, the U.S. Preventive Services Task Force issued its first guidelines on tanning, stating that the evidence is strong enough to recommend that women aged 10-24 years who have fair skin should avoid prime-time sun exposure and tanning beds.

Additionally, a wellness provision of the Patient Protection and Affordable Care Act that will go into effect in May provides for full reimbursement to health care providers for counseling about skin cancer prevention and tanning bed reduction.

"We want to study this because we think this will have a huge effect on increasing the rate of counseling," he said.

Mr. Geller reported having no disclosures.

MIAMI BEACH – Data from several recently published studies have shed new light on the behavior and natural history of melanoma in children and adolescents – and much of the news is good, according to Dr. Sheilagh M. Maguiness.

For example, the findings suggest that the risk of malignant melanoma arising in large congenital nevi is lower than previously thought, at about 2%. Also, outside of the neonatal period the prognosis is excellent for most children diagnosed with melanoma, said Dr. Maguiness of Boston Children’s Hospital.

Data from three of the studies, taken together, show that 36 deaths occurred in 278 cases involving melanoma during childhood or adolescence, for a mortality rate of 13%.

"There was only one death in a child under 10, and that was in the setting of a large congenital nevus," she said at the annual meeting of the American Academy of Dermatology.

Furthermore, the presentation of melanoma in adolescents is similar to that in adults, and the outcomes seem to parallel – and perhaps exceed – those of adults with similar stage tumors, she noted.

The studies do little, however, to clear up controversy about the value of sentinel lymph node biopsy for predicting outcomes in children with melanoma, she said.

Pediatric melanoma represents only about 1%-3% of all melanomas and about 2% of all pediatric malignancies, and it is best considered based on the timing of presentation – presentation during the congenital period, during childhood up to the age of 10 years, and during adolescence – because findings during these stages differ substantially, she said.

Melanoma during the congenital and neonatal period is extremely rare. Four cases involving transplacental metastases from maternal malignant melanoma, nine cases involving large or giant congenital melanocytic nevi, and seven de novo cases have been reported in the literature.

"Unfortunately, when melanoma presents this early, it really does have a poor prognosis, with greater than 50% of the patients dying from their disease," Dr. Maguiness said.

The outlook is much better for older children with melanoma, but any discussion of these cases must include consideration of cases that arise in large congenital melanocytic nevi (LCMN). Controversy has existed over the actual risk of melanoma in these cases, with reports citing risks of anywhere from 7% to 40%, but the studies reviewed by Dr. Maguiness demonstrate that the risk is actually quite low.

A retrospective analysis of data on this topic published in March in the Journal of the American Academy of Dermatology, for example, showed that melanoma developed in only 2% of 2,578 cases of LCMN in 14 studies (J. Am. Acad. Dermatol. 2013;68:493-8.e14).

Other "very, very valuable points" coming out of this data include a finding that 14% of the melanomas occurred viscerally or noncutaneously, and a finding that the mortality rate is high in these patients at about 55%.

"And one of the most important points that I had never appreciated before is a finding that in over 90% of the cases where melanoma developed in these children, satellite nevi were present. Historically we’ve known that the risk of melanoma arising within the satellite nevi itself is quite low – it almost never occurs – but (the finding) that they confer an elevated risk of development of cutaneous melanoma is very interesting," she said.

These findings suggest that a careful examination and regular follow-up is crucial in patients with LCMN, she said.

Findings from three large single-institution studies also have provided interesting new information about pediatric melanoma, she said.

Researchers at the University of Texas Health Science Center at Houston reviewed data on 109 patients under age 19 years with melanoma, including 25 under age 10 years. Seven of 82 patients with adequate follow-up died from their disease, and none of those were in the group under age 10, Dr. Maguiness said.

Among other notable findings from this study: Patients were more likely to be nonwhite, 44% had spitzoid histology, and 52% of those under age 10 who underwent sentinel lymph node biopsy had positive results, compared with 26% in the adolescent cohort (Ann. Surg. 2011;253:1211-15).

The rate of positivity decreased by 13% for each year of increasing age, and because those under age 10 did paradoxically well, the authors suggested that sentinel lymph node positivity does not predict prognosis or outcome in childhood melanoma, Dr. Maguiness noted.

However, investigators from the Moffitt Cancer Center in Tampa concluded, conversely, that sentinel lymph node biopsy does predict outcomes in pediatric melanoma.

