Black patients have higher lung cancer risk despite lower pack years of smoking. We assessed lung cancer risk by race, ethnicity, and sex among a nationally representative population eligible for ...lung cancer screening based on Medicare criteria.
We used data from the National Health and Nutrition Examination Survey, 2007-2012 to assess lung cancer risk by sex, race and ethnicity among persons satisfying Medicare age and pack-year smoking eligibility criteria for lung cancer screening. We assessed Medicare eligibility based on age (55-77 years) and pack-years (≥ 30). We assessed 6-year lung cancer risk using a risk prediction model from Prostate, Lung, Colorectal and Ovarian Cancer Screening trial that was modified in 2012 (PLCOm2012). We compared the proportions of eligible persons by sex, race and ethnicity using Medicare criteria with a risk cut-point that was adjusted to achieve comparable total number of persons eligible for screening.
Among the 29.7 million persons aged 55-77 years who ever smoked, we found that 7.3 million (24.5%) were eligible for lung cancer screening under Medicare criteria. Among those eligible, Blacks had statistically significant higher (4.4%) and Hispanics lower lung cancer risk (1.2%) than non-Hispanic Whites (3.2%). At a cut-point of 2.12% risk for lung screening eligibility, the percentage of Blacks and Hispanics showed statistically significant changes. Blacks eligible rose by 48% and Hispanics eligible declined by 63%. Black men and Hispanic women were affected the most. There was little change in eligibility among Whites.
Medicare eligibility criteria for lung cancer screening do not align with estimated risk for lung cancer among Blacks and Hispanics. Data are urgently needed to determine whether use of risk-based eligibility screening improves lung cancer outcomes among minority patients.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
We evaluated whether patients' initial screening symptoms were related to subsequent utilization of supportive care services and hospitalizations, and whether patient-level demographics, symptoms, ...hospitalizations, and supportive care service utilization were associated with mortality in primarily low-income, older, Black Veterans with cancer.
This quality improvement project created collaborative clinics to conduct cancer distress screenings and refer to supportive care services at an urban, VA medical center. All patients completed a distress screen with follow-up screening every 3 months. Supportive care utilization, hospitalization rates, and mortality were abstracted through medical records. Poisson regression models and cox proportional hazard models were utilized.
Five hundred and eighty five screened patients were older (m = 72), mostly Black 70% (n = 412), and had advanced cancer 54%. Fifty-eight percent (n = 340) were screened only once with 81% (n = 470) receiving ≥1 supportive care service and 51.5% (n = 297) being hospitalized ≥1 time 18 months following initial screen. Symptom severity was significantly related to number of hospitalizations. Low mood was significantly related to higher supportive services (p < 0.001), but not hospitalizations (p ≥ 0.52). Pain, fatigue, physical function, nutrition, and physical symptoms were significantly associated with more supportive services and hospitalizations (p < 0.01). Twenty percent (n = 168) died; Veterans who were Black, had lower stage cancers, better physical health, and utilized less supportive care services had lower odds of mortality (p ≤ 0.01).
Individuals with elevated distress needs and those reporting lower physical function utilized more supportive care services and had higher hospitalization rates. Lower physical function, greater supportive care use, higher stage cancer, and being non-Black were associated with higher odds of death.
Drugs and alcohol are the third leading cause of death in U.S. jails. We analyzed 2000 to 2013 national jail mortality data by coding text data. We identified 1,442 deaths associated with drugs and ...alcohol. Drug-associated deaths were more than double alcohol-associated deaths during 2009 to 2013 when drug type was available for drug-associated mortality. Only 18% of deaths within 7 days of arrest for alcohol intoxication were officially coded as involving drugs/alcohol intoxication. Among the 103 deaths associated with substance withdrawal, 66 involved alcohol, 21 involved drugs (primarily opioids), and 16 could not be determined. Drugs and alcohol likely contribute to more deaths in jails than has been recognized due to how deaths are coded. Alcohol and opioid withdrawal represent a small but underappreciated contributor to jail deaths.
Most patients want more health information than their clinicians provide during office visits. Written information can complement information that is provided verbally, yet most primary care ...practices, including federally qualified health centers, have not implemented systematic programs to ensure that patients receive understandable, relevant, and accurate health information at the point of care. MedlinePlus in particular is underutilized.
