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Da Porto A, Candido R, Rocca A, Manicardi V, Nicolucci A, Miranda C, Cimino E, Di Bartolo P, Di Cianni G, Russo G. Quality of care and clinical inertia in the management of cardiovascular risk factors in patients with type 1 and type 2 diabetes: data from AMD annals. J Endocrinol Invest 2024:10.1007/s40618-024-02327-0. [PMID: 38436903 DOI: 10.1007/s40618-024-02327-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/29/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Cardiovascular disease is the leading cause of morbidity and mortality among patients with diabetes, and for this reason, all guidelines for CV risk management provide the same targets in controlling traditional CV risk factors in patients with type 1 or type 2 diabetes at equal CV risk class. Aim of our study was to evaluate and compare CV risk management in patients with type 1 and type 2 diabetes included in AMD Annals Database paying particular attention to indicators of clinical inertia. METHODS This was a multicenter, observational, retrospective study of AMD Annals Database during year 2022. Patients with diabetes were stratified on the basis of their cardiovascular risk, according to ESC-EASD guidelines. The proportion of patients not treated with lipid-lowering despite LDL cholesterol > to 100 mg/dl or the proportion of patients not treated with antihypertensive drug despite BP > 140/90 mmhg and proportion of patients with proteinuria not treated with angiotensin converting enzyme inhibitors or angiotensinogen receptor blockers (ACE/ARBs) were considered indicators of clinical inertia. The proportion of patients reaching at the same time HbA1c < 7% LDL < 70 mg/dl and BP < 130/80 mmhg were considered to have good multifactorial control. Overall quality of health care was evaluated by the Q-score. RESULTS Using the inclusion criteria and stratifying patients by ESC/EASD Cardiovascular Risk categories, we included in the analysis 118.442 patients at High Cardiovascular risk and 416.246 patients at Very High Cardiovascular risk. The proportion of patients with good multifactorial risk factor control was extremely low in both T1D and T2D patients in each risk class. At equal risk class, the patients with T1D had lower proportion of subjects reaching HbA1c, LDL, or Blood Pressure targets. Indicators of clinical inertia were significantly higher compared with patients with T2D at equal risk class. Data regarding patients with albuminuria not treated with RAAS inhibitors were available only for those at Very High risk and showed that the proportion of patients not treated was again significantly higher in patients with T1DM. CONCLUSIONS In conclusion, this study provides evidence of wide undertreatment of traditional cardiovascular risk factors among patients with diabetes included in AMD Annals Database. Undertreatment seems to be more pronounced in individuals with T1D compared to those with T2D and is frequently due to clinical inertia.
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Affiliation(s)
- A Da Porto
- Diabetes and Metabolism Unit, Clinica Medica, University of Udine, Udine, Italy.
| | - R Candido
- Department of Medical Surgical and Health Sciences, University of Trieste, Diabetes Center, ASUGI, Trieste, Italy
| | - A Rocca
- "G. Segalini" H. Bassini Cinisello Balsamo ASST Nord, Milan, Italy
| | | | - A Nicolucci
- Center for Outcomes Research and Clinical Epidemiology-CORESEARCH, Pescara, Italy
| | - C Miranda
- Endocrinology and Diabetes Unit, ASFO, Pordenone, Italy
| | - E Cimino
- UOC Medicina Generale ad Indirizzo Metabolico e Diabetologico, ASST Spedali Civili of Brescia, Brescia, Italy
| | - P Di Bartolo
- Ravenna Diabetes Center-Romagna Local Health Authority, Ravenna, Italy
| | - G Di Cianni
- USL Tuscany Northwest Location Livorno, Diabetes and Metabolic Disease, Livorno, Italy
| | - G Russo
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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Lorentzen EH, Minami CA. Avoiding Locoregional Overtreatment in Older Adults With Early-Stage Breast Cancer. Clin Breast Cancer 2024:S1526-8209(24)00042-9. [PMID: 38461117 DOI: 10.1016/j.clbc.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/01/2024] [Accepted: 02/07/2024] [Indexed: 03/11/2024]
Abstract
Advances in the treatment of older women with early-stage breast cancer, particularly opportunities for de-escalation of therapy, have afforded patients and providers opportunity to individualize care. As the majority of women ≥65 have estrogen receptor-positive, HER2-negative disease, locoregional therapy (surgery and/or radiation) may be tailored based on a patient's physiologic age to avoid either over- or undertreatment. To determine who would derive benefit from more or less intensive therapy, an accurate assessment of an older patient's physiologic age and incorporation of patient-specific values are paramount. While there now exist well-validated geriatric assessment tools whose use is encouraged by the American Society of Clinical Oncology when considering systemic therapy, these instruments have not been widely integrated into the locoregional breast cancer care model. This review aims to highlight the importance of assessing frailty and the concepts of and over- and undertreatment, in the context of trial data supporting opportunities for safe deescalation of locoregional therapy, when treating older women with early-stage breast cancer.
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Affiliation(s)
- Eliza H Lorentzen
- Department of Surgery, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA.
| | - Christina A Minami
- Department of Surgery, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA; Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA
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3
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Sauhta R, Makkar D, Siwach PS. The Sequential Therapy in Osteoporosis. Indian J Orthop 2023; 57:150-162. [PMID: 38107815 PMCID: PMC10721775 DOI: 10.1007/s43465-023-01067-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/15/2023] [Indexed: 12/19/2023]
Abstract
Background Osteoporosis management often involves a sequential treatment approach to optimize patient outcomes and minimize fracture risks. This strategy is tailored to individual patient characteristics, treatment responses, and fracture risk profiles. Methods A thorough literature review was systematically executed using prominent databases, including PubMed and EMBASE. The primary aim was to identify original articles and clinical trials evaluating the effectiveness of sequential therapy with anti-osteoporosis drugs, focusing on the period from 1995 to 2023. The analysis encompassed an in-depth examination of osteoporosis drugs, delineating their mechanisms of action, side effects, and current trends as elucidated in the literature. Results and Discussion Our study yielded noteworthy insights into the optimal sequencing of pharmacologic agents for the long-term treatment of patients necessitating multiple drugs. Notably, the achievement of optimal improvements in bone mass is observed when commencing treatment with an anabolic medication, followed by the subsequent utilization of an antiresorptive drug. This stands in contrast to initiating therapy with a bisphosphonate, which may potentially diminish outcomes in the post-anabolic intervention period. Furthermore, it has been discerned that caution should be exercised against transitioning from denosumab to PTH homologs due to the adverse effects of heightened bone turnover and sustained weakening of bone structure. Despite the absence of fracture data substantiating the implementation of integrated anabolic/antiresorptive pharmacotherapy, the incorporation of denosumab and teriparatide presents a potential avenue worthy of consideration for individuals at a heightened vulnerability to fragility fractures. Conclusions A judiciously implemented sequential treatment strategy in osteoporosis offers a flexible and tailored approach to address diverse clinical scenarios, optimizing fracture prevention and patient outcomes.
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Affiliation(s)
- Ravi Sauhta
- Department Orthopedics and Joint
Replacement, Artemis Hospitals, Gurgaon, India
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Kudaravalli S, Kam LY, Huang DQ, Cheung R, Nguyen MH. Utilization of Antiviral Therapy for Patients With Hepatitis B-Related Hepatocellular Carcinoma: A Nationwide Real-World US Study. Clin Gastroenterol Hepatol 2023; 21:3305-3313.e4. [PMID: 37805836 DOI: 10.1016/j.cgh.2023.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/01/2023] [Accepted: 04/17/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND & AIMS Although oral antiviral therapy (OAV) is reported to improve outcomes in patients with hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC), it is underutilized. We determined the rate and factors associated with OAV utilization among patients with HBV-related HCC in a US population with health insurance. METHODS Patients with HBV-related HCC were identified from the de-identified administrative health claims database for patients with private insurance, Optum Clinformatics (2003-2021). RESULTS We identified 2129 patients with HBV-related HCC: 71% male, mean age 62.7 ± 12.5 years, 40% Asian individuals, 72% with cirrhosis, and 37% received OAV. The treatment rate improved over time (40.5% after 2010 vs 26.3% earlier; P < .001). Significantly lower treatment rates were noted for females, non-Asian patients, noncirrhotic patients, and patients without gastroenterologist/hepatologist or infectious disease (GI/ID) specialist care (P < .0001). OAV treatment predictors included Asian race and ethnicity (adjusted odds ratio [aOR], 3.6; 95% CI, 2.8-4.5; P < .001), male sex (aOR, 1.6; 95% CI, 1.3-2.0; P < .001), seeing a GI/ID specialist (aOR, 1.5; 95% CI, 1.10-1.99; P = .0091), having compensated cirrhosis (aOR, 2.2; 95% CI, 1.7-2.8; P < .001), and being treated from 2011 to 2021 (aOR, 2.3; 95% CI, 1.8-3.0; P < .001); being younger (aOR, 0.98; 95% CI, 0.98-0.99; P < .001) was less likely for treatment. OAV initiated at or before HCC diagnosis was associated independently with improved survival (adjusted hazard ratio, 0.84; 95% CI, 0.72-0.99; P = .037). CONCLUSIONS Among patients with HBV-related HCC, only 1 in 3 received OAV despite having insurance coverage. Efforts must continue to develop ways to improve HBV OAV treatment, especially among females, non-Asian patients, and patients without cirrhosis or not seen by specialists.
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Affiliation(s)
- Sahith Kudaravalli
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California; Trinity College of Arts and Sciences, Duke University, Durham, North Carolina
| | - Leslie Y Kam
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California
| | - Daniel Q Huang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Gastroenterology and Hepatology, National University Health System, Singapore
| | - Ramsey Cheung
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California; Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Mindie H Nguyen
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California; Department of Epidemiology and Population Health, Stanford University School of Medicine, Palo Alto, California.