Of 126 patients with pediatric melanoma in that retrospective review, 62 underwent sentinel lymph node biopsy and 29% had positive findings. Overall, 19 melanoma-related deaths occurred, for a rate of 16%.

Six patients under the age of 12 were included in the study, but these patients did not undergo sentinel lymph node biopsy. All survived, but there were several late recurrences – after 5 years – even in the node-negative patients, she said.

When the investigators looked at recurrence-free survival, they found that node-positive patients had significantly worse recurrence-free survival and melanoma-specific survival than that of node-negative patients (60% vs.94% and 78% vs. 97%, respectively) at a median follow-up of 5 years (Ann. Surg. Oncol. 2012;19:3888-95).

A study by investigators at the University of California, San Francisco, focused more on historical data, finding that many of the 70 patients included in the study had putative risk factors for melanoma. For example, 20% had numerous nevi, 27% had a positive family history, and 25% had a history of sunburn. Also, this study was the only one of the three to address the presence of LCMN, and only three patients had melanoma arising in a nevus, providing further evidence of a low risk of melanoma in LCMN.

The diagnosis of pediatric melanoma was delayed by about a year in more than 60% of the patients.

The investigators noted that primary lesion characteristics differed from those seen in adults, and they concluded that the conventional ABCDE criteria used to help in the diagnosis of melanoma did not capture melanoma in about 60% of the childhood cases and 40% of the adolescent cases.

Lesions in this study were much more likely to be amelanotic in children, and of uniform color in adolescents. Lesional evolution was nearly universal, and bleeding, bumps, variable diameter, and de novo development were common.

On histopathology, a majority of tumors were not superficial spreading type; more were unclassified spitzoid and other histopathologic subtypes, she noted.

Ten patients (14%) died from their melanoma, and of these, 7 had amelanotic melanoma. Only 1 patient under age 10 years died, and that was in the setting of a large congenital melanocytic nevus.

Based on their findings, the investigators suggested pediatric-specific ABCD criteria (A = amelanotic, B = bleeding, bumps, C = color uniformity, and D = de novo and any diameter) to be used along with the conventional ABCDE criteria to facilitate earlier recognition and treatment of pediatric melanoma (J. Am. Acad. Dermatol. 2013 [doi:10.1016/j.jaad.2012.12.953]).

Although there are some conflicting findings in these three studies – including differing conclusions with respect to the value of sentinel lymph node biopsy for predicting outcomes – there also are some consistent findings, Dr. Maguiness said.

Prepubertal melanoma tends to involve thicker tumors, and darker skin types are overrepresented. Also, lesions in all ages in the pediatric population tend to be amelanotic with spitzoid histology, and tend to have higher rates of positive sentinel lymph node biopsies, compared with adult cases. Prepubertal cases have the highest rates of node positivity, she said.

"So, in conclusion, the risk of malignant melanoma within large congenital nevi seems to be lower than we thought, and the diagnosis of malignant melanoma of childhood has excellent prognosis – speaking to the unique natural history and biology of these tumors, which we probably don’t fully understand," she said, adding that adolescent presentations of melanoma seem to be similar to those in adults, with a slightly better overall prognosis.

Dr. Maguiness reported having no disclosures.

MIAMI BEACH – Data from several recently published studies have shed new light on the behavior and natural history of melanoma in children and adolescents – and much of the news is good, according to Dr. Sheilagh M. Maguiness.

For example, the findings suggest that the risk of malignant melanoma arising in large congenital nevi is lower than previously thought, at about 2%. Also, outside of the neonatal period the prognosis is excellent for most children diagnosed with melanoma, said Dr. Maguiness of Boston Children’s Hospital.

Data from three of the studies, taken together, show that 36 deaths occurred in 278 cases involving melanoma during childhood or adolescence, for a mortality rate of 13%.

"There was only one death in a child under 10, and that was in the setting of a large congenital nevus," she said at the annual meeting of the American Academy of Dermatology.

Furthermore, the presentation of melanoma in adolescents is similar to that in adults, and the outcomes seem to parallel – and perhaps exceed – those of adults with similar stage tumors, she noted.

The studies do little, however, to clear up controversy about the value of sentinel lymph node biopsy for predicting outcomes in children with melanoma, she said.