The authors conducted a multimodal intervention to promote the use of MedlinePlus at a federally qualified health center. We provided MedlinePlus training to clinicians and patients through group and one-on-one trainings and multimedia promotion. We administered pre- and post-intervention surveys to patients, clinicians, and nurses to assess changes in the use and recognition of MedlinePlus at the point of care. We used quantitative and qualitative data to understand the impact of the intervention. A National Library of Medicine grant provided resources that supported equipment and staff. Group training improved use of MedlinePlus by clinicians and staff. One-on-one training was most effective for patients, particularly when it was integrated into the work-flow.
A multimodal approach can promote use of MedlinePlus among community health center patients. However, the process is labor- and resource-intensive and requires careful attention to work flow and leveraging of brief opportunities.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Nonmass enhancement (NME) on breast MRI impacts surgical planning.
To evaluate positive predictive values (PPVs) and identify malignancy discriminators of NME ipsilateral to breast cancer on initial ...staging MRI.
Retrospective.
Eighty-six women (median age, 48 years; range, 26-75 years) with 101 NME lesions (BI-RADS 4 and 5) ipsilateral to known cancers and confirmed histopathology.
1.5 T and 3.0 T dynamic contrast-enhanced fat-suppressed T1-weighted fast spoiled gradient-echo.
Three radiologists blinded to pathology independently reviewed MRI features (distribution, internal enhancement pattern, and enhancement kinetics) of NME, locations relative to index cancers (contiguous, non-contiguous, and different quadrants), associated mammographic calcifications, lymphovascular invasion (LVI), axillary node metastasis, and radiology-pathology correlations. Clinical factors, NME features, and cancer characteristics were analyzed for associations with NME malignancy.
Fisher's exact, Chi-square, Wilcoxon rank sum tests, and mixed-effect multivariable logistic regression were used. Significance threshold was set at P < 0.05.
Overall NME malignancy rate was 48.5% (49/101). Contiguous NME had a significantly higher malignancy rate (86.7%) than non-contiguous NME (25.0%) and NME in different quadrants (10.7%), but no significant difference was observed by distance from cancer for non-contiguous NME, P = 0.68. All calcified NME lesions contiguous to the calcified index cancer were malignant. NME was significantly more likely malignant when index cancers were masses compared to NME (52.9% vs. 21.4%), had mammographic calcifications (63.2% vs. 39.7%), LVI (81.8% vs. 44.4%), and axillary node metastasis (70.8% vs. 41.6%). NME features with highest PPVs were segmental distribution (85.7%), clumped enhancement (66.7%), and nonpersistent kinetics (77.1%). On multivariable analysis, contiguous NME, segmental distribution, and nonpersistent kinetics were associated with malignancy.
Malignancy discriminators of ipsilateral NME on staging MRI included contiguous location to index cancers, segmental distribution, and nonpersistent kinetics.
3 TECHNICAL EFFICACY: Stage 2.
Background
In this multicenter, single‐arm, multicohort, phase 2 trial, the efficacy of nivolumab and ipilimumab was evaluated in patients with advanced rare genitourinary cancers, including bladder ...and upper tract carcinoma of variant histology (BUTCVH), adrenal tumors, platinum‐refractory germ cell tumors, penile carcinoma, and prostate cancer of variant histology (NCT03333616).
Methods
Patients with rare genitourinary malignancies and no prior immune checkpoint inhibitor exposure were enrolled. Patients received nivolumab at 3 mg/kg and ipilimumab at 1 mg/kg intravenously every 3 weeks for 4 doses, and this was followed by 480 mg of nivolumab intravenously every 4 weeks. The primary endpoint was the objective response rate (ORR) by the Response Evaluation Criteria in Solid Tumors (version 1.1).
Results
Fifty‐five patients were enrolled at 6 institutions between April 2018 and July 2019 in 3 cohorts: BUTCVH (n = 19), adrenal tumors (n = 18), and other tumors (n = 18). The median follow‐up was 9.9 months (range, 1 to 21 months). Twenty‐eight patients (51%) received 4 doses of nivolumab and ipilimumab; 25 patients received nivolumab maintenance for a median of 4 cycles (range, 1‐18 cycles). The ORR for the entire study was 16% (80% confidence interval, 10%‐25%); the ORR in the BUTCVH cohort, including 2 complete responses, was 37%, and it was 6% in the other 2 cohorts. Twenty‐two patients (40%) developed treatment‐related grade 3 or higher toxicities; 24% (n = 13) required high‐dose steroids (≥40 mg of prednisone or the equivalent). Grade 5 events occurred in 3 patients; 1 death was treatment related.