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Gillespie IA, Barnes E, Wong ICK, Matthews PC, Cooke GS, Tipple C, Elston RC, Liu Y, Smith DA, Wang T, Davies J, Várnai KA, Freeman O, Man KKC, Lau WCY, Glampson B, Meng X, Morais E, Liu S, Mercuri L, Boxall N, Jenner S, Kendrick S, Dong J, Theodore D. Patient Biochemistry and Treatment Need in Chronic Hepatitis B Virus Infection Across Three Continents: Retrospective Cross-Sectional Cohort Studies. Infect Dis Ther 2023; 12:2513-2532. [PMID: 37432642 PMCID: PMC10651815 DOI: 10.1007/s40121-023-00824-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/16/2023] [Indexed: 07/12/2023] Open
Abstract
INTRODUCTION Chronic hepatitis B virus (HBV) infection is associated with significant global morbidity and mortality. Low treatment rates are observed in patients living with HBV; the reasons for this are unclear. This study sought to describe patients' demographic, clinical and biochemical characteristics across three continents and their associated treatment need. METHODS This retrospective cross-sectional post hoc analysis of real-world data used four large electronic databases from the United States, United Kingdom and China (specifically Hong Kong and Fuzhou). Patients were identified by first evidence of chronic HBV infection in a given year (their index date) and characterized. An algorithm was designed and applied, wherein patients were categorized as treated, untreated but indicated for treatment and untreated and not indicated for treatment based on treatment status and demographic, clinical, biochemical and virological characteristics (age; evidence of fibrosis/cirrhosis; alanine aminotransferase [ALT] levels, HCV/HIV coinfection and HBV virology markers). RESULTS In total, 12,614 US patients, 503 UK patients, 34,135 patients from Hong Kong and 21,614 from Fuzhou were included. Adults (99.4%) and males (59.0%) predominated. Overall, 34.5% of patients were treated at index (range 15.9-49.6%), with nucleos(t)ide analogue monotherapy most commonly prescribed. The proportion of untreated-but-indicated patients ranged from 12.9% in Hong Kong to 18.2% in the UK; almost two-thirds of these patients (range 61.3-66.7%) had evidence of fibrosis/cirrhosis. A quarter (25.3%) of untreated-but-indicated patients were aged ≥ 65 years. CONCLUSION This large real-world dataset demonstrates that chronic hepatitis B infection remains a global health concern; despite the availability of effective suppressive therapy, a considerable proportion of predominantly adult patients apparently indicated for treatment are currently untreated, including many patients with fibrosis/cirrhosis. Causes of disparity in treatment status warrant further investigation.
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Affiliation(s)
| | - Eleanor Barnes
- Nuffield Department of Medicine, University of Oxford, Old Road, Oxford, OX3 7BN, UK
- NIHR Health Informatics Collaborative, Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford, OX3 9DU, UK
| | - Ian C K Wong
- Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, 21 Sassoon Road, Pokfulam, Hong Kong
- Research Department of Practice and Policy, UCL School of Pharmacy, 29-39 Brunswick Square, London, WC1N 1AX, UK
| | - Philippa C Matthews
- Nuffield Department of Medicine, University of Oxford, Old Road, Oxford, OX3 7BN, UK
- NIHR Health Informatics Collaborative, Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford, OX3 9DU, UK
- The Francis Crick Institute, 1 Midland Road, London, NW1 1AT, UK
- University College London, Gower St, London, WC1E 6BT, UK
| | - Graham S Cooke
- Faculty of Medicine, Department of Infectious Disease, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK
- NIHR Health Informatics Collaborative, Imperial College Healthcare NHS Trust, The Bays, S Wharf Rd, London, W2 1NY, UK
| | - Craig Tipple
- GSK, Gunnels Wood Road, Stevenage, SG1 2NY, Hertfordshire, UK
| | - Robert C Elston
- GSK, Gunnels Wood Road, Stevenage, SG1 2NY, Hertfordshire, UK
| | - Yunhao Liu
- GSK, 1250 S Collegeville Rd, Collegeville, PA, 19426, USA
| | - David A Smith
- NIHR Health Informatics Collaborative, Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford, OX3 9DU, UK
| | - Tingyan Wang
- Nuffield Department of Medicine, University of Oxford, Old Road, Oxford, OX3 7BN, UK
| | - Jim Davies
- Department of Computer Science, University of Oxford, 7 Parks Rd, Oxford, OX1 3QG, UK
| | - Kinga A Várnai
- NIHR Health Informatics Collaborative, Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford, OX3 9DU, UK
| | - Oliver Freeman
- Nuffield Department of Population Health, University of Oxford, University of Oxford Richard Doll Building, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Kenneth K C Man
- Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, 21 Sassoon Road, Pokfulam, Hong Kong
- Research Department of Practice and Policy, UCL School of Pharmacy, 29-39 Brunswick Square, London, WC1N 1AX, UK
| | - Wallis C Y Lau
- Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, 21 Sassoon Road, Pokfulam, Hong Kong
- Research Department of Practice and Policy, UCL School of Pharmacy, 29-39 Brunswick Square, London, WC1N 1AX, UK
| | - Ben Glampson
- NIHR Health Informatics Collaborative, Imperial College Healthcare NHS Trust, The Bays, S Wharf Rd, London, W2 1NY, UK
| | - Xing Meng
- GSK Institute for Infectious Diseases and Public Health, 11F, Bldg 2, Shuangqing Plaza, No. 77, Shuangqing Road, Beijing, China
| | | | - Sen Liu
- GSK Institute for Infectious Diseases and Public Health, 11F, Bldg 2, Shuangqing Plaza, No. 77, Shuangqing Road, Beijing, China
| | - Luca Mercuri
- NIHR Health Informatics Collaborative, Imperial College Healthcare NHS Trust, The Bays, S Wharf Rd, London, W2 1NY, UK
| | - Naomi Boxall
- IQVIA, The Point, 37 N Wharf Rd, London, W2 1AF, UK
| | - Sarah Jenner
- IQVIA, The Point, 37 N Wharf Rd, London, W2 1AF, UK
| | - Stuart Kendrick
- GSK, Gunnels Wood Road, Stevenage, SG1 2NY, Hertfordshire, UK
| | - Jane Dong
- GSK Institute for Infectious Diseases and Public Health, 11F, Bldg 2, Shuangqing Plaza, No. 77, Shuangqing Road, Beijing, China
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Osório F, Hipólito-Reis H, Almeida P, Mourão J, Fougo JL. Same-day discharge pathway for breast cancer surgery in patients aged over 80: A feasibility study. J Geriatr Oncol 2023:101518. [PMID: 37230930 DOI: 10.1016/j.jgo.2023.101518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 03/21/2023] [Accepted: 04/26/2023] [Indexed: 05/27/2023]
Affiliation(s)
- Fernando Osório
- Breast Center, S. João University Hospital, Porto, Portugal; Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal; pGA>70 Program, São João University Hospital, Porto, Portugal; CINTESIS@RISE, GeriMHealth, Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Helena Hipólito-Reis
- pGA>70 Program, São João University Hospital, Porto, Portugal; Department of Internal Medicine, São João University Hospital, Porto, Portugal
| | - Paulo Almeida
- pGA>70 Program, São João University Hospital, Porto, Portugal; Department of Internal Medicine, São João University Hospital, Porto, Portugal
| | - Joana Mourão
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal; pGA>70 Program, São João University Hospital, Porto, Portugal; Department of Anesthesiology, São João University Hospital, Porto, Portugal
| | - José Luís Fougo
- Breast Center, S. João University Hospital, Porto, Portugal; Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
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Puigvert-Martínez AM, Prieto-Castro R, Artigas-Feliu R, Illán-Mateo P, Cruz-Culebra N, González-Ayala G. Management of erectile dysfunction and premature ejaculation: The perspective of Spanish urologists. Results of the PANDORA Project (Part II). Rev Int Androl 2023; 21:100353. [PMID: 37105006 DOI: 10.1016/j.androl.2023.100353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 02/01/2022] [Accepted: 04/12/2022] [Indexed: 04/29/2023]
Abstract
INTRODUCTION ED and PE are the most common male sexual dysfunctions, although they remain underdiagnosed and undertreated. AIM To ascertain how a group of Spanish urologists currently address ED and PE. METHODS Descriptive study based on a self-designed questionnaire about the clinical practice in ED and PE upon diagnosis, treatment and monitoring, patient-physician relationship and the role of the patient's partner. RESULTS The survey was completed by 188 experienced urologists. Most patients went to the urologist's office without a previous diagnosis (92% of the urologists found <10 PE-diagnosed patients in public settings). The diagnosis of ED and/or PE was mainly carried out by the current urologist and not by another professional, particularly in private centres as opposed to public centres (78.8% vs 57.0% for ED; 82.0% vs 62.6% for PE). Most urologists believed that these disorders are underdiagnosed and deemed them as general health issues. 38% of urologists acknowledged using validated questionnaires to diagnose ED. PE was considered a subjective problem rather than a true disease and the use of PRO-based diagnosis of PE was not generally accepted (14%). Treatment options of both disorders were chosen as expected. Referral to the andrologist is usually scheduled in moderate-to-severe PE or severe ED. The cohort seemed to be mostly neutral (50%-75% for ED and 40%-55% for PE) regarding patient reluctancy to talk about their sexual problem. Patients' partners play an important role in helping men seeking treatment. CONCLUSION Urologists should show more proactivity during anamnesis and routine visits to improve management of ED and PD.