Pediatric melanoma represents only about 1%-3% of all melanomas and about 2% of all pediatric malignancies, and it is best considered based on the timing of presentation – presentation during the congenital period, during childhood up to the age of 10 years, and during adolescence – because findings during these stages differ substantially, she said.

Melanoma during the congenital and neonatal period is extremely rare. Four cases involving transplacental metastases from maternal malignant melanoma, nine cases involving large or giant congenital melanocytic nevi, and seven de novo cases have been reported in the literature.

"Unfortunately, when melanoma presents this early, it really does have a poor prognosis, with greater than 50% of the patients dying from their disease," Dr. Maguiness said.

The outlook is much better for older children with melanoma, but any discussion of these cases must include consideration of cases that arise in large congenital melanocytic nevi (LCMN). Controversy has existed over the actual risk of melanoma in these cases, with reports citing risks of anywhere from 7% to 40%, but the studies reviewed by Dr. Maguiness demonstrate that the risk is actually quite low.

A retrospective analysis of data on this topic published in March in the Journal of the American Academy of Dermatology, for example, showed that melanoma developed in only 2% of 2,578 cases of LCMN in 14 studies (J. Am. Acad. Dermatol. 2013;68:493-8.e14).

Other "very, very valuable points" coming out of this data include a finding that 14% of the melanomas occurred viscerally or noncutaneously, and a finding that the mortality rate is high in these patients at about 55%.

"And one of the most important points that I had never appreciated before is a finding that in over 90% of the cases where melanoma developed in these children, satellite nevi were present. Historically we’ve known that the risk of melanoma arising within the satellite nevi itself is quite low – it almost never occurs – but (the finding) that they confer an elevated risk of development of cutaneous melanoma is very interesting," she said.

These findings suggest that a careful examination and regular follow-up is crucial in patients with LCMN, she said.

Findings from three large single-institution studies also have provided interesting new information about pediatric melanoma, she said.

Researchers at the University of Texas Health Science Center at Houston reviewed data on 109 patients under age 19 years with melanoma, including 25 under age 10 years. Seven of 82 patients with adequate follow-up died from their disease, and none of those were in the group under age 10, Dr. Maguiness said.

Among other notable findings from this study: Patients were more likely to be nonwhite, 44% had spitzoid histology, and 52% of those under age 10 who underwent sentinel lymph node biopsy had positive results, compared with 26% in the adolescent cohort (Ann. Surg. 2011;253:1211-15).

The rate of positivity decreased by 13% for each year of increasing age, and because those under age 10 did paradoxically well, the authors suggested that sentinel lymph node positivity does not predict prognosis or outcome in childhood melanoma, Dr. Maguiness noted.

However, investigators from the Moffitt Cancer Center in Tampa concluded, conversely, that sentinel lymph node biopsy does predict outcomes in pediatric melanoma.

Of 126 patients with pediatric melanoma in that retrospective review, 62 underwent sentinel lymph node biopsy and 29% had positive findings. Overall, 19 melanoma-related deaths occurred, for a rate of 16%.

Six patients under the age of 12 were included in the study, but these patients did not undergo sentinel lymph node biopsy. All survived, but there were several late recurrences – after 5 years – even in the node-negative patients, she said.

When the investigators looked at recurrence-free survival, they found that node-positive patients had significantly worse recurrence-free survival and melanoma-specific survival than that of node-negative patients (60% vs.94% and 78% vs. 97%, respectively) at a median follow-up of 5 years (Ann. Surg. Oncol. 2012;19:3888-95).

A study by investigators at the University of California, San Francisco, focused more on historical data, finding that many of the 70 patients included in the study had putative risk factors for melanoma. For example, 20% had numerous nevi, 27% had a positive family history, and 25% had a history of sunburn. Also, this study was the only one of the three to address the presence of LCMN, and only three patients had melanoma arising in a nevus, providing further evidence of a low risk of melanoma in LCMN.

The diagnosis of pediatric melanoma was delayed by about a year in more than 60% of the patients.

The investigators noted that primary lesion characteristics differed from those seen in adults, and they concluded that the conventional ABCDE criteria used to help in the diagnosis of melanoma did not capture melanoma in about 60% of the childhood cases and 40% of the adolescent cases.

Lesions in this study were much more likely to be amelanotic in children, and of uniform color in adolescents. Lesional evolution was nearly universal, and bleeding, bumps, variable diameter, and de novo development were common.

