NEW YORK (Reuters Health) - Sustained viral response (SVR) to hepatitis C virus (HCV) treatment is associated with a reduction in liver and non-liver complications in patients with compensated cirrhosis, researchers from France report.

"The achievement of HCV eradication strikingly decreases the risks of liver-related complications, a benefit that was up to now only suggested by retrospective studies," Dr. Pierre Nahon from Hôpital Jean Verdier in Bondy, France, told Reuters Health by email.

"These benefits extend beyond liver-related complications, in particular for cardiovascular disease and MACE (major adverse cardiovascular events) as well as bacterial infection," he said. "These positive effects are translated into survival benefits, whether considering liver-related or extra-hepatic mortality."

Dr. Nahon and colleagues from 35 clinical centers in France evaluated the impact of SVR in 1,671 patients, 1,323 of whom had HCV-related compensated cirrhosis.

After a median follow-up of 58.2 months, 59.5% of patients had a negative viral load, including 668 patients (51.7%) with SVR and 119 HCV-negative patients who were still undergoing antiviral treatment.

Male gender, absence of esophageal varices, and absence of diabetes were independent predictive factors for SVR, the researchers report in Gastroenterology, online the September 15.

SVR was associated with a significantly decreased risk of hepatocellular carcinoma (HCC; hazard ratio, 0.29) and mortality among patients who had HCC at baseline.

Patients who achieved SVR were also 74% less likely to develop liver decompensation during follow-up.

Extrahepatic events - including bacterial infections and cardiovascular events - were less than half as common among patients who achieved SVR than among others, but SVR had no apparent effect on the occurrence of extrahepatic malignancies.

SVR independently predicted a lower risk of hepatic and extrahepatic complications, a finding that was confirmed by a supporting propensity-matching analysis.

SVR was a protective factor for all-cause mortality (HR, 0.27; p<0.001), as well as a predictive factor for survival without liver-related or extrahepatic deaths.

"The present report, with the advantage of a longer follow-up and by studying virological clearance at endpoint as a time-dependent covariate after interferon- or direct-acting antivirals (DAA)-based regimen, now clearly shows that achieving SVR in HCV-infected cirrhotic patients leads to an improved prognosis," the researchers conclude.

"Overall, the present data are able to specifically highlight the independent influence of SVR on the incidence of liver complications, including HCC and mortality and interestingly a positive impact on the occurrence of extrahepatic manifestations," they add.

"However," the team notes, "the achievement of SVR in DAA-treated patients is too recent to draw any definite conclusion on this point, which will require a longer follow-up of the CirVir cohort to be adequately addressed."

"Although HCV eradication is achievable in almost all patients, physicians must be aware of the persisting risk of HCC occurrence in cirrhotic patients despite viral clearance, in particular in case of associated metabolic syndrome," Dr. Nahon cautioned. "These patients must be maintained in liver cancer surveillance programs."

The study did not have commercial funding. Several authors, including Dr. Nahon, reported financial ties to Gilead Sciences and other companies selling drugs for hepatitis C.

NEW YORK (Reuters Health) - Sustained viral response (SVR) to hepatitis C virus (HCV) treatment is associated with a reduction in liver and non-liver complications in patients with compensated cirrhosis, researchers from France report.

"The achievement of HCV eradication strikingly decreases the risks of liver-related complications, a benefit that was up to now only suggested by retrospective studies," Dr. Pierre Nahon from Hôpital Jean Verdier in Bondy, France, told Reuters Health by email.

"These benefits extend beyond liver-related complications, in particular for cardiovascular disease and MACE (major adverse cardiovascular events) as well as bacterial infection," he said. "These positive effects are translated into survival benefits, whether considering liver-related or extra-hepatic mortality."

Dr. Nahon and colleagues from 35 clinical centers in France evaluated the impact of SVR in 1,671 patients, 1,323 of whom had HCV-related compensated cirrhosis.

After a median follow-up of 58.2 months, 59.5% of patients had a negative viral load, including 668 patients (51.7%) with SVR and 119 HCV-negative patients who were still undergoing antiviral treatment.

Male gender, absence of esophageal varices, and absence of diabetes were independent predictive factors for SVR, the researchers report in Gastroenterology, online the September 15.

SVR was associated with a significantly decreased risk of hepatocellular carcinoma (HCC; hazard ratio, 0.29) and mortality among patients who had HCC at baseline.

Patients who achieved SVR were also 74% less likely to develop liver decompensation during follow-up.

Extrahepatic events - including bacterial infections and cardiovascular events - were less than half as common among patients who achieved SVR than among others, but SVR had no apparent effect on the occurrence of extrahepatic malignancies.

SVR independently predicted a lower risk of hepatic and extrahepatic complications, a finding that was confirmed by a supporting propensity-matching analysis.

SVR was a protective factor for all-cause mortality (HR, 0.27; p<0.001), as well as a predictive factor for survival without liver-related or extrahepatic deaths.

"The present report, with the advantage of a longer follow-up and by studying virological clearance at endpoint as a time-dependent covariate after interferon- or direct-acting antivirals (DAA)-based regimen, now clearly shows that achieving SVR in HCV-infected cirrhotic patients leads to an improved prognosis," the researchers conclude.

"Overall, the present data are able to specifically highlight the independent influence of SVR on the incidence of liver complications, including HCC and mortality and interestingly a positive impact on the occurrence of extrahepatic manifestations," they add.

"However," the team notes, "the achievement of SVR in DAA-treated patients is too recent to draw any definite conclusion on this point, which will require a longer follow-up of the CirVir cohort to be adequately addressed."

"Although HCV eradication is achievable in almost all patients, physicians must be aware of the persisting risk of HCC occurrence in cirrhotic patients despite viral clearance, in particular in case of associated metabolic syndrome," Dr. Nahon cautioned. "These patients must be maintained in liver cancer surveillance programs."

The study did not have commercial funding. Several authors, including Dr. Nahon, reported financial ties to Gilead Sciences and other companies selling drugs for hepatitis C.

NEW YORK (Reuters Health) - Sustained viral response (SVR) to hepatitis C virus (HCV) treatment is associated with a reduction in liver and non-liver complications in patients with compensated cirrhosis, researchers from France report.

"The achievement of HCV eradication strikingly decreases the risks of liver-related complications, a benefit that was up to now only suggested by retrospective studies," Dr. Pierre Nahon from Hôpital Jean Verdier in Bondy, France, told Reuters Health by email.

"These benefits extend beyond liver-related complications, in particular for cardiovascular disease and MACE (major adverse cardiovascular events) as well as bacterial infection," he said. "These positive effects are translated into survival benefits, whether considering liver-related or extra-hepatic mortality."

Dr. Nahon and colleagues from 35 clinical centers in France evaluated the impact of SVR in 1,671 patients, 1,323 of whom had HCV-related compensated cirrhosis.

After a median follow-up of 58.2 months, 59.5% of patients had a negative viral load, including 668 patients (51.7%) with SVR and 119 HCV-negative patients who were still undergoing antiviral treatment.

Male gender, absence of esophageal varices, and absence of diabetes were independent predictive factors for SVR, the researchers report in Gastroenterology, online the September 15.

SVR was associated with a significantly decreased risk of hepatocellular carcinoma (HCC; hazard ratio, 0.29) and mortality among patients who had HCC at baseline.

Patients who achieved SVR were also 74% less likely to develop liver decompensation during follow-up.

Extrahepatic events - including bacterial infections and cardiovascular events - were less than half as common among patients who achieved SVR than among others, but SVR had no apparent effect on the occurrence of extrahepatic malignancies.

SVR independently predicted a lower risk of hepatic and extrahepatic complications, a finding that was confirmed by a supporting propensity-matching analysis.

SVR was a protective factor for all-cause mortality (HR, 0.27; p<0.001), as well as a predictive factor for survival without liver-related or extrahepatic deaths.

"The present report, with the advantage of a longer follow-up and by studying virological clearance at endpoint as a time-dependent covariate after interferon- or direct-acting antivirals (DAA)-based regimen, now clearly shows that achieving SVR in HCV-infected cirrhotic patients leads to an improved prognosis," the researchers conclude.

"Overall, the present data are able to specifically highlight the independent influence of SVR on the incidence of liver complications, including HCC and mortality and interestingly a positive impact on the occurrence of extrahepatic manifestations," they add.

"However," the team notes, "the achievement of SVR in DAA-treated patients is too recent to draw any definite conclusion on this point, which will require a longer follow-up of the CirVir cohort to be adequately addressed."

"Although HCV eradication is achievable in almost all patients, physicians must be aware of the persisting risk of HCC occurrence in cirrhotic patients despite viral clearance, in particular in case of associated metabolic syndrome," Dr. Nahon cautioned. "These patients must be maintained in liver cancer surveillance programs."

The study did not have commercial funding. Several authors, including Dr. Nahon, reported financial ties to Gilead Sciences and other companies selling drugs for hepatitis C.

The American Society of Clinical Oncology (ASCO) is redefining its role in cancer care. In a pair of presentations made at the Association of VA Hematology/Oncology (AVAHO) annual meeting, ASCO President Daniel F. Hayes, MD, FASCO, FACP, and Robin Zon, MD, FACP, FASCO, who chairs  ASCO’s Pathways Task Force, each outlined key initiatives that promise to push the organization of more than 40,000 oncology care providers into new areas of research and care.

Rekated: Veteran Cancer Research Highlighted in ASCO Posters and Abstracts

Pathways

Responding to the burgeoning of clinical pathways for cancer care, ASCO stepped in to develop best practices and a better process for determining appropriate pathways. Concern over the lack of consensus on quality, efficiency, and transparency in developing pathways also spurred ASCO to action.

According to Dr. Zon, clinical pathways aims to improve efficient patient care based on evidence-based practices, optimize outcomes, and reduce variations and costs. “Pathways can promote high quality care,” Dr. Zon explained, “but they must be implemented responsibly. They are here to stay.”

The ASCO task force developed 9 recommendations for clinical pathways:

1. A collaborative, national approach is necessary to remove administrative burdens.
2. The process should be transparent and consistent, including its methodology.
3. Pathways should address the full spectrum of cancer care from diagnosis to end of life.  
4. Pathways should promote the best evidence based care and be updated continuously. 
5. Patient variability and autonomy should be recognized.
6. Pathways should increase efficiency and remove preauthorizations.
7. Education, research, and access to clinical trials should be encouraged.
8. A robust certification process is essential.
9. Pathways developers should support research that examines how pathways impact patients.