Conclusions
Nivolumab and ipilimumab resulted in objective responses in a subset of patients with rare genitourinary malignancies, especially those with BUTCVH. An additional cohort exploring their activity in genitourinary tumors with neuroendocrine differentiation is ongoing.
Lay Summary
Patients with rare cancers are often excluded from studies and have limited treatment options.
Fifty‐five patients with rare tumors of the genitourinary system were enrolled from multiple sites and were treated with nivolumab and ipilimumab, a regimen used for kidney cancer.
The regimen showed activity in some patients, particularly those with bladder or upper tract cancers of unusual or variant histology; 37% of those patients responded to therapy.
Additional studies are ongoing to better determine who benefits the most from this combination.
Patients with rare genitourinary malignancies have limited treatment options and are underrepresented in clinical trials. In this phase 2 trial, which has accrued 55 patients in less than 18 months, the combination of nivolumab and ipilimumab is active in a subset of patients with rare genitourinary malignancies, particularly those with bladder or upper tract carcinoma of variant histology (objective response rate 37%).
CT-based body composition (BC) measurements have historically been too resource intensive to analyze for widespread use and have lacked robust comparison with traditional weight metrics for ...predicting cardiovascular risk.
The aim of this study was to determine whether BC measurements obtained from routine CT scans by use of a fully automated deep learning algorithm could predict subsequent cardiovascular events independently from weight, BMI, and additional cardiovascular risk factors.
This retrospective study included 9752 outpatients (5519 women and 4233 men; mean age, 53.2 years; 890 patients self-reported their race as Black and 8862 self-reported their race as White) who underwent routine abdominal CT at a single health system from January 2012 through December 2012 and who were given no major cardiovascular or oncologic diagnosis within 3 months of undergoing CT. Using publicly available code, fully automated deep learning BC analysis was performed at the L3 vertebral body level to determine three BC areas (skeletal muscle area SMA, visceral fat area VFA, and subcutaneous fat area SFA). Age-, sex-, and race-normalized reference curves were used to generate
scores for the three BC areas. Subsequent myocardial infarction (MI) or stroke was determined from the electronic medical record. Multivariable-adjusted Cox proportional hazards models were used to determine hazard ratios (HRs) for MI or stroke within 5 years after CT for the three BC area
scores, with adjustment for normalized weight, normalized BMI, and additional cardiovascular risk factors (smoking status, diabetes diagnosis, and systolic blood pressure).
In multivariable models, age-, race-, and sex-normalized VFA was associated with subsequent MI risk (HR of highest quartile compared with lowest quartile, 1.31 95% CI, 1.03-1.67,
= .04 for overall effect) and stroke risk (HR of highest compared with lowest quartile, 1.46 95% CI, 1.07-2.00,
= .04 for overall effect). In multivariable models, normalized SMA, SFA, weight, and BMI were not associated with subsequent MI or stroke risk.
VFA derived from fully automated and normalized analysis of abdominal CT examinations predicts subsequent MI or stroke in Black and White patients, independent of traditional weight metrics, and should be considered an adjunct to BMI in risk models.
Fully automated and normalized BC analysis of abdominal CT has promise to augment traditional cardiovascular risk prediction models.
Background
Little is known about strategies to improve patient activation, particularly among persons living with HIV (PLWH).
Objective
To assess the impact of a group intervention and individual ...coaching on patient activation for PLWH.
Design
Pragmatic randomized controlled trial.
Sites
Eight practices in New York and two in New Jersey serving PLWH.
Participants
Three hundred sixty PLWH who received care at participating practices and had at least limited English proficiency and basic literacy.
Intervention
Six 90-min group training sessions covering use of an ePersonal Health Record loaded onto a handheld mobile device and a single 20–30 min individual pre-visit coaching session.
Main Measures
The primary outcome was change in Patient Activation Measure (PAM). Secondary outcomes were changes in eHealth literacy (eHEALS), Decision Self-efficacy (DSES), Perceived Involvement in Care Scale (PICS), health (SF-12), receipt of HIV-related care, and change in HIV viral load (VL).