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Affiliation(s)
| | - Rafael Prieto-Castro
- Andrology Unit, Sexual and Reproductive Medicine, Reina Sofía Regional University Hospital of Cordoba, Córdoba, Spain
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Huang CLC. Underrecognition and un-dertreatment of stress-related psychiatric disorders in physicians: Determinants, challenges, and the impact of the COVID-19 pandemic. World J Psychiatry 2023; 13:131-140. [PMID: 37123097 PMCID: PMC10130963 DOI: 10.5498/wjp.v13.i4.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 03/12/2023] [Accepted: 04/07/2023] [Indexed: 04/18/2023] Open
Abstract
Medical practitioners’ duties are highly stressful and performed in a particularly challenging and competitive work environment. Stress and burnout among physicians have emerged as a worldwide public health problem in recent years. A high level of distress and burnout can lead to clinically significant behavioral health problems, such as stress-related psychiatric disorders. Mounting evidence shows that physicians have higher risks of insomnia, anxiety, and depression than the general population, especially during the coronavirus disease 2019 pandemic. However, the behavioral health problems of these vulnerable healthcare professionals are noteworthy for being underrecognized and undertreated. In this mini-review, we summarize the current progress of studies on the prevalence and determinants of distress and stress-related psychiatric disorders among phy-sicians and their healthcare-seeking behaviors. We discuss future research directions and the clinical approach that may maximize self-awareness and promote prompt and adequate treatment for clinically significant behavioral health problems of physicians.
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Affiliation(s)
- Charles Lung-Cheng Huang
- Department of Psychiatry, Chi Mei Medical Center, Tainan 710, Taiwan
- Department of Medicinal and Applied Chemistry, Kaohsiung Medical University, Kaohsiung 807, Taiwan
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Rachamin Y, Meyer MR, Rosemann T, Grischott T. Impact of the COVID-19 Pandemic on Elective and Emergency Inpatient Procedure Volumes in Switzerland - A Retrospective Study Based on Insurance Claims Data. Int J Health Policy Manag 2022; 12:6932. [PMID: 36243943 PMCID: PMC10125178 DOI: 10.34172/ijhpm.2022.6932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 08/14/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) pandemic forced hospitals to redistribute resources for the treatment of patients with coronavirus disease 2019 (COVID-19), yet the impact on elective and emergency inpatient procedure volumes is unclear. METHODS We analyzed anonymized data on 234 921 hospitalizations in 2017-2020 (55.9% elective) from a big Swiss health insurer. We used linear regression models to predict, based on pre-pandemic data, the expected weekly numbers of procedures in 2020 in the absence of a pandemic and compared these to the observed numbers in 2020. Compensation effects were investigated by discretely integrating the difference between the two numbers over time. RESULTS During the first COVID-19 wave in spring 2020, elective procedure numbers decreased by 52.9% (95% confidence interval -64.5% to -42.5%), with cardiovascular and orthopedic elective procedure numbers specifically decreasing by 45.5% and 72.4%. Elective procedure numbers normalized during summer with some compensation of postponed procedures, leaving a deficit of -9.9% (-15.8% to -4.5%) for the whole year 2020. Emergency procedure numbers also decreased by 17.1% (-23.7% to -9.8%) during the first wave, but over the whole year 2020, net emergency procedure volumes were similar to control years. CONCLUSION Inpatient procedure volumes in Switzerland decreased considerably in the beginning of the pandemic but recovered quickly after the first wave. Still, there was a net deficit in procedures at the end of the year. Health system leaders must work to ensure that adequate access to non-COVID-19 related care is maintained during future pandemic phases in order to prevent negative health consequences.
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Affiliation(s)
- Yael Rachamin
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Matthias R. Meyer
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zurich, Switzerland
- Division of Cardiology, Cantonal Hospital Graubuenden, Chur, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Thomas Grischott
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zurich, Switzerland
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Navarro M, Reguero L, Subirà C, Blázquez-Pérez A, Requena-Méndez A. Estimating chagas disease prevalence and number of underdiagnosed, and undertreated individuals in Spain. Travel Med Infect Dis 2022; 47:102284. [PMID: 35245657 DOI: 10.1016/j.tmaid.2022.102284] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 12/29/2021] [Accepted: 02/23/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Chagas disease constitutes a public health problem, and Spain is the non-endemic country with the highest burden of disease outside the Americas. It represents a model for non-endemic countries regarding health policies to control the disease. This study is aimed to generate estimates of the T.cruzi prevalence and the number of undetected and untreated individuals with the infection in Spain and to compare them with the actual number of cases reported by official sources. METHODS Using aggregate data collected from the literature and official sources (Spanish National Statistics Institute; Spanish Agency of Medicines and Medical Devices) from 2010 to 2018, this study estimates the number of Chagas disease cases, plus the underdiagnosis and undertreatment rates. RESULTS We estimated that 55,367 out of 2,602,285 migrants originally from endemic countries were living with Chagas disease in Spain in 2018, accounting for a prevalence of 2.1%. Only 1% of these cases(613/455,566) were children aged 14 years or less resulting in a prevalence of 0.1%. Bolivian migrants accounted for 53.9% of the total estimated cases. The index of underdiagnosis and undertreatment were heterogeneous across different Spanish autonomous regions, but the overall index of underdiagnosis was around 71%, and the overall index of undertreatment was 82.5% in patients aged 15 years or older, and 60% in children. CONCLUSION The burden of Chagas disease in Spain is considerable. Index of underdiagnosis and undertreatment are high, particularly in women of childbearing age, but they have improved in children since the implementation of antenatal screening programmes.
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Osório F, Barros AS, Peleteiro B, Barradas AR, Urbano J, Fougo JL, Leite-Moreira A. Frailty-Independent Undertreatment Negative Impact on Survival in Older Patients With Breast Cancer. J Breast Cancer 2021; 24:542-553. [PMID: 34877829 PMCID: PMC8724373 DOI: 10.4048/jbc.2021.24.e45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/25/2021] [Accepted: 10/11/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose The management of older adults with breast cancer (BC) remains controversial. The challenging assessment of aging idiosyncrasies and the scarce evidence of therapeutic guidelines can lead to undertreatment. Our goal was to measure undertreatment and assess its impact on survival. Methods Consecutive patients with BC aged 70 years or older were prospectively enrolled in 2014. Three frailty screening tools (G8, fTRST, and GFI) and two functional status scales (Karnofsky performance score and Eastern Cooperative Oncology Group Performance Status) were applied. Disease characteristics, treatment options, and causes of mortality were recorded during a 5-year follow-up. In addition, we defined undertreatment and correlated its survival impact with frailty. Results A total of 92 patients were included in the study. The median age was 77 (range 70–94) years. The prevalence of frailty was discordant (G8, 41.9%; fTRST, 74.2%; GFI, 32.3%). Only 47.8% of the patients had a local disease, probably due to a late diagnosis (73.9% based on self-examination). Thirty-three patients (35.6%) died, of which 15 were from BC. We found a considerably high proportion (53.3%) of undertreatment, which had a frailty-independent negative impact on the 5-year survival (hazard ratio [HR], 5.1; 95% confidence interval [CI], 2.1–12.5). Additionally, omission of surgery had a frailty-independent negative impact on overall survival (HR, 3.9; 95% CI, 1.9–7.9). Conclusion BC treatment in older adults should be individualized. More importantly, assessing frailty (not to treat) is essential to be aware of the risk-benefit profile and the patient's well-informed willingness to be treated. Undertreatment in daily practice is frequent and might have a negative impact on survival, as we report.
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Affiliation(s)
- Fernando Osório
- Breast Center, São João University Hospital, Faculty of Medicine, University of Porto, Porto, Portugal.,Center for Research in Health Technologies and Services (CINTESIS.UP), University of Porto, Porto, Portugal.
| | - António S Barros
- Department of Surgery and Physiology, Cardiovascular Research and Development Unit, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Bárbara Peleteiro
- Hospital Epidemiology Center, Faculty of Medicine, São João University Hospital, Porto, Portugal.,EPIUnit, Institute of Public Health, University of Porto, Porto, Portugal.,Department of Public Health and Forensic Sciences, and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Ana Rita Barradas
- Department of Internal Medicine, Egas Moniz Hospital, Lisboa, Portugal
| | - Joana Urbano
- Department of Internal Medicine, Alto Minho Hospital, Viana do Castelo, Portugal
| | - José Luís Fougo
- Breast Center, São João University Hospital, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Adelino Leite-Moreira
- Department of Surgery and Physiology, Cardiovascular Research and Development Unit, Faculty of Medicine, University of Porto, Porto, Portugal
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Erküner Ö, van Eck M, Xhaet O, Verheij H, Neefs J, Duygun A, Nijmeijer R, Saïd SAM, Uiterwaal H, Hagens V, Bhagwandien R, Szili-Torok T, Bijsterveld N, Tjeerdsma G, Vijgen J, Friart A, Hoffer E, Evrard P, Srynger M, Meeder J, de Groot JR, van Opstal J, Gevers R, Lip GYH, Boriani G, Crijns HJGM, Luermans JGLM, Mairesse GH. Contemporary management of patients with atrial fibrillation in the Netherlands and Belgium: a report from the EORP-AF long-term general registry. Neth Heart J 2021; 29:584-594. [PMID: 34524620 PMCID: PMC8556427 DOI: 10.1007/s12471-021-01634-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Contemporary data regarding the characteristics, treatment and outcomes of patients with atrial fibrillation (AF) are needed. We aimed to assess these data and guideline adherence in the EURObservational Research Programme on Atrial Fibrillation (EORP-AF) long-term general registry. METHODS We analysed 967 patients from the EORP-AF long-term general registry included in the Netherlands and Belgium from 2013 to 2016. Baseline and 1‑year follow-up data were gathered. RESULTS At baseline, 887 patients (92%) received anticoagulant treatment. In 88 (10%) of these patients, no indication for chronic anticoagulant treatment was present. A rhythm intervention was performed or planned in 52 of these patients, meaning that the remaining 36 (41%) were anticoagulated without indication. Forty patients were not anticoagulated, even though they had an indication for chronic anticoagulation. Additionally, 63 of the 371 patients (17%) treated with a non-vitamin K antagonist oral anticoagulant (NOAC) were incorrectly dosed. In total, 50 patients (5%) were overtreated and 89 patients (9%) were undertreated. However, the occurrence of major adverse cardiac and cerebrovascular events (MACCE) was still low with 4.2% (37 patients). CONCLUSIONS Overtreatment and undertreatment with anticoagulants are still observable in 14% of this contemporary, West-European AF population. Still, MACCE occurred in only 4% of the patients after 1 year of follow-up.