Although the pathways currently have a more significant impact in private care settings, it is likely that truly evidence-based pathways can provide an important tool for oncology providers in the federal system.

TAPUR

The Targeted Agent and Profiling Utilization Registry (TAPUR) study is one of ASCO’s first forays into clinical trials and seeks to evaluate multiple the efficacy of precision medicine. Targeted therapies “should be more likely to help the patient,” asks Dr. Hayes, “but do they?” The trial is evaluating multiple molecularly guided therapies in a single master protocol with a common entry point for patients. TAPUR will include commercially available targeted drugs, but in different cancer types, ie, off label. The trial is supported by a number of pharmaceutical companies. For the trial, each tumor type-genomic variant-drug is a group with 19 patients per group. If 3 or fewer patients respond the group is stopped, but if at least 4 patients have a good overall response rate, 14 additional patients will be enrolled, with the prospect of growing further.

Related: ASCO's Chemotherapy Administration Safety Standards

Dr. Hayes also highlighted other key ASCO initiatives. The group is developing a value framework, which will provide an objective means for both patients and providers to assess the relative value for a specific patient of an intended therapy. Different patients may wish to differently weigh endpoints (overall survival [OS], progression-free survival, or response rate). The framework scores a drug based on its clinical benefits, toxicity, and cost among other factors. ASCO also is developing Cancer-LinQ, a data collection and storage system for oncology practices that consolidates data from electronic health records in a central database that can be

aggregated for research.

The American Society of Clinical Oncology (ASCO) is redefining its role in cancer care. In a pair of presentations made at the Association of VA Hematology/Oncology (AVAHO) annual meeting, ASCO President Daniel F. Hayes, MD, FASCO, FACP, and Robin Zon, MD, FACP, FASCO, who chairs  ASCO’s Pathways Task Force, each outlined key initiatives that promise to push the organization of more than 40,000 oncology care providers into new areas of research and care.

Rekated: Veteran Cancer Research Highlighted in ASCO Posters and Abstracts

Pathways

Responding to the burgeoning of clinical pathways for cancer care, ASCO stepped in to develop best practices and a better process for determining appropriate pathways. Concern over the lack of consensus on quality, efficiency, and transparency in developing pathways also spurred ASCO to action.

According to Dr. Zon, clinical pathways aims to improve efficient patient care based on evidence-based practices, optimize outcomes, and reduce variations and costs. “Pathways can promote high quality care,” Dr. Zon explained, “but they must be implemented responsibly. They are here to stay.”

The ASCO task force developed 9 recommendations for clinical pathways:

1. A collaborative, national approach is necessary to remove administrative burdens.
2. The process should be transparent and consistent, including its methodology.
3. Pathways should address the full spectrum of cancer care from diagnosis to end of life.  
4. Pathways should promote the best evidence based care and be updated continuously. 
5. Patient variability and autonomy should be recognized.
6. Pathways should increase efficiency and remove preauthorizations.
7. Education, research, and access to clinical trials should be encouraged.
8. A robust certification process is essential.
9. Pathways developers should support research that examines how pathways impact patients.

Although the pathways currently have a more significant impact in private care settings, it is likely that truly evidence-based pathways can provide an important tool for oncology providers in the federal system.

TAPUR

The Targeted Agent and Profiling Utilization Registry (TAPUR) study is one of ASCO’s first forays into clinical trials and seeks to evaluate multiple the efficacy of precision medicine. Targeted therapies “should be more likely to help the patient,” asks Dr. Hayes, “but do they?” The trial is evaluating multiple molecularly guided therapies in a single master protocol with a common entry point for patients. TAPUR will include commercially available targeted drugs, but in different cancer types, ie, off label. The trial is supported by a number of pharmaceutical companies. For the trial, each tumor type-genomic variant-drug is a group with 19 patients per group. If 3 or fewer patients respond the group is stopped, but if at least 4 patients have a good overall response rate, 14 additional patients will be enrolled, with the prospect of growing further.

Related: ASCO's Chemotherapy Administration Safety Standards

Dr. Hayes also highlighted other key ASCO initiatives. The group is developing a value framework, which will provide an objective means for both patients and providers to assess the relative value for a specific patient of an intended therapy. Different patients may wish to differently weigh endpoints (overall survival [OS], progression-free survival, or response rate). The framework scores a drug based on its clinical benefits, toxicity, and cost among other factors. ASCO also is developing Cancer-LinQ, a data collection and storage system for oncology practices that consolidates data from electronic health records in a central database that can be

aggregated for research.

The American Society of Clinical Oncology (ASCO) is redefining its role in cancer care. In a pair of presentations made at the Association of VA Hematology/Oncology (AVAHO) annual meeting, ASCO President Daniel F. Hayes, MD, FASCO, FACP, and Robin Zon, MD, FACP, FASCO, who chairs  ASCO’s Pathways Task Force, each outlined key initiatives that promise to push the organization of more than 40,000 oncology care providers into new areas of research and care.

Rekated: Veteran Cancer Research Highlighted in ASCO Posters and Abstracts

Pathways

Responding to the burgeoning of clinical pathways for cancer care, ASCO stepped in to develop best practices and a better process for determining appropriate pathways. Concern over the lack of consensus on quality, efficiency, and transparency in developing pathways also spurred ASCO to action.

According to Dr. Zon, clinical pathways aims to improve efficient patient care based on evidence-based practices, optimize outcomes, and reduce variations and costs. “Pathways can promote high quality care,” Dr. Zon explained, “but they must be implemented responsibly. They are here to stay.”

The ASCO task force developed 9 recommendations for clinical pathways:

1. A collaborative, national approach is necessary to remove administrative burdens.
2. The process should be transparent and consistent, including its methodology.
3. Pathways should address the full spectrum of cancer care from diagnosis to end of life.  
4. Pathways should promote the best evidence based care and be updated continuously. 
5. Patient variability and autonomy should be recognized.
6. Pathways should increase efficiency and remove preauthorizations.
7. Education, research, and access to clinical trials should be encouraged.
8. A robust certification process is essential.
9. Pathways developers should support research that examines how pathways impact patients.

Although the pathways currently have a more significant impact in private care settings, it is likely that truly evidence-based pathways can provide an important tool for oncology providers in the federal system.

TAPUR

The Targeted Agent and Profiling Utilization Registry (TAPUR) study is one of ASCO’s first forays into clinical trials and seeks to evaluate multiple the efficacy of precision medicine. Targeted therapies “should be more likely to help the patient,” asks Dr. Hayes, “but do they?” The trial is evaluating multiple molecularly guided therapies in a single master protocol with a common entry point for patients. TAPUR will include commercially available targeted drugs, but in different cancer types, ie, off label. The trial is supported by a number of pharmaceutical companies. For the trial, each tumor type-genomic variant-drug is a group with 19 patients per group. If 3 or fewer patients respond the group is stopped, but if at least 4 patients have a good overall response rate, 14 additional patients will be enrolled, with the prospect of growing further.

Related: ASCO's Chemotherapy Administration Safety Standards

Dr. Hayes also highlighted other key ASCO initiatives. The group is developing a value framework, which will provide an objective means for both patients and providers to assess the relative value for a specific patient of an intended therapy. Different patients may wish to differently weigh endpoints (overall survival [OS], progression-free survival, or response rate). The framework scores a drug based on its clinical benefits, toxicity, and cost among other factors. ASCO also is developing Cancer-LinQ, a data collection and storage system for oncology practices that consolidates data from electronic health records in a central database that can be

aggregated for research.

Help us celebrate the AATS Centennial. Experience activities, events, historical artifacts and memorabilia commemorating the 100th anniversary of the American Association for Thoracic Surgery and the field of cardiothoracic surgery.

April 29 – May 3, 2017
Boston Hynes Convention Center
Boston, MA

A unique aspect of this year’s meeting is our collaboration with the American Society of Extracorporeal Technology (AmSECT). During the didactic portion of the program, the two organizations will be conducting joint panel sessions of interest to all members of the team.

AATS President & Annual Meeting Chair
Thoralf M. Sundt, III

AATS Annual Meeting Co-Chairs
Robert D. Jaquiss & Bryan F. Meyers

AmSECT President
Kenneth Shann

AmSECT International Conference Co-Chairs
Emily Saulitis & Larissa M.V. Teresi

More Information

Saturday Courses 

Adult Cardiac Skills Chairs
Volkmar Falk, David Fitzgerald, Kenton Zehr

Congenital Skills Chairs
Ron Angona, David Bichell, Bohdan Maruszewski

General Thoracic Skills Chairs
Virginia Litle, Kazuhiro Yasufuku

Cardiothoracic Transplant and Mechanical Circulatory Support of Heart and Lung Failure Chairs
Matthew Bacchetta, Carmelo Milano, Rich Walczak

Surgical Ethics Forum Chairs
Bill DeBois, Martin McKneally, Robert Sade

Sunday Symposia

AATS/STS Adult Cardiac Surgery Symposium  Chairs
David Fitzgerald, Hitoshi Ognio, Vinod Thourani 

AATS/STS Congenital Heart Disease Symposium Chairs
Ron Angona, Michael Mitchell, Giovanni Stellin 

AATS/STS General Thoracic Surgery Symposium Chairs
 Seth Force, Moishe Liberman

Interprofessional Cardiothoracic Team Symposium Chairs
Steven Gottesfeld, Katherine Hoercher, Bruce Searles, Glenn Whitman

Saturday Course/Sunday Symposia Program

Share:

Help us celebrate the AATS Centennial. Experience activities, events, historical artifacts and memorabilia commemorating the 100th anniversary of the American Association for Thoracic Surgery and the field of cardiothoracic surgery.

April 29 – May 3, 2017
Boston Hynes Convention Center
Boston, MA

A unique aspect of this year’s meeting is our collaboration with the American Society of Extracorporeal Technology (AmSECT). During the didactic portion of the program, the two organizations will be conducting joint panel sessions of interest to all members of the team.