Key Results
The intervention group showed significantly greater improvement than the control group in the primary outcome, the PAM (difference 2.82: 95% confidence interval CI 0.32–5.32). Effects were largest among participants with lowest quartile PAM at baseline (
p
< 0.05). The intervention doubled the odds of improving one level on the PAM (odds ratio 1.96; 95% CI 1.16–3.31). The intervention group also had significantly greater improvement in eHEALS (difference 2.67: 95% CI 1.38–3.9) and PICS (1.27: 95% CI 0.41–2.13) than the control group. Intervention effects were similar by race/ethnicity and low education with the exception of eHealth literacy where effects were stronger for minority participants. No statistically significant effects were observed for decision self-efficacy, health status, adherence, receipt of HIV relevant care, or HIV viral load.
Conclusions
The patient activation intervention modestly improved several domains related to patient empowerment; effects on patient activation were largest among those with the lowest levels of baseline patient activation.
Trial Registration
This study is registered at Clinical Trials.Gov (NCT02165735).
Medications contribute to patients' out-of-pocket costs, yet most clinicians do not routinely screen for patients' cost-of-medication (COM) concerns.
To assess whether a single training session ...improves COM conversations.
Before-after cross-sectional surveys of patients and qualitative interviews with clinicians and staff.
7 primary care practices in 3 U.S. states.
In total, 700 patients were surveyed from May 2017 to January 2018: 50 patients per practice before the intervention and another 50 patients per practice after the intervention. Eligibility criteria included age 18 years or older and taking 1 or more long-term medications. Qualitative interviews with 45 staff members were conducted.
A single 60-minute training session for clinicians and staff from each practice on COM importance, team-based screening, and cost-saving strategies.
Patient data (demographics, number of long-term medications, total monthly out-of-pocket medication costs, and history of cost-related medication nonadherence) were obtained immediately before and 3 months after the intervention. Practice staff were interviewed 3 months after the intervention.
A total of 700 patient surveys were completed. Frequency of COM discussion improved in 6 of the 7 practices and remained unchanged in 1 practice. Overall, COM conversations with patients increased from 17% at baseline to 32% postintervention (P = 0.00). There was substantial heterogeneity among sites in before-after differences in patient-reported out-of-pocket COM. Qualitative analyses from key informant interviews showed wide variation in implementation of screening approaches, workflow, adoption of a team-based approach, and strategies for addressing COM.
It is not known whether improvements in COM conversations were sustained beyond 3 months.
A single team training to screen and address patients' medication cost concerns improved COM discussions over the short term. Further research is needed to assess sustained effects and impact on patient costs and medication adherence and to determine whether more intensive, scalable interventions are needed.
Robert Wood Johnson Foundation.
Antiangiogenic VEGF receptor (VEGFR) inhibitors are approved for metastatic clear cell renal cell carcinoma (mccRCC) and their efficacy is higher in high angiogenic tumors. As cabozantinib inhibits ...multiple tyrosine kinase receptors, including VEGFRs, we tested whether markers of angiogenesis, including microvascular density (MVD) and mast cell density (MCD), could predict benefit from cabozantinib versus everolimus, using RCC samples from the METEOR (NCT01865747) trial.
MVD and MCD were studied in 430 patients (cabozantinib = 216, everolimus = 214) by double immunohistochemistry for CD31 (vascular marker) and tryptase (mast cell marker) coupled with automated image analysis. Results from evaluable cases (MVD = 360, MCD = 325) were correlated with progression-free survival (PFS), overall survival (OS), and objective response rate (ORR).
MVD was positively correlated with MCD. In the whole cohort, high MVD and high MCD were associated with longer PFS; improved PFS was most evident in patients with high levels of both MCD and MVD. Cabozantinib was associated with improved PFS, OS, and ORR compared with everolimus, irrespective of MVD levels. Cabozantinib was also associated with improved ORR compared with everolimus, irrespective of MCD levels. For PFS and OS, the treatment effect for cabozantinib versus everolimus tended to be greater in tumors with low MCD.
High MVD and high MCD are associated with improved outcome in mccRCC but do not predict efficacy to cabozantinib versus everolimus. The high efficacy of cabozantinib in low angiogenic tumors allows us to speculate that its antitumor activity is not exclusively mediated by VEGFR inhibition.
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