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Affiliation(s)
- Ö Erküner
- Department of Cardiology, Maastricht University Medical Center + (MUMC+), Maastricht, The Netherlands. .,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.
| | - M van Eck
- Department of Cardiology, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands
| | - O Xhaet
- Department of Cardiology, CHU Namur, Yvoir, Belgium
| | - H Verheij
- Department of Cardiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - J Neefs
- Department of Cardiology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - A Duygun
- Department of Cardiology, VieCuri Medical Center, Venlo, The Netherlands
| | - R Nijmeijer
- Department of Cardiology, Tjongerschans Hospital Heerenveen, Heerenveen, The Netherlands
| | - S A M Saïd
- Department of Cardiology, Ziekenhuis Groep Twente, Hengelo, The Netherlands
| | - H Uiterwaal
- Department of Cardiology, Flevo Hospital, Almere, The Netherlands
| | - V Hagens
- Department of Cardiology, Ommelander Hospital Group, Delfzijl, The Netherlands
| | - R Bhagwandien
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - T Szili-Torok
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - N Bijsterveld
- Department of Cardiology, Flevo Hospital, Almere, The Netherlands
| | - G Tjeerdsma
- Department of Cardiology, Tjongerschans Hospital Heerenveen, Heerenveen, The Netherlands
| | - J Vijgen
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
| | - A Friart
- Department of Cardiology, CHU Tivoli, La Louvière, Belgium
| | - E Hoffer
- Department of Cardiology, CHR Citadelle, Liège, Belgium
| | - P Evrard
- Department of Cardiology, CHC St Joseph, Liège, Belgium
| | - M Srynger
- Department of Cardiology, CHU Liège, Liège, Belgium
| | - J Meeder
- Department of Cardiology, VieCuri Medical Center, Venlo, The Netherlands
| | - J R de Groot
- Department of Cardiology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - J van Opstal
- Department of Cardiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - R Gevers
- Department of Cardiology, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands
| | - G Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - G Boriani
- Modena University Hospital, Department of Cardiology, University of Modena and Reggio Emilia, Modena, Italy
| | - H J G M Crijns
- Department of Cardiology, Maastricht University Medical Center + (MUMC+), Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - J G L M Luermans
- Department of Cardiology, Maastricht University Medical Center + (MUMC+), Maastricht, The Netherlands
| | - G H Mairesse
- Arlon and Clinique Ste Thérèse, Department of Cardiology, Cliniques du Sud-Luxembourg, Bastogne, Belgium
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13
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Hubscher E, Sikirica S, Bell T, Brown A, Welch V, Russell-Smith A, D'Amico P. Patterns of undertreatment among patients with acute myeloid leukemia (AML): considerations for patients eligible for non-intensive chemotherapy (NIC). J Cancer Res Clin Oncol 2021; 147:3359-3368. [PMID: 34462785 PMCID: PMC8484094 DOI: 10.1007/s00432-021-03756-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/04/2021] [Indexed: 11/30/2022]
Abstract
Acute myeloid leukemia (AML) is a life-threatening malignancy that is more prevalent in the elderly. Because the patient population is heterogenous and advanced in age, choosing the optimal therapy can be challenging. There is strong evidence supporting antileukemic therapy, including standard intensive induction chemotherapy (IC) and non-intensive chemotherapy (NIC), for older patients with AML, and guidelines recommend treatment selection based on a patient’s individual and disease characteristics as opposed to age alone. Nonetheless, historic evidence indicates that a high proportion of patients who may be candidates for NIC receive no active antileukemic treatment (NAAT), instead receiving only best supportive care (BSC). We conducted a focused literature review to assess current real-world patterns of undertreatment in AML. From a total of 25 identified studies reporting the proportion of patients with AML receiving NAAT, the proportion of patients treated with NAAT varied widely, ranging from 10 to 61.4% in the US and 24.1 to 35% in Europe. Characteristics associated with receipt of NAAT included clinical factors such as age, poor performance status, comorbidities, and uncontrolled concomitant conditions, as well as sociodemographic factors such as female sex, unmarried status, and lower income. Survival was diminished among patients receiving NAAT, with reported median overall survival values ranging from 1.2 to 4.8 months compared to 5 to 14.4 months with NIC. These findings suggest a proportion of patients who are candidates for NIC receive NAAT, potentially forfeiting the survival benefit of active antileukemic treatment.
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Keister LA, Stecher C, Aronson B, McConnell W, Hustedt J, Moody JW. Provider Bias in prescribing opioid analgesics: a study of electronic medical Records at a Hospital Emergency Department. BMC Public Health 2021; 21:1518. [PMID: 34362330 PMCID: PMC8344207 DOI: 10.1186/s12889-021-11551-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/26/2021] [Indexed: 11/10/2022] Open
Abstract
Background Physicians do not prescribe opioid analgesics for pain treatment equally across groups, and such disparities may pose significant public health concerns. Although research suggests that institutional constraints and cultural stereotypes influence doctors’ treatment of pain, prior quantitative evidence is mixed. The objective of this secondary analysis is therefore to clarify which institutional constraints and patient demographics bias provider prescribing of opioid analgesics. Methods We used electronic medical record data from an emergency department of a large U.S hospital during years 2008–2014. We ran multi-level logistic regression models to estimate factors associated with providing an opioid prescription during a given visit while controlling for ICD-9 diagnosis codes and between-patient heterogeneity. Results A total of 180,829 patient visits for 63,513 unique patients were recorded during the period of analysis. Overall, providers were significantly less likely to prescribe opioids to the same individual patient when the visit occurred during higher rates of emergency department crowding, later times of day, earlier in the week, later years in our sample, and when the patient had received fewer previous opioid prescriptions. Across all patients, providers were significantly more likely to prescribe opioids to patients who were middle-aged, white, and married. We found no bias towards women and no interaction effects between race and crowding or between race and sex. Conclusions Providers tend to prescribe fewer opioids during constrained diagnostic situations and undertreat pain for patients from high-risk and marginalized demographic groups. Potential harms resulting from previous treatment decisions may accumulate by informing future treatment decisions. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11551-9.
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Affiliation(s)
- Lisa A Keister
- Department of Sociology, Duke Network Analysis, Sanford School of Public Policy, Duke University, Durham, NC, 27705, USA.
| | - Chad Stecher
- College of Health Solutions, Arizona State University, Phoenix, AZ, 85004, USA
| | - Brian Aronson
- The Adecco Group, 10151 Deerwood Park Blvd bldg 200 ste 101, Jacksonville, FL, 32256, USA
| | - William McConnell
- Department of Sociology, Florida Atlantic University, 777 Glades Road
- CU 97 Rm 253, Boca Raton, FL, 33431, USA
| | - Joshua Hustedt
- Department of Orthopedics, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, 85004, USA
| | - James W Moody
- Department of Sociology, Duke Network Analysis, Duke University, Durham, NC, 27705, USA
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15
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Becker J, Huschak G, Petzold HC, Thieme V, Stehr S, Bercker S. Non-medical risk factors associated with postponing elective surgery: a prospective observational study. BMC Med Ethics 2021; 22:90. [PMID: 34256762 PMCID: PMC8275631 DOI: 10.1186/s12910-021-00660-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/06/2021] [Indexed: 11/18/2022] Open
Abstract
Background Operation room (OR) planning is a complex process, especially in large hospitals with high rates of unplanned emergency procedures. Postponing elective surgery in order to provide capacity for emergency operations is inevitable at times. Elderly patients, residents of nursing homes, women, patients with low socioeconomic status and ethnic minorities are at risk for undertreatment in other contexts, as suggested by reports in the medical literature. We hypothesized that specific patient groups could be at higher risk for having their elective surgery rescheduled for non-medical reasons. Methods In this single center, prospective observational trial, we analysed 2519 patients undergoing elective surgery from October 2018 to May 2019. A 14-item questionnaire was handed out to illicit patient details. Additional characteristics were collected using electronic patient records. Information on the timely performance of the scheduled surgery was obtained using the OR’s patient data management system. 6.45% of all planned procedures analysed were postponed. Association of specific variables with postponement rates were analysed using the Mann–Whitney U test and Fisher's exact test/χ2-test. Results Significantly higher rates of postponing elective surgery were found in elderly patients. No significant differences in postponing rates were found for the variables gender, nationality (Germany, EU, non-EU), native language, professional medical background and level of education. Significantly lower rescheduling rates were found in patients with ties to hospital staff and in patients with a private health insurer. Conclusions Elderly patients, retirees and nursing home residents seem to be at higher risk for having their elective surgery rescheduled. However, owing to the study design, causality could not be proven. Our findings raise concern about possible undertreatment of these patient groups and provide data on short-term postponement of elective surgery. Trial registration DRKS00015836. Retrospectively registered.
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Affiliation(s)
- Julia Becker
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Gerald Huschak
- Operating Room Management, University Hospital of Leipzig, Leipzig, Germany
| | - Hannes-Caspar Petzold
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.,Clinical Ethics Committee, University Hospital of Leipzig, Leipzig, Germany
| | - Volker Thieme
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Sebastian Stehr
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Sven Bercker
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany. .,Clinical Ethics Committee, University Hospital of Leipzig, Leipzig, Germany.