On histopathology, a majority of tumors were not superficial spreading type; more were unclassified spitzoid and other histopathologic subtypes, she noted.

Ten patients (14%) died from their melanoma, and of these, 7 had amelanotic melanoma. Only 1 patient under age 10 years died, and that was in the setting of a large congenital melanocytic nevus.

Based on their findings, the investigators suggested pediatric-specific ABCD criteria (A = amelanotic, B = bleeding, bumps, C = color uniformity, and D = de novo and any diameter) to be used along with the conventional ABCDE criteria to facilitate earlier recognition and treatment of pediatric melanoma (J. Am. Acad. Dermatol. 2013 [doi:10.1016/j.jaad.2012.12.953]).

Although there are some conflicting findings in these three studies – including differing conclusions with respect to the value of sentinel lymph node biopsy for predicting outcomes – there also are some consistent findings, Dr. Maguiness said.

Prepubertal melanoma tends to involve thicker tumors, and darker skin types are overrepresented. Also, lesions in all ages in the pediatric population tend to be amelanotic with spitzoid histology, and tend to have higher rates of positive sentinel lymph node biopsies, compared with adult cases. Prepubertal cases have the highest rates of node positivity, she said.

"So, in conclusion, the risk of malignant melanoma within large congenital nevi seems to be lower than we thought, and the diagnosis of malignant melanoma of childhood has excellent prognosis – speaking to the unique natural history and biology of these tumors, which we probably don’t fully understand," she said, adding that adolescent presentations of melanoma seem to be similar to those in adults, with a slightly better overall prognosis.

Dr. Maguiness reported having no disclosures.

MIAMI BEACH – Data from several recently published studies have shed new light on the behavior and natural history of melanoma in children and adolescents – and much of the news is good, according to Dr. Sheilagh M. Maguiness.

For example, the findings suggest that the risk of malignant melanoma arising in large congenital nevi is lower than previously thought, at about 2%. Also, outside of the neonatal period the prognosis is excellent for most children diagnosed with melanoma, said Dr. Maguiness of Boston Children’s Hospital.

Data from three of the studies, taken together, show that 36 deaths occurred in 278 cases involving melanoma during childhood or adolescence, for a mortality rate of 13%.

"There was only one death in a child under 10, and that was in the setting of a large congenital nevus," she said at the annual meeting of the American Academy of Dermatology.

Furthermore, the presentation of melanoma in adolescents is similar to that in adults, and the outcomes seem to parallel – and perhaps exceed – those of adults with similar stage tumors, she noted.

The studies do little, however, to clear up controversy about the value of sentinel lymph node biopsy for predicting outcomes in children with melanoma, she said.

Pediatric melanoma represents only about 1%-3% of all melanomas and about 2% of all pediatric malignancies, and it is best considered based on the timing of presentation – presentation during the congenital period, during childhood up to the age of 10 years, and during adolescence – because findings during these stages differ substantially, she said.

Melanoma during the congenital and neonatal period is extremely rare. Four cases involving transplacental metastases from maternal malignant melanoma, nine cases involving large or giant congenital melanocytic nevi, and seven de novo cases have been reported in the literature.

"Unfortunately, when melanoma presents this early, it really does have a poor prognosis, with greater than 50% of the patients dying from their disease," Dr. Maguiness said.

The outlook is much better for older children with melanoma, but any discussion of these cases must include consideration of cases that arise in large congenital melanocytic nevi (LCMN). Controversy has existed over the actual risk of melanoma in these cases, with reports citing risks of anywhere from 7% to 40%, but the studies reviewed by Dr. Maguiness demonstrate that the risk is actually quite low.

A retrospective analysis of data on this topic published in March in the Journal of the American Academy of Dermatology, for example, showed that melanoma developed in only 2% of 2,578 cases of LCMN in 14 studies (J. Am. Acad. Dermatol. 2013;68:493-8.e14).

Other "very, very valuable points" coming out of this data include a finding that 14% of the melanomas occurred viscerally or noncutaneously, and a finding that the mortality rate is high in these patients at about 55%.

"And one of the most important points that I had never appreciated before is a finding that in over 90% of the cases where melanoma developed in these children, satellite nevi were present. Historically we’ve known that the risk of melanoma arising within the satellite nevi itself is quite low – it almost never occurs – but (the finding) that they confer an elevated risk of development of cutaneous melanoma is very interesting," she said.