AATS President & Annual Meeting Chair
Thoralf M. Sundt, III

AATS Annual Meeting Co-Chairs
Robert D. Jaquiss & Bryan F. Meyers

AmSECT President
Kenneth Shann

AmSECT International Conference Co-Chairs
Emily Saulitis & Larissa M.V. Teresi

More Information

Saturday Courses 

Adult Cardiac Skills Chairs
Volkmar Falk, David Fitzgerald, Kenton Zehr

Congenital Skills Chairs
Ron Angona, David Bichell, Bohdan Maruszewski

General Thoracic Skills Chairs
Virginia Litle, Kazuhiro Yasufuku

Cardiothoracic Transplant and Mechanical Circulatory Support of Heart and Lung Failure Chairs
Matthew Bacchetta, Carmelo Milano, Rich Walczak

Surgical Ethics Forum Chairs
Bill DeBois, Martin McKneally, Robert Sade

Sunday Symposia

AATS/STS Adult Cardiac Surgery Symposium  Chairs
David Fitzgerald, Hitoshi Ognio, Vinod Thourani 

AATS/STS Congenital Heart Disease Symposium Chairs
Ron Angona, Michael Mitchell, Giovanni Stellin 

AATS/STS General Thoracic Surgery Symposium Chairs
 Seth Force, Moishe Liberman

Interprofessional Cardiothoracic Team Symposium Chairs
Steven Gottesfeld, Katherine Hoercher, Bruce Searles, Glenn Whitman

Saturday Course/Sunday Symposia Program

Share:

Help us celebrate the AATS Centennial. Experience activities, events, historical artifacts and memorabilia commemorating the 100th anniversary of the American Association for Thoracic Surgery and the field of cardiothoracic surgery.

April 29 – May 3, 2017
Boston Hynes Convention Center
Boston, MA

A unique aspect of this year’s meeting is our collaboration with the American Society of Extracorporeal Technology (AmSECT). During the didactic portion of the program, the two organizations will be conducting joint panel sessions of interest to all members of the team.

AATS President & Annual Meeting Chair
Thoralf M. Sundt, III

AATS Annual Meeting Co-Chairs
Robert D. Jaquiss & Bryan F. Meyers

AmSECT President
Kenneth Shann

AmSECT International Conference Co-Chairs
Emily Saulitis & Larissa M.V. Teresi

More Information

Saturday Courses 

Adult Cardiac Skills Chairs
Volkmar Falk, David Fitzgerald, Kenton Zehr

Congenital Skills Chairs
Ron Angona, David Bichell, Bohdan Maruszewski

General Thoracic Skills Chairs
Virginia Litle, Kazuhiro Yasufuku

Cardiothoracic Transplant and Mechanical Circulatory Support of Heart and Lung Failure Chairs
Matthew Bacchetta, Carmelo Milano, Rich Walczak

Surgical Ethics Forum Chairs
Bill DeBois, Martin McKneally, Robert Sade

Sunday Symposia

AATS/STS Adult Cardiac Surgery Symposium  Chairs
David Fitzgerald, Hitoshi Ognio, Vinod Thourani 

AATS/STS Congenital Heart Disease Symposium Chairs
Ron Angona, Michael Mitchell, Giovanni Stellin 

AATS/STS General Thoracic Surgery Symposium Chairs
 Seth Force, Moishe Liberman

Interprofessional Cardiothoracic Team Symposium Chairs
Steven Gottesfeld, Katherine Hoercher, Bruce Searles, Glenn Whitman

Saturday Course/Sunday Symposia Program

Share:

As more and more patients with cancer become cancer survivors, the treatment landscape is changing. Increasingly, primary care providers bear much of the burden of care, but the lack of care coordination and clinical guidelines hamper efforts to care for the growing number of survivors. A number of speakers at the recent Association of VA Hematology/Oncology (AVAHO) sought to address these challenges and report on approaches to improving the quality of care for survivors.

Related: Putting the Focus on Quality of Life in Cancer Care

The VA Survivorship Interest Group (SIG) is trying to raise awareness and facilitate the delivery of high-quality survivorship care to veterans diagnosed with cancer, according to David A. Haggstrom, MD, MAS, of the Indianapolis VA Medical Center and Indiana University School of Medicine. Through monthly meetings, SIG is  encouraging new research and promoting initiatives to develop survivorship related products and appropriate models of care delivery.

A Survivorship care plan that includes a treatment summary, and follow-up plan for a patient who has completed cancer treatment is one approach to improve care for cancer survivors. According to Haggstrom, the VA appears to be on track to meet the Commission on Care’s recommendation that ≥ 25% of eligible patients receive a survivorship care plan by the end of 2016, but more work needs to be done to get to the 2017 goal of ≥ 50%.

Related: Defining Quality Cancer Survivorship Care: Symptom Burden and Distress in Veteran Cancer Survivors. VA Puget Sound Cancer Survivorship Clinic

For example, the more than 2 million prostate cancer survivors have a number of complex problems that pose challenges to VA care providers, according to Ted A. Skolarus, MD, MPH, of the University of Michigan and VA Ann Arbor Healthcare System. Poor urinary control and sexual function can have a significant impact on quality of life for survivors. Furthermore, the lack of organized symptom assessment, clinical guidelines, and other support for patients and providers remains a challenge for providing high-quality care. Much of that burden is born by primary care providers, who are frequently uncomfortable addressing incontinence, impotence, and other psychosocial issues that are common among prostate cancer survivors.

Dr. Skolarus discussed an ongoing randomized self-management trial of veteran prostate cancer survivors, which tested self-management. Patients were assessed using an interactive voice response tool to administer a quality of life survey based on the Expanded Prostate Cancer Index Composite (EPIC), which measures urinary, sexual, bowel, and hormonal/vitality health. Patients are then provided with self-management tools that are specifically developed based on their EPIC responses. The trial is expected to close at the end of 2016.

Related: Cancer Survivorship Care

Sharon L. Bober, PhD, director of the Sexual Health Program at Dana-Farber Cancer Institute, delved in greater detail into the impact of sexual health on quality of life among cancer survivors. The majority of survivors are not prepared to deal with changes in sexual health, Dr. Bober reported, and “more than 50% have profound long lasting dysfunction.” Estimates of sexual dysfunction after cancer range from 40% to 100%, and while the issues for patients with breast or prostate cancer are more obvious, the sexual health problems are not limited to those types of cancer. Moreover, Dr. Bober argued, sexual health involves both physical and psychological aspects and proper treatment should address both.

As more and more patients with cancer become cancer survivors, the treatment landscape is changing. Increasingly, primary care providers bear much of the burden of care, but the lack of care coordination and clinical guidelines hamper efforts to care for the growing number of survivors. A number of speakers at the recent Association of VA Hematology/Oncology (AVAHO) sought to address these challenges and report on approaches to improving the quality of care for survivors.

Related: Putting the Focus on Quality of Life in Cancer Care

The VA Survivorship Interest Group (SIG) is trying to raise awareness and facilitate the delivery of high-quality survivorship care to veterans diagnosed with cancer, according to David A. Haggstrom, MD, MAS, of the Indianapolis VA Medical Center and Indiana University School of Medicine. Through monthly meetings, SIG is  encouraging new research and promoting initiatives to develop survivorship related products and appropriate models of care delivery.

A Survivorship care plan that includes a treatment summary, and follow-up plan for a patient who has completed cancer treatment is one approach to improve care for cancer survivors. According to Haggstrom, the VA appears to be on track to meet the Commission on Care’s recommendation that ≥ 25% of eligible patients receive a survivorship care plan by the end of 2016, but more work needs to be done to get to the 2017 goal of ≥ 50%.

Related: Defining Quality Cancer Survivorship Care: Symptom Burden and Distress in Veteran Cancer Survivors. VA Puget Sound Cancer Survivorship Clinic

For example, the more than 2 million prostate cancer survivors have a number of complex problems that pose challenges to VA care providers, according to Ted A. Skolarus, MD, MPH, of the University of Michigan and VA Ann Arbor Healthcare System. Poor urinary control and sexual function can have a significant impact on quality of life for survivors. Furthermore, the lack of organized symptom assessment, clinical guidelines, and other support for patients and providers remains a challenge for providing high-quality care. Much of that burden is born by primary care providers, who are frequently uncomfortable addressing incontinence, impotence, and other psychosocial issues that are common among prostate cancer survivors.

Dr. Skolarus discussed an ongoing randomized self-management trial of veteran prostate cancer survivors, which tested self-management. Patients were assessed using an interactive voice response tool to administer a quality of life survey based on the Expanded Prostate Cancer Index Composite (EPIC), which measures urinary, sexual, bowel, and hormonal/vitality health. Patients are then provided with self-management tools that are specifically developed based on their EPIC responses. The trial is expected to close at the end of 2016.

Related: Cancer Survivorship Care

Sharon L. Bober, PhD, director of the Sexual Health Program at Dana-Farber Cancer Institute, delved in greater detail into the impact of sexual health on quality of life among cancer survivors. The majority of survivors are not prepared to deal with changes in sexual health, Dr. Bober reported, and “more than 50% have profound long lasting dysfunction.” Estimates of sexual dysfunction after cancer range from 40% to 100%, and while the issues for patients with breast or prostate cancer are more obvious, the sexual health problems are not limited to those types of cancer. Moreover, Dr. Bober argued, sexual health involves both physical and psychological aspects and proper treatment should address both.

As more and more patients with cancer become cancer survivors, the treatment landscape is changing. Increasingly, primary care providers bear much of the burden of care, but the lack of care coordination and clinical guidelines hamper efforts to care for the growing number of survivors. A number of speakers at the recent Association of VA Hematology/Oncology (AVAHO) sought to address these challenges and report on approaches to improving the quality of care for survivors.

Related: Putting the Focus on Quality of Life in Cancer Care

The VA Survivorship Interest Group (SIG) is trying to raise awareness and facilitate the delivery of high-quality survivorship care to veterans diagnosed with cancer, according to David A. Haggstrom, MD, MAS, of the Indianapolis VA Medical Center and Indiana University School of Medicine. Through monthly meetings, SIG is  encouraging new research and promoting initiatives to develop survivorship related products and appropriate models of care delivery.

A Survivorship care plan that includes a treatment summary, and follow-up plan for a patient who has completed cancer treatment is one approach to improve care for cancer survivors. According to Haggstrom, the VA appears to be on track to meet the Commission on Care’s recommendation that ≥ 25% of eligible patients receive a survivorship care plan by the end of 2016, but more work needs to be done to get to the 2017 goal of ≥ 50%.

Related: Defining Quality Cancer Survivorship Care: Symptom Burden and Distress in Veteran Cancer Survivors. VA Puget Sound Cancer Survivorship Clinic

For example, the more than 2 million prostate cancer survivors have a number of complex problems that pose challenges to VA care providers, according to Ted A. Skolarus, MD, MPH, of the University of Michigan and VA Ann Arbor Healthcare System. Poor urinary control and sexual function can have a significant impact on quality of life for survivors. Furthermore, the lack of organized symptom assessment, clinical guidelines, and other support for patients and providers remains a challenge for providing high-quality care. Much of that burden is born by primary care providers, who are frequently uncomfortable addressing incontinence, impotence, and other psychosocial issues that are common among prostate cancer survivors.