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16
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Passalacqua G, Musarra A, Senna G, Bousquet J, Ferrara C, Lonati C, Canonica GW. Physicians' prescribing behaviour and clinical practice patterns for allergic rhinitis management in Italy. Clin Mol Allergy 2020; 18:20. [PMID: 33292294 PMCID: PMC7640419 DOI: 10.1186/s12948-020-00135-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/16/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Despite availability of clinical guidelines, underdiagnosis, undertreatment, and poor adherence are still significant concerns in allergic rhinitis (AR) therapeutic management. We investigated clinical practice patterns and prescribing behavior of Italian healthcare professionals (HCPs) specialized in AR. METHODS One-hundred allergologists, 100 ear, nose and throat (ENT) specialists, and 150 general practitioners (GPs) were recruited. The survey assessed: socio-demographic, work experience, monthly caseload, prescription drivers. Next, HCPs were invited to retrospectively recover patients' clinical data to investigate: AR clinical characteristics, therapy management, prescription patterns, patient adherence. Descriptive statistics, Chi square, One-Way analysis of variance, and Two-Way Analysis of Variance were performed. RESULTS Allergologists visited more AR patients (31% of monthly caseload) than ENTs (21%, p < 0.001), while GPs' caseload was the lowest (6%). Clinical information of 2823 patients were retrieved of whom 1906 (67.5%) suffered from moderate/severe AR (discomfort score: 7.7 ± 1.3) and 917 (32.4%) from mild AR (5.7 ± 1.9). About one-third of mild patients had a discomfort score ≥ 7. Main prescription drivers were "effective on all symptoms" (54.3% patients) and "quick symptom relief" (47.8%), whereas minor drivers were "affordable price" (13.4%) and "refundable" (8.7%). The most prescribed drugs were antihistamines and intranasal corticosteroids (79% and 55% prescriptions), followed by fixed-dose-combination of intranasal azelastine/fluticasone (19%). Polytherapy was the most common treatment strategy (59.6%). HCPs' believe that the majority of the patients was adherent to treatment (88% with score > 7). CONCLUSIONS This survey describes the therapeutic approach adopted by Italian physicians to cope with AR and shows that HCPs underestimated AR severity and had a non-realistic perception of patients' adherence. These findings suggest that further efforts are required to improve AR clinical management in Italy.
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Affiliation(s)
- Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Antonino Musarra
- Allergy Unit, National Healthcare System, Scilla, Reggio Calabria, Italy
| | - Gianenrico Senna
- Unità Operativa di Allergologia-Asma Center-Azienda Ospedaliera, Universitaria Integrata di Verona, Verona, Italy
| | - Jean Bousquet
- Comprehensive Allergy Center, Department of Dermatology and Allergy, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Centre Hospitalier Universitaire de Montpellier, Montpellier, France
- MACVIA-France, Montpellier, France
| | | | - Caterina Lonati
- Center for Preclinical Research, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via Pace 9, 20122, Milan, Italy.
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17
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Di Lascio S, Tognazzo E, Bigiotti S, Bonollo M, Costa A, Pagani O, Meani F. Breast cancer in the oldest old (≥ 89 years): Tumor characteristics, treatment choices, clinical outcomes and literature review. Eur J Surg Oncol 2021; 47:796-803. [PMID: 33097334 DOI: 10.1016/j.ejso.2020.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/04/2020] [Accepted: 10/07/2020] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Risk of breast cancer increases with age and very few data are available in patients older than 89. METHODS A retrospective analysis on patients aged 89 and older treated between 2008 and 2019 at our certified breast center. The aim was to analyze clinical characteristics, decision-making, treatment, outcomes and open questions regarding this subpopulation for which there is a lack of guidelines. RESULTS 58 patients included. Tumor characteristics were analyzed, 85% patients underwent surgery of which 44% had a mastectomy. The median follow-up and overall survival were 20 and 76 months, respectively.The median survival of metastatic and non-metastatic patients were 14 and 50 months, respectively. Most patients did not receive any adjuvant treatment and among these 14% had a relapse. CONCLUSIONS Elderly patients should not be under or over-treated because of their age; they represent a large heterogeneous group deserving a sub-stratification for a better tailored treatment.
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18
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Feliu J, Espinosa E, Basterretxea L, Paredero I, Llabrés E, Jiménez-Munárriz B, Antonio-Rebollo M, Losada B, Pinto A, Gironés R, Custodio AB, Muñoz MDM, Gómez-Mediavilla J, Torregrosa MD, Soler G, Cruz P, Higuera O, Molina-Garrido MJ. Undertreatment and overtreatment in older patients treated with chemotherapy. J Geriatr Oncol 2020; 12:381-387. [PMID: 33109485 DOI: 10.1016/j.jgo.2020.10.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/02/2020] [Accepted: 10/15/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Inconsistent doses and schemes are commonly used in older patients receiving cancer chemotherapy. We performed this study in patients with cancer and age ≥ 70 years to determine the frequency of undertreatment and overtreatment as well as factors influencing the decision to modify chemotherapy doses. PATIENTS AND METHODS Patients aged ≥70 years starting new chemotherapy regimens were prospectively included in a multicentre study. The schedule and drug doses were determined by the treating oncologist. Pre-chemotherapy assessment included sociodemographics, treatment details and geriatric assessment (GA) variables. Association between these factors and undertreatment (use of less intensive cancer treatment [LICT] in a fit patient) or overtreatment (use of standard cancer treatment in an unfit older patient) were examined by multivariate logistic regression. RESULTS Three- hundred ninety-seven patients were included, 43% of whom received LICT. If not adjusted for GA, toxicity did not differ between those receiving LICT (38%) or standard doses of chemotherapy (37%). If the dose of chemotherapy was analyzed according to the results of GA 61 (15%) patients had been undertreated and 133 (34%) had been overtreated. Undertreatment was related with increasing age and decreased renal function. Factors related with overtreatment were younger age, curative intention of treatment, prescription of G-CSF as primary prophylaxis and adequate cognitive status. Overtreated patients had more grade 3-4 toxicity than those receiving treatment adapted to fragility (42% vs 31%; p < 0.05). CONCLUSIONS The use of chemotherapy without considering GA leads to overtreatment more commonly than undertreatment in older patients with cancer. Oncologists should take into account the results of GA to stratify patients and to avoid under or overtreatment.
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Affiliation(s)
- Jaime Feliu
- Oncology department, Hospital Universitario La Paz, Madrid, Spain; Cátedra UAM-AMGEN, CIBERONC, Spain.
| | - Enrique Espinosa
- Oncology department, Hospital Universitario La Paz, Madrid, Spain
| | | | - Irene Paredero
- Oncology department, Hospital Universitario Dr. Peset. Valencia, Spain
| | - Elisenda Llabrés
- Oncology department, Hospital Universitario Insular de Gran Canarias, Spain
| | | | - Maite Antonio-Rebollo
- Oncohematogeriatrics Unit, Institut Català d'Oncologia, IDIBELL, Hospitalet, Barcelona, Spain
| | - Beatriz Losada
- Oncology department, Hospital Universitario de Fuenlabrada, Spain
| | - Alvaro Pinto
- Oncology department, Hospital Universitario La Paz, Madrid, Spain
| | - Regina Gironés
- Oncology department, Hospital Universitari y Politécnic La Fé, Valencia, Spain
| | | | | | | | | | - Gema Soler
- Oncohematogeriatrics Unit, Institut Català d'Oncologia, IDIBELL, Hospitalet, Barcelona, Spain
| | - Patricia Cruz
- Oncology department, Hospital Universitario La Paz, Madrid, Spain
| | - Oliver Higuera
- Oncology department, Hospital Universitario La Paz, Madrid, Spain
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Hellingman T, de Swart ME, Joosten JJA, Meijerink MR, de Vries JJJ, de Waard JWD, van Zweeden AA, Zonderhuis BM, Kazemier G. The value of a dedicated multidisciplinary expert panel to assess treatment strategy in patients suffering from colorectal cancer liver metastases. Surg Oncol 2020; 35:412-417. [PMID: 33035790 DOI: 10.1016/j.suronc.2020.09.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/18/2020] [Accepted: 09/27/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND For patients with colorectal cancer liver metastases (CRLM), local treatment is the only treatment with curative intent. The majority of patients with CRLM are however evaluated in multidisciplinary teams of colorectal cancer specialists often lacking expertise in local treatment of liver tumors. The aim of this study was therefore to assess the value of a dedicated multidisciplinary panel consisting of hepatobiliary surgeons and interventional radiologists for patients suffering from liver-only CRLM. METHODS Patients diagnosed with liver-only CRLM in 2016 were identified in a tertiary referral hospital, and two of the referring hospitals in the Netherlands. Diagnostic imaging was independently reviewed by a panel of four hepatobiliary surgeons and two interventional radiologists to re-evaluate treatment strategy retrospectively. If two or more panelists assessed all lesions eligible for resection and/or ablation, patients were deemed eligible for local treatment with curative intent. Interrater reliability between hepatobiliary surgeons was assessed through intraclass correlation coefficient (ICC) and weighted Cohen's kappa. RESULTS Diagnostic imaging of 61 patients with liver-only metastases were reviewed. Local treatment strategies appeared feasible in 40/61 (65.6%) patients. Five out of 25 patients (20.0%) initially assigned to systemic therapy were deemed eligible for upfront local treatment with curative intent (p = 0.015). In this subgroup, interrater reliability between hepatobiliary surgeons was substantial (ICC: 0.704, 95% CI: 0.536-0.838, n = 25). CONCLUSION Assessment of treatment strategy by a dedicated multidisciplinary panel including liver experts may result in an increased number of patients eligible for potentially curative treatment and reduce undertreatment of patients suffering from liver-only CRLM.