These findings suggest that a careful examination and regular follow-up is crucial in patients with LCMN, she said.

Findings from three large single-institution studies also have provided interesting new information about pediatric melanoma, she said.

Researchers at the University of Texas Health Science Center at Houston reviewed data on 109 patients under age 19 years with melanoma, including 25 under age 10 years. Seven of 82 patients with adequate follow-up died from their disease, and none of those were in the group under age 10, Dr. Maguiness said.

Among other notable findings from this study: Patients were more likely to be nonwhite, 44% had spitzoid histology, and 52% of those under age 10 who underwent sentinel lymph node biopsy had positive results, compared with 26% in the adolescent cohort (Ann. Surg. 2011;253:1211-15).

The rate of positivity decreased by 13% for each year of increasing age, and because those under age 10 did paradoxically well, the authors suggested that sentinel lymph node positivity does not predict prognosis or outcome in childhood melanoma, Dr. Maguiness noted.

However, investigators from the Moffitt Cancer Center in Tampa concluded, conversely, that sentinel lymph node biopsy does predict outcomes in pediatric melanoma.

Of 126 patients with pediatric melanoma in that retrospective review, 62 underwent sentinel lymph node biopsy and 29% had positive findings. Overall, 19 melanoma-related deaths occurred, for a rate of 16%.

Six patients under the age of 12 were included in the study, but these patients did not undergo sentinel lymph node biopsy. All survived, but there were several late recurrences – after 5 years – even in the node-negative patients, she said.

When the investigators looked at recurrence-free survival, they found that node-positive patients had significantly worse recurrence-free survival and melanoma-specific survival than that of node-negative patients (60% vs.94% and 78% vs. 97%, respectively) at a median follow-up of 5 years (Ann. Surg. Oncol. 2012;19:3888-95).

A study by investigators at the University of California, San Francisco, focused more on historical data, finding that many of the 70 patients included in the study had putative risk factors for melanoma. For example, 20% had numerous nevi, 27% had a positive family history, and 25% had a history of sunburn. Also, this study was the only one of the three to address the presence of LCMN, and only three patients had melanoma arising in a nevus, providing further evidence of a low risk of melanoma in LCMN.

The diagnosis of pediatric melanoma was delayed by about a year in more than 60% of the patients.

The investigators noted that primary lesion characteristics differed from those seen in adults, and they concluded that the conventional ABCDE criteria used to help in the diagnosis of melanoma did not capture melanoma in about 60% of the childhood cases and 40% of the adolescent cases.

Lesions in this study were much more likely to be amelanotic in children, and of uniform color in adolescents. Lesional evolution was nearly universal, and bleeding, bumps, variable diameter, and de novo development were common.

On histopathology, a majority of tumors were not superficial spreading type; more were unclassified spitzoid and other histopathologic subtypes, she noted.

Ten patients (14%) died from their melanoma, and of these, 7 had amelanotic melanoma. Only 1 patient under age 10 years died, and that was in the setting of a large congenital melanocytic nevus.

Based on their findings, the investigators suggested pediatric-specific ABCD criteria (A = amelanotic, B = bleeding, bumps, C = color uniformity, and D = de novo and any diameter) to be used along with the conventional ABCDE criteria to facilitate earlier recognition and treatment of pediatric melanoma (J. Am. Acad. Dermatol. 2013 [doi:10.1016/j.jaad.2012.12.953]).

Although there are some conflicting findings in these three studies – including differing conclusions with respect to the value of sentinel lymph node biopsy for predicting outcomes – there also are some consistent findings, Dr. Maguiness said.

Prepubertal melanoma tends to involve thicker tumors, and darker skin types are overrepresented. Also, lesions in all ages in the pediatric population tend to be amelanotic with spitzoid histology, and tend to have higher rates of positive sentinel lymph node biopsies, compared with adult cases. Prepubertal cases have the highest rates of node positivity, she said.

"So, in conclusion, the risk of malignant melanoma within large congenital nevi seems to be lower than we thought, and the diagnosis of malignant melanoma of childhood has excellent prognosis – speaking to the unique natural history and biology of these tumors, which we probably don’t fully understand," she said, adding that adolescent presentations of melanoma seem to be similar to those in adults, with a slightly better overall prognosis.

Dr. Maguiness reported having no disclosures.