Dr. Skolarus discussed an ongoing randomized self-management trial of veteran prostate cancer survivors, which tested self-management. Patients were assessed using an interactive voice response tool to administer a quality of life survey based on the Expanded Prostate Cancer Index Composite (EPIC), which measures urinary, sexual, bowel, and hormonal/vitality health. Patients are then provided with self-management tools that are specifically developed based on their EPIC responses. The trial is expected to close at the end of 2016.

Related: Cancer Survivorship Care

Sharon L. Bober, PhD, director of the Sexual Health Program at Dana-Farber Cancer Institute, delved in greater detail into the impact of sexual health on quality of life among cancer survivors. The majority of survivors are not prepared to deal with changes in sexual health, Dr. Bober reported, and “more than 50% have profound long lasting dysfunction.” Estimates of sexual dysfunction after cancer range from 40% to 100%, and while the issues for patients with breast or prostate cancer are more obvious, the sexual health problems are not limited to those types of cancer. Moreover, Dr. Bober argued, sexual health involves both physical and psychological aspects and proper treatment should address both.

Man using a computer

The Lymphoma Association has launched Lymphoma TrialsLink, an online information service that can help lymphoma patients in the UK find clinical trials that might be right for them.

Lymphoma TrialsLink pulls information from different clinical trials databases and puts it in one place.

Lymphoma TrialsLink also provides information about different types of clinical trials and interviews with clinicians and patients who have participated in trials.

The service is available via the Lymphoma Association website: www.lymphomas.org.uk/TrialsLink.

At Lymphoma TrialsLink, patients can search by their type of lymphoma and geographical location to find easy-to-understand information about trials.

At present, treatment trials (phases 1/2 and 2/3), non-drug and non-treatment trials, and cross-tumoral trials that are currently recruiting participants in the UK are available on the Lymphoma TrialsLink website. Information on phase 1, phase 4, and invitation-only trials will be introduced in 2017.

Trial information, which is searchable by type of lymphoma and location, is sourced from a number of databases, including Cancer Research UK trials, UK clinical trials gateway, clinicaltrials.gov, and the NCRI Lymphoma Clinical Studies Group.

The data is verified by the coordinating trial center to ensure that closing dates and trial centers are up-to-date. The content on Lymphoma TrialsLink will be updated monthly.

“Clinical trials are essential for investigating drugs for the treatment of lymphatic cancer and improving survivorship rates,” said Jonathan Pearce, Lymphoma Association chief executive.

“Clinical trials aren’t right for everyone, but we want people to feel empowered to make an informed decision. Lymphoma TrialsLink will mean that lymphoma patients who aren’t currently aware of clinical trials will have the opportunity to find out more about relevant trials and make the best possible decisions about their healthcare.”

A recent Lymphoma Association survey of more than 3000 lymphoma patients* revealed that 78% were not given the option of participating in a clinical trial. Of those who were, the majority joined a trial.

“Lymphoma is the UK’s fifth most common cancer, yet it is neither well-known nor easily understood,” Pearce noted. “We are committed to supporting clinical research to help improve knowledge of lymphoma, to drive advances in treatments, and to deliver better outcomes for people affected by lymphoma.”

Lymphoma TrialsLink is funded by voluntary donations from Lymphoma Association supporters who responded to a fundraising appeal earlier this year.

*A quality health survey commissioned in 2016 by the Lymphoma Association. The full results of the survey are expected to be published soon.

Man using a computer

The Lymphoma Association has launched Lymphoma TrialsLink, an online information service that can help lymphoma patients in the UK find clinical trials that might be right for them.

Lymphoma TrialsLink pulls information from different clinical trials databases and puts it in one place.

Lymphoma TrialsLink also provides information about different types of clinical trials and interviews with clinicians and patients who have participated in trials.

The service is available via the Lymphoma Association website: www.lymphomas.org.uk/TrialsLink.

At Lymphoma TrialsLink, patients can search by their type of lymphoma and geographical location to find easy-to-understand information about trials.

At present, treatment trials (phases 1/2 and 2/3), non-drug and non-treatment trials, and cross-tumoral trials that are currently recruiting participants in the UK are available on the Lymphoma TrialsLink website. Information on phase 1, phase 4, and invitation-only trials will be introduced in 2017.

Trial information, which is searchable by type of lymphoma and location, is sourced from a number of databases, including Cancer Research UK trials, UK clinical trials gateway, clinicaltrials.gov, and the NCRI Lymphoma Clinical Studies Group.

The data is verified by the coordinating trial center to ensure that closing dates and trial centers are up-to-date. The content on Lymphoma TrialsLink will be updated monthly.

“Clinical trials are essential for investigating drugs for the treatment of lymphatic cancer and improving survivorship rates,” said Jonathan Pearce, Lymphoma Association chief executive.

“Clinical trials aren’t right for everyone, but we want people to feel empowered to make an informed decision. Lymphoma TrialsLink will mean that lymphoma patients who aren’t currently aware of clinical trials will have the opportunity to find out more about relevant trials and make the best possible decisions about their healthcare.”

A recent Lymphoma Association survey of more than 3000 lymphoma patients* revealed that 78% were not given the option of participating in a clinical trial. Of those who were, the majority joined a trial.

“Lymphoma is the UK’s fifth most common cancer, yet it is neither well-known nor easily understood,” Pearce noted. “We are committed to supporting clinical research to help improve knowledge of lymphoma, to drive advances in treatments, and to deliver better outcomes for people affected by lymphoma.”

Lymphoma TrialsLink is funded by voluntary donations from Lymphoma Association supporters who responded to a fundraising appeal earlier this year.

*A quality health survey commissioned in 2016 by the Lymphoma Association. The full results of the survey are expected to be published soon.

Man using a computer

The Lymphoma Association has launched Lymphoma TrialsLink, an online information service that can help lymphoma patients in the UK find clinical trials that might be right for them.

Lymphoma TrialsLink pulls information from different clinical trials databases and puts it in one place.

Lymphoma TrialsLink also provides information about different types of clinical trials and interviews with clinicians and patients who have participated in trials.

The service is available via the Lymphoma Association website: www.lymphomas.org.uk/TrialsLink.

At Lymphoma TrialsLink, patients can search by their type of lymphoma and geographical location to find easy-to-understand information about trials.

At present, treatment trials (phases 1/2 and 2/3), non-drug and non-treatment trials, and cross-tumoral trials that are currently recruiting participants in the UK are available on the Lymphoma TrialsLink website. Information on phase 1, phase 4, and invitation-only trials will be introduced in 2017.

Trial information, which is searchable by type of lymphoma and location, is sourced from a number of databases, including Cancer Research UK trials, UK clinical trials gateway, clinicaltrials.gov, and the NCRI Lymphoma Clinical Studies Group.

The data is verified by the coordinating trial center to ensure that closing dates and trial centers are up-to-date. The content on Lymphoma TrialsLink will be updated monthly.

“Clinical trials are essential for investigating drugs for the treatment of lymphatic cancer and improving survivorship rates,” said Jonathan Pearce, Lymphoma Association chief executive.

“Clinical trials aren’t right for everyone, but we want people to feel empowered to make an informed decision. Lymphoma TrialsLink will mean that lymphoma patients who aren’t currently aware of clinical trials will have the opportunity to find out more about relevant trials and make the best possible decisions about their healthcare.”

A recent Lymphoma Association survey of more than 3000 lymphoma patients* revealed that 78% were not given the option of participating in a clinical trial. Of those who were, the majority joined a trial.

“Lymphoma is the UK’s fifth most common cancer, yet it is neither well-known nor easily understood,” Pearce noted. “We are committed to supporting clinical research to help improve knowledge of lymphoma, to drive advances in treatments, and to deliver better outcomes for people affected by lymphoma.”

Lymphoma TrialsLink is funded by voluntary donations from Lymphoma Association supporters who responded to a fundraising appeal earlier this year.

*A quality health survey commissioned in 2016 by the Lymphoma Association. The full results of the survey are expected to be published soon.

Elena Fidarova, MD

Photo courtesy of ASTRO

BOSTON—A new study suggests that roughly half of cancer patients in developing countries need radiation therapy (RT) to treat their disease, but many of these patients do not have access to it.

Examining 9 developing countries, investigators found that between 18% and 82% of patients who can benefit from RT do not receive the treatment.

These findings were presented at ASTRO’s 58th Annual Meeting (abstract 82).

“Access to radiation therapy remains limited in low-and middle-income countries,” said study investigator Elena Fidarova, MD, of the International Atomic Energy Agency in Vienna, Austria.

“In Ghana and the Philippines, for example, about 8 in 10 cancer patients who need radiation therapy will not receive needed treatment.”

Dr Fidarova and her colleagues conducted this study to assess levels of optimal and actual RT utilization (RTU) and calculate unmet RT need in 9 developing countries—Costa Rica, Ghana, Malaysia, the Philippines, Romania, Serbia, Slovenia, Tunisia, and Uruguay.

The investigators determined the optimal and actual RTU rates for each country. The optimal RTU rate is the proportion of all newly diagnosed cancer patients who have an indication for RT at least once in their lifetime.

An indication for RT was defined as a clinical scenario for which RT is recommended as the treatment of choice because there is evidence of its superiority to alternative modalities and/or no treatment (eg, better survival, local control, or quality of life profiles).

In clinical situations where RT was equivalent to other treatment options, all comparable modalities were included in the model, and a subsequent sensitivity analysis was conducted to determine the proportion of these patients for whom RT was indicated.

Results

The median optimal RTU for all countries was 52%. Optimal RTU rates ranged from a low of 47% for Costa Rica to a high of 56% for Tunisia. Differences in optimal RTU rates are attributable to varying incidence rates of cancer types in each country.

The median actual RTU rate was roughly half of optimal utilization, suggesting that nearly half of cancer patients across these 9 countries combined may not be receiving adequate care for their disease.

The median actual RTU rate was 28%. The lowest rates of utilization were in Ghana (9%) and the Philippines (10.3%), while the highest utilization rates were in Tunisia (46%) and Uruguay (37%).

Actual RTU rates were lower than optimal RTU rates for all 9 countries, with the smallest difference in Tunisia and the widest gap in Ghana—at nearly 43 percentage points.

The median level of unmet need was 47% for all countries combined.