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Affiliation(s)
- T Hellingman
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Cancer Center Amsterdam, De Boelelaan, 1117, Amsterdam, the Netherlands.
| | - M E de Swart
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Cancer Center Amsterdam, De Boelelaan, 1117, Amsterdam, the Netherlands
| | - J J A Joosten
- Dijklander Hospital, Department of Surgery, Maelsonstraat 3, Hoorn, the Netherlands
| | - M R Meijerink
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Radiology and Nuclear Medicine, Cancer Center Amsterdam, De Boelelaan, 1117, Amsterdam, the Netherlands
| | - J J J de Vries
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Radiology and Nuclear Medicine, Cancer Center Amsterdam, De Boelelaan, 1117, Amsterdam, the Netherlands
| | - J W D de Waard
- Dijklander Hospital, Department of Surgery, Maelsonstraat 3, Hoorn, the Netherlands
| | - A A van Zweeden
- Amstelland Hospital, Department of Internal Medicine, Laan van de Helende Meesters 8, Amstelveen, the Netherlands
| | - B M Zonderhuis
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Cancer Center Amsterdam, De Boelelaan, 1117, Amsterdam, the Netherlands
| | - G Kazemier
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Cancer Center Amsterdam, De Boelelaan, 1117, Amsterdam, the Netherlands
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Sonmez A, Tasci I, Demirci I, Haymana C, Barcin C, Aydin H, Cetinkalp S, Ozturk FY, Gul K, Sabuncu T, Satman I, Bayram F. A Cross-Sectional Study of Overtreatment and Deintensification of Antidiabetic and Antihypertensive Medications in Diabetes Mellitus: The TEMD Overtreatment Study. Diabetes Ther 2020; 11:1045-1059. [PMID: 32088879 PMCID: PMC7193034 DOI: 10.1007/s13300-020-00779-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Targeting better glycated hemoglobin (HbA1c) and blood pressure (BP) goals may endanger older adults with type 2 diabetes mellitus (T2DM). Overtreatment of T2DM and hypertension is a trending issue, although undertreatment is still common. We investigated the rates and predictors of overtreatment and undertreatment of glycemia and BP in older adults with T2DM and physicians' attitudes to deintensify or intensify treatment. METHODS Data from older adults (≥ 65 years) enrolled in a large nationwide T2DM survey in 2017 across Turkey were analyzed. Overtreatment of glycemia was defined as HbA1c < 6.5% plus the use of ≥ 2 oral antihyperglycemics or insulin, and BP overtreatment was defined as systolic BP (SBP) < 120 mmHg or diastolic BP (DBP) < 65 mmHg plus the use of ≥ 2 drugs. Undertreatment of glycemia was defined as HbA1c > 9%, and BP undertreatment was defined as SBP > 150 mmHg or DBP > 90 mmHg. Deintensification or intensification rates were calculated according to treatment modification initiated by the treating physician(s). RESULTS The rate of overtreatment in the glycemia group (n = 1264) was 9.8% (n = 124) and that in the BP group (n = 1052) was 7.3% (n = 77), whereas the rate of undertreatment was 14.2% (n = 180) and 15.2% (n = 160), respectively. In the adjusted model, use of oral secretagogues (sulfonylureas or glinides) (odds ratio [OR] 1.94, 95% confidence interval [CI] 1.2-3.1) and follow-up at a private clinic (OR 1.81, 95% CI 1.0-3.3) were predictors of glycemia overtreatment. BP overtreatment was independently associated with the use insulin-based diabetes therapies (OR 1.86, 95% CI 1.14-3.04). There was no independent association of BP undertreatment to the study confounders. The deintensification and intensification rates were 25 and 75.6%, respectively, for glycemia and 10.9 and 9.2%, respectively, for BP. CONCLUSIONS The results show that one in ten older adults with T2DM are overtreated while one in four require modification of their current antihyperglycemic and antihypertensive treatments. Physicians are eager to intensify medications while they largely ignore deintensification in diabetes management. These results warrant enforced measures to improve the care of older adults with T2DM. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT03455101.
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Affiliation(s)
- Alper Sonmez
- Department of Endocrinology and Metabolism, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey.
| | - Ilker Tasci
- Department of Internal Medicine, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Ibrahim Demirci
- Department of Endocrinology and Metabolism, Gulhane Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Cem Haymana
- Department of Endocrinology and Metabolism, Gulhane Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Cem Barcin
- Department of Cardiology, Gulhane School of Medicine, University of Health Sciences, Ankara, Turkey
| | - Hasan Aydin
- Department of Endocrinology and Metabolism, School of Medicine, Yeditepe University, Istanbul, Turkey
| | - Sevki Cetinkalp
- Department of Endocrinology and Metabolism, School of Medicine, Ege University, Izmir, Turkey
| | - Feyza Yener Ozturk
- Department of Endocrinology and Metabolism, Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Kamile Gul
- Department of Endocrinology and Metabolism, School of Medicine, Sutcu Imam University, Kahramanmaras, Turkey
| | - Tevfik Sabuncu
- Department of Endocrinology and Metabolism, School of Medicine, Harran University, Sanliurfa, Turkey
| | - Ilhan Satman
- Department of Endocrinology and Metabolism, School of Medicine, Istanbul University, Istanbul, Turkey
| | - Fahri Bayram
- Department of Endocrinology and Metabolism, School of Medicine, Erciyes University, Kayseri, Turkey
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Monés J, Singh RP, Bandello F, Souied E, Liu X, Gale R. Undertreatment of Neovascular Age-Related Macular Degeneration after 10 Years of Anti-Vascular Endothelial Growth Factor Therapy in the Real World: The Need for A Change of Mindset. Ophthalmologica 2019; 243:1-8. [PMID: 31743912 DOI: 10.1159/000502747] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 08/15/2019] [Indexed: 11/19/2022]
Abstract
PURPOSE To assess the gap between visual acuity (VA) outcomes with anti-vascular endothelial growth factor (anti-VEGF) therapies in clinical trials and real-world practice, and explore the reasons for this gap. METHODS The literature was searched from January 1, 2013, to June 30, 2018, for studies reporting VA gains and injection frequencies in clinical trials and real-world practice. RESULTS Clinical trials of anti-VEGF agents and their extension studies demonstrated initial VA gains maintained at 4 years and beyond (up to 7 years) with continuous proactive treatment. Visual outcomes correlated with injection frequency. In real-world practice, patients are usually undertreated, accounting for the VA decline over time. Reasons for undertreatment include the burden of injections and monitoring visits imposed on patients/caregivers. However, another primary reason is the general mindset in the ophthalmological community that sustained benefits with treatment are not possible, leading to poor compliance and creating a vicious circle. CONCLUSIONS Initial VA gains can be maintained with more intensive/proactive approaches. Promising new treatments requiring less frequent injections/monitoring will help in the near future; meanwhile, better results could be achieved by changing the community mindset that contributes to undertreatment.
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Affiliation(s)
- Jordi Monés
- Institut de la Màcula and Barcelona Macula Foundation, Barcelona, Spain,
| | - Rishi P Singh
- Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Francesco Bandello
- Department of Ophthalmology, University Vita-Salute, Scientific Institute San Raffaele, Milan, Italy
| | - Eric Souied
- Department of Ophthalmology, Hopital Intercommunal de Creteil, Creteil, France
| | - Xin Liu
- Novartis Pharma AG, Basel, Switzerland
| | - Richard Gale
- Department of Ophthalmology, York Teaching Hospital's NHS Foundation Trust and Department of Health Sciences, University of York, York, United Kingdom.,York Teaching Hospitals, York, United Kingdom
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Affiliation(s)
- Ammar Asban
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sophie Dream
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Brenessa Lindeman
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA.
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Torregrosa MD, Escudero MJ, Paredero I, Carrasco E, Bermejo B, Gavila J, García-Saenz J, Santaballa A, Martínez P, Llombart A, Andrés R, Batista N, Fernández A, Antón A, Seguí M, Gonzalez S, Ruiz A; GEICAM, the Spanish Breast Cancer Group. Evolution of older patients diagnosed with early breast cancer in Spain between 1998 and 2001 included in El Alamo III project. Clin Transl Oncol 2019; 21:1746-53. [PMID: 31385227 DOI: 10.1007/s12094-019-02189-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 07/17/2019] [Indexed: 12/19/2022]
Abstract
INTRODUCTION An increase in the number of cancer cases is expected in the near future. Breast cancer (BC) mortality rates increase with age even when adjusted for other variables. Here we analyzed BC disease-free survival (BCDFS) and BC specific survival (BCSS) in the El Alamo III BC registry of GEICAM Spanish Breast Cancer Group. MATERIALS AND METHODS El Alamo III is a retrospective registry of BC patients diagnosed between 1998 and 2001. Patients with stage I-III invasive BC of age groups 55-64 years (y), 70-74 years and ≥ 75 years were included. Patients and tumors characteristics, treatments and recurrences and deaths were analyzed. RESULTS 4343 patients were included within the following age intervals: 2288 (55-64 years), 960 (70-74 years), and 1095 (≥ 75 years). Older patients (≥ 70 years) were diagnosed with more advanced tumors (stage III) than younger patients (21.5% versus 13.4%, p < 0.0001). Mastectomies were performed more on older patients and they received less chemotherapy than younger patients (66.6% versus 43.1%, p < 0.00001 and 30.8% versus 71.6%, p < 0.0001, respectively). With a median follow-up of 5.9 years, 17.7% patients had BCDFS events in the younger group and 19.8% in the older group (p < 0.0001). A decrease in BCSS was also observed in older patients, either when analyzing patients ≥ 70y (p < 0.0001) and when differentiating by the two older groups (p < 0.0001). CONCLUSIONS Our study suggests that older BC patients have worse outcomes what can be a consequence of receiving inadequate adjuvant treatments. Specific trials for these patients are warranted to allow us to treat them with the same scientific rigor than younger patients.