Ghana and the Philippines had the highest levels of unmet need, at 82.3% and 80.5%, respectively. Costa Rica and Tunisia had the lowest levels of unmet need, at 25.5% and 18%, respectively.

The unmet need was especially high in countries with limited resources and a large population. The number of teletherapy machines per 1000 cancer cases ranged from a high of 1.3 in Tunisia to a low of 0.19 in Ghana.

The strong correlation between the actual RTU rates and the number of teletherapy machines per 1000 cancer cases/year in each country confirms that, although other access factors may be at play, the availability of RT machines is an important factor in RT utilization.

“Differences between optimal and actual RTU rates and the high percentage of unmet RT need likely stem from a number of complex reasons, although inadequate capacity for radiation therapy is the most obvious factor,” Dr Fidarova said.

“As obstacles in access to existing RT services—such as inadequate referral patterns, affordability of treatment, and geographical distribution of centers—differ by country, so does the ideal mix of solutions.”

Elena Fidarova, MD

Photo courtesy of ASTRO

BOSTON—A new study suggests that roughly half of cancer patients in developing countries need radiation therapy (RT) to treat their disease, but many of these patients do not have access to it.

Examining 9 developing countries, investigators found that between 18% and 82% of patients who can benefit from RT do not receive the treatment.

These findings were presented at ASTRO’s 58th Annual Meeting (abstract 82).

“Access to radiation therapy remains limited in low-and middle-income countries,” said study investigator Elena Fidarova, MD, of the International Atomic Energy Agency in Vienna, Austria.

“In Ghana and the Philippines, for example, about 8 in 10 cancer patients who need radiation therapy will not receive needed treatment.”

Dr Fidarova and her colleagues conducted this study to assess levels of optimal and actual RT utilization (RTU) and calculate unmet RT need in 9 developing countries—Costa Rica, Ghana, Malaysia, the Philippines, Romania, Serbia, Slovenia, Tunisia, and Uruguay.

The investigators determined the optimal and actual RTU rates for each country. The optimal RTU rate is the proportion of all newly diagnosed cancer patients who have an indication for RT at least once in their lifetime.

An indication for RT was defined as a clinical scenario for which RT is recommended as the treatment of choice because there is evidence of its superiority to alternative modalities and/or no treatment (eg, better survival, local control, or quality of life profiles).

In clinical situations where RT was equivalent to other treatment options, all comparable modalities were included in the model, and a subsequent sensitivity analysis was conducted to determine the proportion of these patients for whom RT was indicated.

Results

The median optimal RTU for all countries was 52%. Optimal RTU rates ranged from a low of 47% for Costa Rica to a high of 56% for Tunisia. Differences in optimal RTU rates are attributable to varying incidence rates of cancer types in each country.

The median actual RTU rate was roughly half of optimal utilization, suggesting that nearly half of cancer patients across these 9 countries combined may not be receiving adequate care for their disease.

The median actual RTU rate was 28%. The lowest rates of utilization were in Ghana (9%) and the Philippines (10.3%), while the highest utilization rates were in Tunisia (46%) and Uruguay (37%).

Actual RTU rates were lower than optimal RTU rates for all 9 countries, with the smallest difference in Tunisia and the widest gap in Ghana—at nearly 43 percentage points.

The median level of unmet need was 47% for all countries combined.

Ghana and the Philippines had the highest levels of unmet need, at 82.3% and 80.5%, respectively. Costa Rica and Tunisia had the lowest levels of unmet need, at 25.5% and 18%, respectively.

The unmet need was especially high in countries with limited resources and a large population. The number of teletherapy machines per 1000 cancer cases ranged from a high of 1.3 in Tunisia to a low of 0.19 in Ghana.

The strong correlation between the actual RTU rates and the number of teletherapy machines per 1000 cancer cases/year in each country confirms that, although other access factors may be at play, the availability of RT machines is an important factor in RT utilization.

“Differences between optimal and actual RTU rates and the high percentage of unmet RT need likely stem from a number of complex reasons, although inadequate capacity for radiation therapy is the most obvious factor,” Dr Fidarova said.

“As obstacles in access to existing RT services—such as inadequate referral patterns, affordability of treatment, and geographical distribution of centers—differ by country, so does the ideal mix of solutions.”

Elena Fidarova, MD

Photo courtesy of ASTRO

BOSTON—A new study suggests that roughly half of cancer patients in developing countries need radiation therapy (RT) to treat their disease, but many of these patients do not have access to it.

Examining 9 developing countries, investigators found that between 18% and 82% of patients who can benefit from RT do not receive the treatment.

These findings were presented at ASTRO’s 58th Annual Meeting (abstract 82).

“Access to radiation therapy remains limited in low-and middle-income countries,” said study investigator Elena Fidarova, MD, of the International Atomic Energy Agency in Vienna, Austria.

“In Ghana and the Philippines, for example, about 8 in 10 cancer patients who need radiation therapy will not receive needed treatment.”

Dr Fidarova and her colleagues conducted this study to assess levels of optimal and actual RT utilization (RTU) and calculate unmet RT need in 9 developing countries—Costa Rica, Ghana, Malaysia, the Philippines, Romania, Serbia, Slovenia, Tunisia, and Uruguay.

The investigators determined the optimal and actual RTU rates for each country. The optimal RTU rate is the proportion of all newly diagnosed cancer patients who have an indication for RT at least once in their lifetime.

An indication for RT was defined as a clinical scenario for which RT is recommended as the treatment of choice because there is evidence of its superiority to alternative modalities and/or no treatment (eg, better survival, local control, or quality of life profiles).

In clinical situations where RT was equivalent to other treatment options, all comparable modalities were included in the model, and a subsequent sensitivity analysis was conducted to determine the proportion of these patients for whom RT was indicated.

Results

The median optimal RTU for all countries was 52%. Optimal RTU rates ranged from a low of 47% for Costa Rica to a high of 56% for Tunisia. Differences in optimal RTU rates are attributable to varying incidence rates of cancer types in each country.

The median actual RTU rate was roughly half of optimal utilization, suggesting that nearly half of cancer patients across these 9 countries combined may not be receiving adequate care for their disease.

The median actual RTU rate was 28%. The lowest rates of utilization were in Ghana (9%) and the Philippines (10.3%), while the highest utilization rates were in Tunisia (46%) and Uruguay (37%).

Actual RTU rates were lower than optimal RTU rates for all 9 countries, with the smallest difference in Tunisia and the widest gap in Ghana—at nearly 43 percentage points.

The median level of unmet need was 47% for all countries combined.

Ghana and the Philippines had the highest levels of unmet need, at 82.3% and 80.5%, respectively. Costa Rica and Tunisia had the lowest levels of unmet need, at 25.5% and 18%, respectively.

The unmet need was especially high in countries with limited resources and a large population. The number of teletherapy machines per 1000 cancer cases ranged from a high of 1.3 in Tunisia to a low of 0.19 in Ghana.

The strong correlation between the actual RTU rates and the number of teletherapy machines per 1000 cancer cases/year in each country confirms that, although other access factors may be at play, the availability of RT machines is an important factor in RT utilization.

“Differences between optimal and actual RTU rates and the high percentage of unmet RT need likely stem from a number of complex reasons, although inadequate capacity for radiation therapy is the most obvious factor,” Dr Fidarova said.

“As obstacles in access to existing RT services—such as inadequate referral patterns, affordability of treatment, and geographical distribution of centers—differ by country, so does the ideal mix of solutions.”

Micrograph showing MF

The National Comprehensive Cancer Network (NCCN) has published new clinical practice guidelines for myeloproliferative neoplasms (MPNs).

The current guidelines focus on the management of patients with myelofibrosis (MF), but NCCN said recommendations for managing essential thrombocythemia (ET) and polycythemia vera (PV) will be included in subsequent versions of the NCCN guidelines for MPNs.

The new guidelines provide recommendations on the workup and diagnosis of primary MF, post-ET MF, and post-PV MF.

The document also includes recommendations for managing MF-associated anemia, supportive care options, and treatment recommendations according to a patient’s risk group.

Treatment of low-risk MF

The guidelines recommend that patients with low-risk, asymptomatic MF be observed or enrolled in a clinical trial. They should be monitored for progression every 3 to 6 months.

Patients with low-risk, symptomatic MF should receive ruxolitinib or interferons or be enrolled on a clinical trial. They should be monitored for progression every 3 to 6 months.

If patients respond to treatment, they should continue to receive it. If they do not respond or lose their response, they should receive ruxolitinib or interferons or be enrolled on a clinical trial. If these patients progress, they should be treated according to their risk category.

Intermediate-1-risk MF

Patients with intermediate-1-risk MF should be assessed for symptom burden and observed if asymptomatic. If symptomatic, they should receive ruxolitinib, be enrolled on a clinical trial, or undergo allogeneic hematopoietic stem cell transplant (HSCT).

Patients should be monitored for response and progression every 3 to 6 months. If they respond to treatment, they should continue to receive it.

If patients do not respond or lose their response, they should be observed, receive ruxolitinib, be enrolled on a clinical trial, or undergo allogeneic HSCT. If these patients progress, they should be treated according to their risk category.

Intermediate-2- or high-risk MF

Patients who are transplant candidates should receive allogeneic HSCT.

Patients who are ineligible for transplant should be assessed for symptom burden. Those with a platelet count of 50,000 or lower should be considered for a clinical trial.

Those with higher platelet counts should receive ruxolitinib or be enrolled on a clinical trial. They should be monitored for response or progression every 3 to 6 months.

If these patients respond to treatment, they should continue on that treatment. If they do not respond or lose their response, the patients should be monitored for progression.

If they progress and are candidates for transplant, these patients should receive hypomethylating agents or chemotherapy to induce remission, followed by HSCT.

If the patients progress and are ineligible for transplant, they should be enrolled on a clinical trial or receive hypomethylating agents or chemotherapy.

For patients who are ineligible for transplant and only have symptomatic anemia, they should receive treatment to manage that anemia. The guidelines list a range of treatment options.

“The management of MPNs has been variable in the past and largely driven by review articles and individual opinions,” said Ruben A. Mesa, MD, chair of the NCCN Guidelines Panel for MPN.

“The NCCN Guidelines Panel for MPN hopes these inaugural guidelines will help leverage the evidence base in MPN care for clear, well-informed treatment guidelines to hopefully improve quality of care and provide better outcomes for patients with MPN.”

Dr Mesa is scheduled to present the new NCCN guidelines during the NCCN 11th Annual Congress: Hematologic Malignancies™ on September 30, in a session titled, “Myeloprofilerative Neoplasms and Myelofibrosis: Evolving Management.”

Micrograph showing MF

The National Comprehensive Cancer Network (NCCN) has published new clinical practice guidelines for myeloproliferative neoplasms (MPNs).

The current guidelines focus on the management of patients with myelofibrosis (MF), but NCCN said recommendations for managing essential thrombocythemia (ET) and polycythemia vera (PV) will be included in subsequent versions of the NCCN guidelines for MPNs.

The new guidelines provide recommendations on the workup and diagnosis of primary MF, post-ET MF, and post-PV MF.

The document also includes recommendations for managing MF-associated anemia, supportive care options, and treatment recommendations according to a patient’s risk group.

Treatment of low-risk MF

The guidelines recommend that patients with low-risk, asymptomatic MF be observed or enrolled in a clinical trial. They should be monitored for progression every 3 to 6 months.

Patients with low-risk, symptomatic MF should receive ruxolitinib or interferons or be enrolled on a clinical trial. They should be monitored for progression every 3 to 6 months.

If patients respond to treatment, they should continue to receive it. If they do not respond or lose their response, they should receive ruxolitinib or interferons or be enrolled on a clinical trial. If these patients progress, they should be treated according to their risk category.

Intermediate-1-risk MF

Patients with intermediate-1-risk MF should be assessed for symptom burden and observed if asymptomatic. If symptomatic, they should receive ruxolitinib, be enrolled on a clinical trial, or undergo allogeneic hematopoietic stem cell transplant (HSCT).

Patients should be monitored for response and progression every 3 to 6 months. If they respond to treatment, they should continue to receive it.

If patients do not respond or lose their response, they should be observed, receive ruxolitinib, be enrolled on a clinical trial, or undergo allogeneic HSCT. If these patients progress, they should be treated according to their risk category.

Intermediate-2- or high-risk MF

Patients who are transplant candidates should receive allogeneic HSCT.

Patients who are ineligible for transplant should be assessed for symptom burden. Those with a platelet count of 50,000 or lower should be considered for a clinical trial.

Those with higher platelet counts should receive ruxolitinib or be enrolled on a clinical trial. They should be monitored for response or progression every 3 to 6 months.

If these patients respond to treatment, they should continue on that treatment. If they do not respond or lose their response, the patients should be monitored for progression.

If they progress and are candidates for transplant, these patients should receive hypomethylating agents or chemotherapy to induce remission, followed by HSCT.

If the patients progress and are ineligible for transplant, they should be enrolled on a clinical trial or receive hypomethylating agents or chemotherapy.

For patients who are ineligible for transplant and only have symptomatic anemia, they should receive treatment to manage that anemia. The guidelines list a range of treatment options.

“The management of MPNs has been variable in the past and largely driven by review articles and individual opinions,” said Ruben A. Mesa, MD, chair of the NCCN Guidelines Panel for MPN.

“The NCCN Guidelines Panel for MPN hopes these inaugural guidelines will help leverage the evidence base in MPN care for clear, well-informed treatment guidelines to hopefully improve quality of care and provide better outcomes for patients with MPN.”

Dr Mesa is scheduled to present the new NCCN guidelines during the NCCN 11th Annual Congress: Hematologic Malignancies™ on September 30, in a session titled, “Myeloprofilerative Neoplasms and Myelofibrosis: Evolving Management.”

Micrograph showing MF

The National Comprehensive Cancer Network (NCCN) has published new clinical practice guidelines for myeloproliferative neoplasms (MPNs).

The current guidelines focus on the management of patients with myelofibrosis (MF), but NCCN said recommendations for managing essential thrombocythemia (ET) and polycythemia vera (PV) will be included in subsequent versions of the NCCN guidelines for MPNs.

The new guidelines provide recommendations on the workup and diagnosis of primary MF, post-ET MF, and post-PV MF.

The document also includes recommendations for managing MF-associated anemia, supportive care options, and treatment recommendations according to a patient’s risk group.

Treatment of low-risk MF

The guidelines recommend that patients with low-risk, asymptomatic MF be observed or enrolled in a clinical trial. They should be monitored for progression every 3 to 6 months.

Patients with low-risk, symptomatic MF should receive ruxolitinib or interferons or be enrolled on a clinical trial. They should be monitored for progression every 3 to 6 months.

If patients respond to treatment, they should continue to receive it. If they do not respond or lose their response, they should receive ruxolitinib or interferons or be enrolled on a clinical trial. If these patients progress, they should be treated according to their risk category.

Intermediate-1-risk MF

Patients with intermediate-1-risk MF should be assessed for symptom burden and observed if asymptomatic. If symptomatic, they should receive ruxolitinib, be enrolled on a clinical trial, or undergo allogeneic hematopoietic stem cell transplant (HSCT).

Patients should be monitored for response and progression every 3 to 6 months. If they respond to treatment, they should continue to receive it.

If patients do not respond or lose their response, they should be observed, receive ruxolitinib, be enrolled on a clinical trial, or undergo allogeneic HSCT. If these patients progress, they should be treated according to their risk category.

Intermediate-2- or high-risk MF

Patients who are transplant candidates should receive allogeneic HSCT.

Patients who are ineligible for transplant should be assessed for symptom burden. Those with a platelet count of 50,000 or lower should be considered for a clinical trial.

Those with higher platelet counts should receive ruxolitinib or be enrolled on a clinical trial. They should be monitored for response or progression every 3 to 6 months.

If these patients respond to treatment, they should continue on that treatment. If they do not respond or lose their response, the patients should be monitored for progression.

If they progress and are candidates for transplant, these patients should receive hypomethylating agents or chemotherapy to induce remission, followed by HSCT.

If the patients progress and are ineligible for transplant, they should be enrolled on a clinical trial or receive hypomethylating agents or chemotherapy.

For patients who are ineligible for transplant and only have symptomatic anemia, they should receive treatment to manage that anemia. The guidelines list a range of treatment options.

“The management of MPNs has been variable in the past and largely driven by review articles and individual opinions,” said Ruben A. Mesa, MD, chair of the NCCN Guidelines Panel for MPN.

“The NCCN Guidelines Panel for MPN hopes these inaugural guidelines will help leverage the evidence base in MPN care for clear, well-informed treatment guidelines to hopefully improve quality of care and provide better outcomes for patients with MPN.”

Dr Mesa is scheduled to present the new NCCN guidelines during the NCCN 11th Annual Congress: Hematologic Malignancies™ on September 30, in a session titled, “Myeloprofilerative Neoplasms and Myelofibrosis: Evolving Management.”

Blood samples

Photo by Graham Colm

The US Office of Special Counsel (OSC) has called for further review of allegations made about the Trioplex assay, a test used to detect Zika and other viruses.

A whistleblower recently alleged that the Centers for Disease Control and Prevention (CDC) has been using and promoting the Trioplex assay even though this test is nearly 40% less effective for Zika virus detection than another test, the Singleplex assay.

The CDC conducted an investigation that suggested this claim is not accurate, but the OSC has recommended additional review of the issue. (The OSC is an independent federal investigative and prosecutorial agency.)

Allegations

The allegations about the Trioplex assay were made by Robert Lanciotti, PhD, a CDC microbiologist based in Fort Collins, Colorado.

Dr Lanciotti conducted a study in which the Trioplex assay—which tests for Zika, dengue, and chikungunya—missed 39% of Zika infections detected by the Singleplex assay, which only tests for Zika.

Dr Lanciotti also raised concerns that the CDC’s Emergency Operations Center (EOC) withheld from public health laboratories information about the sensitivity differences between the Trioplex and Singleplex assays.

He said the CDC may have given laboratories the mistaken impression that Trioplex was a better test.

The Singleplex assay was made by Dr Lanciotti’s lab, while the Trioplex assay was developed at the CDC’s dengue branch lab in Puerto Rico.

Investigation

The OSC referred Dr Lanciotti’s claims to the Department of Health and Human Services (HHS) for investigation on July 1, 2016.

HHS Secretary Sylvia Mathews Burwell directed Steve Monroe, PhD, associate director for laboratory science and safety at the CDC, to conduct the investigation. The investigative team did not include employees who worked in EOC or in the zoonotic infectious diseases branch of the CDC.

The CDC said its investigation did not substantiate Dr Lanciotti’s claims. Investigators said they were unable to reach a “statistically valid conclusion about the relative performance” of the tests.

The CDC’s report pointed to a study conducted by its dengue branch in Puerto Rico that “found no difference in sensitivity” between the assays. The Trioplex assay was developed at this lab.

The report also said the CDC acted reasonably when it withheld information about the sensitivity differences between the Trioplex and Singleplex assays because there was conflicting data from different  labs. The investigators said releasing that data could have created “considerable confusion during an ongoing emergency response.”

The CDC also noted that, in late August, the agency made changes intended to improve the sensitivity of the Trioplex assay, such as increasing sample volumes and allowing whole blood as a specimen type.

Response

Dr Lanciotti took issue with several points in the CDC’s report. Perhaps most importantly, he said “there was clearly enough data to warrant a ‘pause’ in the recommendation of the Trioplex until an extensive comparison could be performed.”

He referenced a multicenter study conducted independently by the Blood Systems Research Institute in San Francisco, California, which demonstrated the Trioplex assay’s lower sensitivity.

Dr Lanciotti added that the method used by this institution to assess the tests is “the most accurate method to evaluate the clinical sensitivity . . . of individual assays.”

Reassignment

Prior to disclosing his concerns to the OSC, Dr Lanciotti voiced the concerns internally and in an email to state public health officials in April 2016.

In May, he was reassigned to a non‐supervisory position within his lab. After the reassignment, Dr Lanciotti filed a whistleblower retaliation claim alleging that his diminished duties, from lab chief to a non‐supervisory position, was in reprisal for his disclosures.

After an investigation, the OSC secured an agreement from the CDC to reinstate Dr Lanciotti as chief of his lab.

OSC assessment

In a letter to President Barack Obama, Carolyn Lerner, head of the OSC, said the CDC “conducted a thorough investigation into Dr Lanciotti’s allegations, and its findings appear reasonable.”

On the other hand, Dr Lanciotti has raised “serious concerns” about the CDC’s findings.

“As the agency contemplates additional improvements or changes to the Zika testing protocol, I encourage CDC to review Dr Lanciotti’s comments, respond to each of his concerns, and utilize his expertise as the agency works to ensure it is implementing the most effective testing methods in response to this public health emergency,” Lerner said.