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Kocik J, Pajączek M, Kryczka T. Worse survival in breast cancer in elderly may not be due to underutilization of medical procedures as observed upon changing healthcare system in Poland. BMC Cancer 2019; 19:749. [PMID: 31362702 PMCID: PMC6668291 DOI: 10.1186/s12885-019-5930-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 07/12/2019] [Indexed: 11/24/2022] Open
Abstract
Background Evidence is emerging that older women may tolerate breast cancer therapies equally well as the young ones, providing that they receive good supportive care. It has also been reported that these patients remain outside the current therapeutic standards. The aim of this observational study was to assess the access of breast cancer patients to medical procedures. Methods We retrospectively reviewed a database of breast cancer patients registered in the National Cancer Registry in Poland, searching for the numbers of new cases and deaths in the years 2010–2015. We obtained the numbers and costs of key medical procedures provided for these patients from the National Health Fund in Poland. Breast cancer survival in the years 2010–2015 was estimated based on the mortality/incidence ratio. The t-Student test and Spearman correlation coefficient were used for the analysis of data obtained from both databases. Results There was no increase in survival throughout the years 2010–2015 in both analysed subpopulations of all breast cancer patients below and over 65 years of age, despite an unprecedented rise in healthcare funding in Poland. We noted 37% lower probability of 5-year survival in patients older than 65 years. The average number of outpatient visits and surgical procedures per person per year were slightly, yet significantly (p < 0.01), higher in younger vs. older patients (3.9 vs. 3.4 and 1.18 vs. 1.02, respectively). Outpatient chemotherapy was more common in older patients (6.0 vs. 5.25 cycles a year per person on average, p < 0.01). There were no significant differences in the average numbers of hospitalisations for chemotherapy, frequencies of radiotherapy and in the use of targeted therapy programmes (calculated per person per year), between younger and older patients. Conclusions Older women with breast cancer are treated similarly to younger patients, but have significantly worse chances to survive breast cancer in Poland. A simple increase in healthcare financing will not improve the survival in the elderly with breast cancer without developing funded individualised care and survivorship programmes. Electronic supplementary material The online version of this article (10.1186/s12885-019-5930-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Janusz Kocik
- Gerontooncology Department, School of Public Health, Centre of Postgraduate Medical Education, Warsaw, Poland.
| | | | - Tomasz Kryczka
- Department of Development of Nursing & Medical Sciences, Medical University of Warsaw, Warsaw, Poland.,Department of Experimental Pharmacology, Mosakowski Medical Research Center of Polish Academy of Science, Warsaw, Poland
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Thronæs M, Balstad TR, Brunelli C, Løhre ET, Klepstad P, Vagnildhaug OM, Kaasa S, Knudsen AK, Solheim TS. Pain management index (PMI)-does it reflect cancer patients' wish for focus on pain? Support Care Cancer 2020; 28:1675-84. [PMID: 31290020 DOI: 10.1007/s00520-019-04981-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 07/02/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The pain management index (PMI) was developed to combine information about the prescribed analgesics and the self-reported pain intensity in order to assess physicians' response to patients' pain. However, PMI has been used to explore undertreatment of cancer pain. The present study explores prevalence of negative PMI and its associations to clinical variables, including the patient-perceived wish for more attention to pain. METHODS A single-center, cross-sectional, observational study of cancer patients was conducted. Data on demographics and clinical variables, as well as patient-perceived wish for more attention to pain, were registered. PMI was calculated. Negative PMI indicates that the analgesics prescribed might not be appropriate to the pain intensity reported by the patient, and associations to negative PMI were explored by logistic regression models. RESULTS One hundred eighty-seven patients were included, 53% had a negative PMI score. Negative PMI scores were more frequent among patients with breast cancer (OR 4.2, 95% CI 1.3, 13.5), in a follow-up setting (OR 12.1, 95% CI 1.4, 101.4), and were inversely associated to low performance status (OR 0.14, 95% CI 0.03, 0.65). Twenty-two percent of patients with negative PMI scores reported that they wanted more focus on pain management, versus 13% among patients with a non-negative PMI score; the difference was not statistically significant. CONCLUSION A high prevalence of negative PMI was observed, but only 1/5 of patients with a negative PMI wanted more attention to pain by their physician. Our findings challenge the use of PMI as a measure of undertreatment of cancer pain.
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Morgado A, Moura ML, Dinis P, Silva CM. Misdiagnosis And Undertreatment Of Erectile Dysfunction In The Portuguese Primary Health Care. Sex Med 2019; 7:177-183. [PMID: 30880000 PMCID: PMC6522934 DOI: 10.1016/j.esxm.2019.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 01/06/2019] [Accepted: 01/12/2019] [Indexed: 12/26/2022] Open
Abstract
Introduction The importance of erectile dysfunction (ED) diagnosis and treatment has been highlighted since the early 2000s. However, nearly 20 years after the first phosphodiesterase 5 inhibitor (PDE5i) was marketed, underdiagnosis and undertreatment of ED in the primary health care setting may still be present. Aim To assess the relative frequency of patients who are medically treated for ED before referral to specialized urology care. The secondary objectives were to evaluate possible reasons for non-treatment prior to referral and other signs of undertreatment, namely cardiovascular risk assessment and antihypertensive treatment. Methods 200 male patients referred for ED to specialist urology care by general practitioners were screened after consent between January 2016–December 2018. A full standardized medical and sexual history were taken. Previous medical treatment of ED, namely pharmacologic name and dosages, and cardiovascular risk factors were noted. Main Outcome Measures Of the 115 included patients, only 33.9% of patients had already taken PDE5i before referral, and none had taken alprostadil by intracavernous route. Results The mean patient age was 58.68 ± 10.01 years old. Only 45.2% had been prescribed the highest dose of PD5i. From the remaining untreated patients, only 19.7% had ≥3 cardiovascular risk factors, including 5.6% of patients who also presented moderate-to-severe stable or unstable angina requiring a stress test or cardiology assessment before treatment. Regarding the 54 patients with medical history of arterial hypertension, 43.4% and 30.2% were treated for hypertension with a diuretic and a beta blocker, respectively. Conclusion More focus on the primary healthcare continuous medical education regarding sexual dysfunction, namely ED, is needed because major undertreatment of ED is still present because low prescription of PD5i before referral is noted. Morgado A, Moura ML, Dinis P, et al. Misdiagnosis And Undertreatment Of Erectile Dysfunction In The Portuguese Primary Health Care. Sex Med 2019;7:177–183.
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Affiliation(s)
- Afonso Morgado
- Serviço de Urologia, Centro Hospitalar São João, Porto, Portugal; Departamento de Biomedicina, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.
| | | | - Paulo Dinis
- Serviço de Urologia, Centro Hospitalar São João, Porto, Portugal; Departamento de Cirurgia e Fisiologia, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Carlos Martins Silva
- Serviço de Urologia, Centro Hospitalar São João, Porto, Portugal; Departamento de Cirurgia e Fisiologia, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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Ambrose JA, Najafi A. Strategies for the Prevention of Coronary Artery Disease Complications: Can We Do Better? Am J Med 2018; 131:1003-1009. [PMID: 29729244 DOI: 10.1016/j.amjmed.2018.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 04/03/2018] [Accepted: 04/03/2018] [Indexed: 12/21/2022]
Abstract
Billions of dollars have been spent over the past 25 years on developing new therapies for the prevention/treatment of adverse cardiac events related to atherosclerotic cardiovascular disease. Although some therapies have been lifesaving, several mega-randomized studies have shown only a <2% absolute reduction in adverse events with a large residual event rate. Is all this money well spent? Atherosclerosis develops decades before an adverse event, and the trials previously alluded to have nearly always been applied to secondary prevention, decades after disease initiation. Will earlier intervention result in a lower incidence of events? Individuals with an absence of the usual cardiac risk factors have a lifelong low incidence of events. Early initiation of strategies against the common cardiovascular risk factors in primary or primordial prevention will lower the incidence of adverse events, although many groups have not been well studied, including individuals younger than 40 years of age. New strategies are required to realize a radical reduction in events, and this article proposes new methods of prevention/treatment for coronary artery disease complications.
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Affiliation(s)
| | - Amir Najafi
- University of California San Francisco, Fresno
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Corsi N, Roberto A, Cortesi L, Nobili A, Mannucci PM, Corli O. Prevalence, characteristics and treatment of chronic pain in elderly patients hospitalized in internal medicine wards. Eur J Intern Med 2018; 55:35-39. [PMID: 29853269 DOI: 10.1016/j.ejim.2018.05.031] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/10/2018] [Accepted: 05/23/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Chronic pain is a frequent characteristic of elderly people and represents an actual and still poorly debated topic. OBJECTIVE We investigated pain prevalence and intensity, and its pharmacological therapy in elderly patients hospitalized in 101 internal medicine wards. METHODS Taking advantage of the "REgistro POliterapie Società Italiana Medicina Interna" (REPOSI), we collected 2535 patients of whom almost a quarter was older than 85 years old. Among them, 582 patients were affected by pain (either chronic or acute) and 296 were diagnosed with chronic pain. RESULTS Patients with pain showed worse cognitive status, higher depression and comorbidities, and a longer duration of hospital stay compared to those without pain (all p < .0366). Patients with chronic pain revealed lower level of independency in their daily life, worse cognitive status and higher level of depression compared to acute pain patients (all p < .0156). Moreover, most of them were not treated for pain at admission (73.4%) and half of them was not treated with any analgesic drug at discharge (50.5%). This difference affected also the reported levels of pain intensity. Patients who received analgesics at both admission and discharge remained stable (p = .172). Conversely, those not treated at admission who received an analgesic treatment during the hospital stay decreased their perceived pain (p < .0001). CONCLUSIONS Our results show the need to focus more attention on the pharmacological treatment of chronic pain, especially in hospitalized elderly patients, in order to support them and facilitate their daily life after hospital discharge.