“I also encourage the CDC to promote scientific debate within its labs. Whistleblowers should be encouraged to speak out on matters of public concern.”

Blood samples

Photo by Graham Colm

The US Office of Special Counsel (OSC) has called for further review of allegations made about the Trioplex assay, a test used to detect Zika and other viruses.

A whistleblower recently alleged that the Centers for Disease Control and Prevention (CDC) has been using and promoting the Trioplex assay even though this test is nearly 40% less effective for Zika virus detection than another test, the Singleplex assay.

The CDC conducted an investigation that suggested this claim is not accurate, but the OSC has recommended additional review of the issue. (The OSC is an independent federal investigative and prosecutorial agency.)

Allegations

The allegations about the Trioplex assay were made by Robert Lanciotti, PhD, a CDC microbiologist based in Fort Collins, Colorado.

Dr Lanciotti conducted a study in which the Trioplex assay—which tests for Zika, dengue, and chikungunya—missed 39% of Zika infections detected by the Singleplex assay, which only tests for Zika.

Dr Lanciotti also raised concerns that the CDC’s Emergency Operations Center (EOC) withheld from public health laboratories information about the sensitivity differences between the Trioplex and Singleplex assays.

He said the CDC may have given laboratories the mistaken impression that Trioplex was a better test.

The Singleplex assay was made by Dr Lanciotti’s lab, while the Trioplex assay was developed at the CDC’s dengue branch lab in Puerto Rico.

Investigation

The OSC referred Dr Lanciotti’s claims to the Department of Health and Human Services (HHS) for investigation on July 1, 2016.

HHS Secretary Sylvia Mathews Burwell directed Steve Monroe, PhD, associate director for laboratory science and safety at the CDC, to conduct the investigation. The investigative team did not include employees who worked in EOC or in the zoonotic infectious diseases branch of the CDC.

The CDC said its investigation did not substantiate Dr Lanciotti’s claims. Investigators said they were unable to reach a “statistically valid conclusion about the relative performance” of the tests.

The CDC’s report pointed to a study conducted by its dengue branch in Puerto Rico that “found no difference in sensitivity” between the assays. The Trioplex assay was developed at this lab.

The report also said the CDC acted reasonably when it withheld information about the sensitivity differences between the Trioplex and Singleplex assays because there was conflicting data from different  labs. The investigators said releasing that data could have created “considerable confusion during an ongoing emergency response.”

The CDC also noted that, in late August, the agency made changes intended to improve the sensitivity of the Trioplex assay, such as increasing sample volumes and allowing whole blood as a specimen type.

Response

Dr Lanciotti took issue with several points in the CDC’s report. Perhaps most importantly, he said “there was clearly enough data to warrant a ‘pause’ in the recommendation of the Trioplex until an extensive comparison could be performed.”

He referenced a multicenter study conducted independently by the Blood Systems Research Institute in San Francisco, California, which demonstrated the Trioplex assay’s lower sensitivity.

Dr Lanciotti added that the method used by this institution to assess the tests is “the most accurate method to evaluate the clinical sensitivity . . . of individual assays.”

Reassignment

Prior to disclosing his concerns to the OSC, Dr Lanciotti voiced the concerns internally and in an email to state public health officials in April 2016.

In May, he was reassigned to a non‐supervisory position within his lab. After the reassignment, Dr Lanciotti filed a whistleblower retaliation claim alleging that his diminished duties, from lab chief to a non‐supervisory position, was in reprisal for his disclosures.

After an investigation, the OSC secured an agreement from the CDC to reinstate Dr Lanciotti as chief of his lab.

OSC assessment

In a letter to President Barack Obama, Carolyn Lerner, head of the OSC, said the CDC “conducted a thorough investigation into Dr Lanciotti’s allegations, and its findings appear reasonable.”

On the other hand, Dr Lanciotti has raised “serious concerns” about the CDC’s findings.

“As the agency contemplates additional improvements or changes to the Zika testing protocol, I encourage CDC to review Dr Lanciotti’s comments, respond to each of his concerns, and utilize his expertise as the agency works to ensure it is implementing the most effective testing methods in response to this public health emergency,” Lerner said.

“I also encourage the CDC to promote scientific debate within its labs. Whistleblowers should be encouraged to speak out on matters of public concern.”

Blood samples

Photo by Graham Colm

The US Office of Special Counsel (OSC) has called for further review of allegations made about the Trioplex assay, a test used to detect Zika and other viruses.

A whistleblower recently alleged that the Centers for Disease Control and Prevention (CDC) has been using and promoting the Trioplex assay even though this test is nearly 40% less effective for Zika virus detection than another test, the Singleplex assay.

The CDC conducted an investigation that suggested this claim is not accurate, but the OSC has recommended additional review of the issue. (The OSC is an independent federal investigative and prosecutorial agency.)

Allegations

The allegations about the Trioplex assay were made by Robert Lanciotti, PhD, a CDC microbiologist based in Fort Collins, Colorado.

Dr Lanciotti conducted a study in which the Trioplex assay—which tests for Zika, dengue, and chikungunya—missed 39% of Zika infections detected by the Singleplex assay, which only tests for Zika.

Dr Lanciotti also raised concerns that the CDC’s Emergency Operations Center (EOC) withheld from public health laboratories information about the sensitivity differences between the Trioplex and Singleplex assays.

He said the CDC may have given laboratories the mistaken impression that Trioplex was a better test.

The Singleplex assay was made by Dr Lanciotti’s lab, while the Trioplex assay was developed at the CDC’s dengue branch lab in Puerto Rico.

Investigation

The OSC referred Dr Lanciotti’s claims to the Department of Health and Human Services (HHS) for investigation on July 1, 2016.

HHS Secretary Sylvia Mathews Burwell directed Steve Monroe, PhD, associate director for laboratory science and safety at the CDC, to conduct the investigation. The investigative team did not include employees who worked in EOC or in the zoonotic infectious diseases branch of the CDC.

The CDC said its investigation did not substantiate Dr Lanciotti’s claims. Investigators said they were unable to reach a “statistically valid conclusion about the relative performance” of the tests.

The CDC’s report pointed to a study conducted by its dengue branch in Puerto Rico that “found no difference in sensitivity” between the assays. The Trioplex assay was developed at this lab.

The report also said the CDC acted reasonably when it withheld information about the sensitivity differences between the Trioplex and Singleplex assays because there was conflicting data from different  labs. The investigators said releasing that data could have created “considerable confusion during an ongoing emergency response.”

The CDC also noted that, in late August, the agency made changes intended to improve the sensitivity of the Trioplex assay, such as increasing sample volumes and allowing whole blood as a specimen type.

Response

Dr Lanciotti took issue with several points in the CDC’s report. Perhaps most importantly, he said “there was clearly enough data to warrant a ‘pause’ in the recommendation of the Trioplex until an extensive comparison could be performed.”

He referenced a multicenter study conducted independently by the Blood Systems Research Institute in San Francisco, California, which demonstrated the Trioplex assay’s lower sensitivity.

Dr Lanciotti added that the method used by this institution to assess the tests is “the most accurate method to evaluate the clinical sensitivity . . . of individual assays.”

Reassignment

Prior to disclosing his concerns to the OSC, Dr Lanciotti voiced the concerns internally and in an email to state public health officials in April 2016.

In May, he was reassigned to a non‐supervisory position within his lab. After the reassignment, Dr Lanciotti filed a whistleblower retaliation claim alleging that his diminished duties, from lab chief to a non‐supervisory position, was in reprisal for his disclosures.

After an investigation, the OSC secured an agreement from the CDC to reinstate Dr Lanciotti as chief of his lab.

OSC assessment

In a letter to President Barack Obama, Carolyn Lerner, head of the OSC, said the CDC “conducted a thorough investigation into Dr Lanciotti’s allegations, and its findings appear reasonable.”

On the other hand, Dr Lanciotti has raised “serious concerns” about the CDC’s findings.

“As the agency contemplates additional improvements or changes to the Zika testing protocol, I encourage CDC to review Dr Lanciotti’s comments, respond to each of his concerns, and utilize his expertise as the agency works to ensure it is implementing the most effective testing methods in response to this public health emergency,” Lerner said.

“I also encourage the CDC to promote scientific debate within its labs. Whistleblowers should be encouraged to speak out on matters of public concern.”

The FP noted patchy alopecia with scaling of the scalp and made the presumptive diagnosis of tinea capitis. A woods lamp examination did not demonstrate fluorescence. The child was very cooperative and the doctor was able to perform a potassium hydroxide (KOH) preparation by scraping the areas of alopecia with the edge of one glass slide while catching the scale on another slide. Microscopic examination revealed branching hyphae and some broken hairs with fungal elements within the hair shaft. (See video on how to perform a KOH preparation.) This microscopic picture was consistent with Trichophyton tonsurans, the most common cause of tinea capitis in the United States. The reason that the infected area did not fluoresce was that the dermatophyte was within the hair shaft (endothrix) rather than external to the hair (exothrix).

Topical antifungal therapy is not adequate for tinea capitis; oral treatment is needed. Oral antifungal choices include griseofulvin, terbinafine, and fluconazole. Griseofulvin comes in an oral suspension making it a desirable option for children who can’t swallow pills. However, at least 6 to 8 weeks of treatment (20 mg/kg/d) is required. Oral terbinafine tablets are less expensive and shorter courses of therapy may be used. Tablets of 250 mg terbinafine (most affordable of all the choices) can be broken in half for younger children and the dose should always be calculated based on weight. Fluconazole comes in various tablets, strengths, and liquid formulations and can be prescribed for 3 to 6 weeks, as needed.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R, Yao C. Tinea capitis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill;2013:782-787.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP noted patchy alopecia with scaling of the scalp and made the presumptive diagnosis of tinea capitis. A woods lamp examination did not demonstrate fluorescence. The child was very cooperative and the doctor was able to perform a potassium hydroxide (KOH) preparation by scraping the areas of alopecia with the edge of one glass slide while catching the scale on another slide. Microscopic examination revealed branching hyphae and some broken hairs with fungal elements within the hair shaft. (See video on how to perform a KOH preparation.) This microscopic picture was consistent with Trichophyton tonsurans, the most common cause of tinea capitis in the United States. The reason that the infected area did not fluoresce was that the dermatophyte was within the hair shaft (endothrix) rather than external to the hair (exothrix).

Topical antifungal therapy is not adequate for tinea capitis; oral treatment is needed. Oral antifungal choices include griseofulvin, terbinafine, and fluconazole. Griseofulvin comes in an oral suspension making it a desirable option for children who can’t swallow pills. However, at least 6 to 8 weeks of treatment (20 mg/kg/d) is required. Oral terbinafine tablets are less expensive and shorter courses of therapy may be used. Tablets of 250 mg terbinafine (most affordable of all the choices) can be broken in half for younger children and the dose should always be calculated based on weight. Fluconazole comes in various tablets, strengths, and liquid formulations and can be prescribed for 3 to 6 weeks, as needed.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R, Yao C. Tinea capitis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill;2013:782-787.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

The FP noted patchy alopecia with scaling of the scalp and made the presumptive diagnosis of tinea capitis. A woods lamp examination did not demonstrate fluorescence. The child was very cooperative and the doctor was able to perform a potassium hydroxide (KOH) preparation by scraping the areas of alopecia with the edge of one glass slide while catching the scale on another slide. Microscopic examination revealed branching hyphae and some broken hairs with fungal elements within the hair shaft. (See video on how to perform a KOH preparation.) This microscopic picture was consistent with Trichophyton tonsurans, the most common cause of tinea capitis in the United States. The reason that the infected area did not fluoresce was that the dermatophyte was within the hair shaft (endothrix) rather than external to the hair (exothrix).

Topical antifungal therapy is not adequate for tinea capitis; oral treatment is needed. Oral antifungal choices include griseofulvin, terbinafine, and fluconazole. Griseofulvin comes in an oral suspension making it a desirable option for children who can’t swallow pills. However, at least 6 to 8 weeks of treatment (20 mg/kg/d) is required. Oral terbinafine tablets are less expensive and shorter courses of therapy may be used. Tablets of 250 mg terbinafine (most affordable of all the choices) can be broken in half for younger children and the dose should always be calculated based on weight. Fluconazole comes in various tablets, strengths, and liquid formulations and can be prescribed for 3 to 6 weeks, as needed.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R, Yao C. Tinea capitis. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill;2013:782-787.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com

Nine popular painkillers – including traditional NSAIDs and cyclo-oxygenase-2 (COX-2) inhibitors – are associated with an increased risk of hospitalization for heart failure in adults, based on data from a case-control study of approximately 92,000 hospital admissions. The findings were published online Sept. 28 in BMJ.

Although data from previous large studies suggest that high doses of NSAIDs as well as COX-2 inhibitors increase the risk of hospital admission for heart failure, “there is still limited information on the risk of heart failure associated with the use of individual NSAIDs in clinical practice,” wrote Andrea Arfè of the University of Milano-Bicocca, Milan, and his colleagues (BMJ. 2016 Sep;354:i4857 doi: 10.1136/bmj.i4857).

©PhotoDisk

The researchers reviewed data from five electronic health databases in the Netherlands, Italy, Germany, and the United Kingdom as part of the SOS (Safety of Non-Steroidal Anti-Inflammatory Drugs) project and conducted a nested, case-control study including 92,163 hospital admissions for heart failure and 8,246,403 controls matched for age, sex, and year of study entry. The study included 23 traditional NSAIDs and four selective COX-2 inhibitors.

Overall, individual use of any of nine different NSAIDs within 14 days was associated with a nearly 20% higher likelihood of hospital admission for heart failure, compared with NSAID use more than 183 days in the past (odds ratio, 1.19). For seven traditional NSAIDS (diclofenac, ibuprofen, indomethacin, ketorolac, naproxen, nimesulide, and piroxicam) and the COX-2 inhibitors etoricoxib and rofecoxib, the odds ratios for heart failure with current use ranged from 1.16 for naproxen to 1.83 for ketorolac, compared with past use.

In addition, the odds of hospitalization for heart failure doubled for diclofenac, etoricoxib, indomethacin, piroxicam, and rofecoxib when dosed at two or more daily dose equivalents, the researchers noted. There was no increase in the odds of hospitalization for heart failure with celecoxib when dosed at standard levels, but “indomethacin and etoricoxib seemed to increase the risk of hospital admission for heart failure, even if used at medium doses,” they said. Other lesser-used NSAIDs were associated with an increased risk, but it was not statistically significant.

“The effect of individual NSAIDs could depend on a complex interaction of pharmacological properties, including duration and extent of platelet inhibition, extent of blood pressure increase, and properties possibly unique to the molecule,” the researchers said.

The findings were limited by several factors including misclassification of outcomes and the observational nature of the study, which prevents conclusions about cause and effect, the researchers noted. However, “Because any potential increased risk could have a considerable impact on public health, the risk effect estimates provided by this study may help inform both clinical practice and regulatory activities,” they said.

The study was funded in part by the European Community’s seventh Framework Programme. Mr. Arfè had no financial conflicts to disclose. Several study coauthors disclosed relationships with multiple companies including AstraZeneca, Bayer, Celgene, GlaxoSmithKline, Schwabe, and Novartis.

Nine popular painkillers – including traditional NSAIDs and cyclo-oxygenase-2 (COX-2) inhibitors – are associated with an increased risk of hospitalization for heart failure in adults, based on data from a case-control study of approximately 92,000 hospital admissions. The findings were published online Sept. 28 in BMJ.

Although data from previous large studies suggest that high doses of NSAIDs as well as COX-2 inhibitors increase the risk of hospital admission for heart failure, “there is still limited information on the risk of heart failure associated with the use of individual NSAIDs in clinical practice,” wrote Andrea Arfè of the University of Milano-Bicocca, Milan, and his colleagues (BMJ. 2016 Sep;354:i4857 doi: 10.1136/bmj.i4857).

©PhotoDisk

The researchers reviewed data from five electronic health databases in the Netherlands, Italy, Germany, and the United Kingdom as part of the SOS (Safety of Non-Steroidal Anti-Inflammatory Drugs) project and conducted a nested, case-control study including 92,163 hospital admissions for heart failure and 8,246,403 controls matched for age, sex, and year of study entry. The study included 23 traditional NSAIDs and four selective COX-2 inhibitors.

Overall, individual use of any of nine different NSAIDs within 14 days was associated with a nearly 20% higher likelihood of hospital admission for heart failure, compared with NSAID use more than 183 days in the past (odds ratio, 1.19). For seven traditional NSAIDS (diclofenac, ibuprofen, indomethacin, ketorolac, naproxen, nimesulide, and piroxicam) and the COX-2 inhibitors etoricoxib and rofecoxib, the odds ratios for heart failure with current use ranged from 1.16 for naproxen to 1.83 for ketorolac, compared with past use.

In addition, the odds of hospitalization for heart failure doubled for diclofenac, etoricoxib, indomethacin, piroxicam, and rofecoxib when dosed at two or more daily dose equivalents, the researchers noted. There was no increase in the odds of hospitalization for heart failure with celecoxib when dosed at standard levels, but “indomethacin and etoricoxib seemed to increase the risk of hospital admission for heart failure, even if used at medium doses,” they said. Other lesser-used NSAIDs were associated with an increased risk, but it was not statistically significant.

“The effect of individual NSAIDs could depend on a complex interaction of pharmacological properties, including duration and extent of platelet inhibition, extent of blood pressure increase, and properties possibly unique to the molecule,” the researchers said.

The findings were limited by several factors including misclassification of outcomes and the observational nature of the study, which prevents conclusions about cause and effect, the researchers noted. However, “Because any potential increased risk could have a considerable impact on public health, the risk effect estimates provided by this study may help inform both clinical practice and regulatory activities,” they said.

The study was funded in part by the European Community’s seventh Framework Programme. Mr. Arfè had no financial conflicts to disclose. Several study coauthors disclosed relationships with multiple companies including AstraZeneca, Bayer, Celgene, GlaxoSmithKline, Schwabe, and Novartis.

Nine popular painkillers – including traditional NSAIDs and cyclo-oxygenase-2 (COX-2) inhibitors – are associated with an increased risk of hospitalization for heart failure in adults, based on data from a case-control study of approximately 92,000 hospital admissions. The findings were published online Sept. 28 in BMJ.

Although data from previous large studies suggest that high doses of NSAIDs as well as COX-2 inhibitors increase the risk of hospital admission for heart failure, “there is still limited information on the risk of heart failure associated with the use of individual NSAIDs in clinical practice,” wrote Andrea Arfè of the University of Milano-Bicocca, Milan, and his colleagues (BMJ. 2016 Sep;354:i4857 doi: 10.1136/bmj.i4857).

©PhotoDisk

The researchers reviewed data from five electronic health databases in the Netherlands, Italy, Germany, and the United Kingdom as part of the SOS (Safety of Non-Steroidal Anti-Inflammatory Drugs) project and conducted a nested, case-control study including 92,163 hospital admissions for heart failure and 8,246,403 controls matched for age, sex, and year of study entry. The study included 23 traditional NSAIDs and four selective COX-2 inhibitors.

Overall, individual use of any of nine different NSAIDs within 14 days was associated with a nearly 20% higher likelihood of hospital admission for heart failure, compared with NSAID use more than 183 days in the past (odds ratio, 1.19). For seven traditional NSAIDS (diclofenac, ibuprofen, indomethacin, ketorolac, naproxen, nimesulide, and piroxicam) and the COX-2 inhibitors etoricoxib and rofecoxib, the odds ratios for heart failure with current use ranged from 1.16 for naproxen to 1.83 for ketorolac, compared with past use.

In addition, the odds of hospitalization for heart failure doubled for diclofenac, etoricoxib, indomethacin, piroxicam, and rofecoxib when dosed at two or more daily dose equivalents, the researchers noted. There was no increase in the odds of hospitalization for heart failure with celecoxib when dosed at standard levels, but “indomethacin and etoricoxib seemed to increase the risk of hospital admission for heart failure, even if used at medium doses,” they said. Other lesser-used NSAIDs were associated with an increased risk, but it was not statistically significant.

“The effect of individual NSAIDs could depend on a complex interaction of pharmacological properties, including duration and extent of platelet inhibition, extent of blood pressure increase, and properties possibly unique to the molecule,” the researchers said.

The findings were limited by several factors including misclassification of outcomes and the observational nature of the study, which prevents conclusions about cause and effect, the researchers noted. However, “Because any potential increased risk could have a considerable impact on public health, the risk effect estimates provided by this study may help inform both clinical practice and regulatory activities,” they said.

The study was funded in part by the European Community’s seventh Framework Programme. Mr. Arfè had no financial conflicts to disclose. Several study coauthors disclosed relationships with multiple companies including AstraZeneca, Bayer, Celgene, GlaxoSmithKline, Schwabe, and Novartis.