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Affiliation(s)
- Nicole Corsi
- Pain and Palliative Care Research Unit, Oncology Department, IRCCS-Mario Negri Institute for Pharmacological Research, Milan, Italy.
| | - Anna Roberto
- Pain and Palliative Care Research Unit, Oncology Department, IRCCS-Mario Negri Institute for Pharmacological Research, Milan, Italy
| | - Laura Cortesi
- Quality Assessment of Geriatric Therapies and Services Laboratory, Neuroscience Department, IRCCS-Mario Negri Institute for Pharmacological Research, Milan, Italy
| | - Alessandro Nobili
- Quality Assessment of Geriatric Therapies and Services Laboratory, Neuroscience Department, IRCCS-Mario Negri Institute for Pharmacological Research, Milan, Italy
| | - Pier Mannuccio Mannucci
- Scientific Direction, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Oscar Corli
- Pain and Palliative Care Research Unit, Oncology Department, IRCCS-Mario Negri Institute for Pharmacological Research, Milan, Italy
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Costa GJ, de Mello MJG, Ferreira CG, Thuler LCS. Undertreatment trend in elderly lung cancer patients in Brazil. J Cancer Res Clin Oncol 2017; 143:1469-75. [PMID: 28389722 DOI: 10.1007/s00432-017-2412-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 03/29/2017] [Indexed: 01/19/2023]
Abstract
PURPOSE Elderly patients with lung cancer tend to be undertreated in comparison to younger patients. The objective of this study is to compare treatment modalities offered to lung cancer patients from 70 years of age or more with patients under 70. METHODS For this study, an analytical cross-sectional epidemiological study conducted with data from the Brazilian hospital-based cancer registries between the years 2000 and 2011. In addition, odds ratios (OR) were calculated, with a 95% confidence intervals (95% CI), in conjunction with the construction of a logistic regression model. RESULTS By analyzing the records of 40,403 patients with lung cancer, we found that overall, patients from 70 years of age or more corresponded to 28.6% of the study population. Squamous cell carcinoma was the most common histological type among patients ≥70 years of age, whereas adenocarcinoma was the more prevalent type among younger patients. In comparison to younger patients, the older ones were treated less often (OR = 0.57; 95% CI: 0.52-0.62). Moreover, older patients were less likely to undergo surgery (OR = 0.69; 95% CI: 0.64-0.75), radiotherapy (OR = 0.86; 95% CI: 0.81-0.92), chemotherapy (OR = 0.61; 95% CI: 0.57-0.64), or an association of two or more treatment modalities (OR = 0.58; 95% CI: 0.54-0.62). CONCLUSION The study finds that Brazilian lung cancer patients ≥70 years of age are often undertreated and higher percentage of early death rates as compared to patients under 70. In regard to treatment, age alone should not determine whether patients with lung cancer are treated or not.
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Abstract
OBJECTIVE To estimate the rate of non-treatment among elderly women with osteoporosis (OP) and to examine the association between patient characteristics and receiving treatment. RESEARCH DESIGN AND METHODS This cross-sectional, retrospective, observational study utilized patient information and claims from the Humana database to identify Medicare covered women aged ≥65 years old and continuously enrolled with evidence of either an OP diagnosis or an OP-related fracture during 2007-2011. The main outcome was receipt of pharmacological treatment of OP during 2012 (follow-up). The percentage of non-treatment was calculated and a stepwise selection logistic regression model was employed to estimate the association between baseline demographic and clinical characteristics and receiving treatment. RESULTS A total of 109,829 patients were included. Mean age was 75.7 years and 79.4% were identified with OP through OP diagnosis codes and did not have evidence of a prior fracture. Approximately one-third (32%) of patients had used OP medications during the baseline period, and 39% had experienced at least one gastro-intestinal event during baseline. Among all patients, 71.4% did not receive OP therapy during follow-up. The strongest factor associated with receiving treatment was prior use of OP therapy (odds ratio [OR] = 31.3; p < .001). Among the subgroup of patients with baseline fractures, 75.9% did not receive OP therapy during follow-up and the strongest factor associated with receiving treatment remained prior use of OP therapy (OR = 20.4; p < .001). Those with high comorbidity burden were less likely to receive treatment in both the overall cohort and within the subgroup with baseline fractures. CONCLUSIONS Among Medicare-eligible women aged ≥65 identified with OP between 2007 and 2011, 71.4% did not receive OP treatment during 2012, including 75.9% of the subgroup of patients with a prior fracture. The use of diagnosis and procedures codes to identify patients with osteoporosis is subject to variation in coding.
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Affiliation(s)
- Luis Masana
- Research Unit of Lipids and Atherosclerosis, University Rovira i Virgili, C. Sant Llorenç 21, 43201, Reus, Spain.
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Lebentrau S, May M, Weckermann D, Speck T, Wick AK, Mathew M, Schostak M. [Non-muscle-invasive bladder cancer: Information transfer from the clinic to the doctor's office : Results of a questionnaire study and presentation of a software solution]. Urologe A 2017; 56:194-201. [PMID: 27637184 DOI: 10.1007/s00120-016-0234-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND OBJECTIVES The adjuvant treatment of non-muscle-invasive bladder cancer (NMIBC) is based on the individual risk profile (RP) and its sufficient transfer from the clinic to the doctor's office. The objectives of our study were to verify the importance and degree of transfer of RP and recommendation for risk-adapted adjuvant treatment (RAAT) in patients with NMIBC as well as to develop appropriate tools for this purpose, if necessary. MATERIALS AND METHODS An email-based survey distributed to urologists in Brandenburg, Berlin, Bavaria and Lower Saxony explored the questions mentioned above. In addition, a tool for risk stratification and information transfer for patients with NMIBC was developed and validated. RESULTS From a total of 134 questionnaires analyzed, 55 were from clinic urologists (CUs) and 79 were from ambulant urologists (AUs). Although 9 out of 10 urologists considered the RP of importance, only 29 % of CUs and 24 % of AUs (p = 0.553) confirmed that the RP was always mentioned in medical reports. The recommendation for RAAT was confirmed from 62 % of CUs and 20 % of AUs (p < 0.001). A recommendation for RAAT in the medical report was requested by 86 % of AUs. The risk calculator presented here - to our knowledge the first with integration of the 2004 WHO grading - is delivered in all mathematically possible constellations a RP, according to guideline recommendations. CONCLUSION Urologists in the clinic and doctor's office both attach considerable importance to the determination and transfer of RP and the recommendation for RAAT. There was evidence to suggest an overestimation of the quality of medical reports by the CU. The risk calculator provides an easy and cost-neutral option to improve risk stratification and information transfer from the clinic to the doctor's office.
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Verschoor AMF, Kuijer A, Verloop J, Van Gils CH, Sonke GS, Jager A, van Dalen T, Elias SG. Adjuvant systemic therapy in early breast cancer: impact of guideline changes and clinicopathological factors associated with nonadherence at a nation-wide level. Breast Cancer Res Treat 2016; 159:357-65. [PMID: 27514397 DOI: 10.1007/s10549-016-3940-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 08/06/2016] [Indexed: 11/21/2022]
Abstract
Over recent years, adjuvant systemic treatment guidelines (AST) for early-stage breast cancer have changed considerably. We aimed to assess the impact of these guideline changes on the administration of AST in early-stage breast cancer patients and to what extent these guidelines are adhered to at a nation-wide level. We used Netherlands Cancer Registry data to describe trends in AST prescription, adherence to AST guidelines, and to identify clinicopathological determinants of nonadherence. Between 1990 and 2012, 231,648 Dutch patients were diagnosed with early breast cancer, of whom 124,472 received AST. Adjuvant endocrine treatment (ET) use increased from 23 % of patients (1990) to 56 % (2012), and chemotherapy from 11 to 44 %. In 2009-2012, 8 % of patients received ET and 3 % received chemotherapy without guideline indication. Conversely, 10-29 % of patients did not receive ET and chemotherapy, respectively, despite a guideline indication. Unfavorable clinicopathological characteristics generally decreased the chance of undertreatment and increased the chance for overtreatment. Remarkable was the increased chance of ET undertreatment in younger women (RR < 35 vs 60-69 years 1.79; 95 % CI 1.30-2.47) and in women with HER2+ disease (RR 1.64; 95 % CI 1.46-1.85). Over the years, AST guidelines expanded resulting in much more Dutch early breast cancer patients receiving AST. In the majority of cases, AST administration was guideline concordant, but the high frequency of chemotherapy undertreatment in some subgroups suggests limited AST guideline support in these patients.
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Affiliation(s)
- A M F Verschoor
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Universiteitsweg 100, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - A Kuijer
- Department of Surgery, Diakonessenhuis Utrecht, Bosboomstraat 1, 3582 KE, Utrecht, The Netherlands.,Department of Radiology, University Medical Center Utrecht, Universiteitsweg 100, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - J Verloop
- Department of Research, Netherlands Comprehensive Cancer Organization, Postbus 19079, 3501 DB, Utrecht, The Netherlands
| | - C H Van Gils
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Universiteitsweg 100, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - G S Sonke
- Department of Medical Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - A Jager
- Department of Medical Oncology, Erasmus Medical Cancer Institute, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
| | - T van Dalen
- Department of Surgery, Diakonessenhuis Utrecht, Bosboomstraat 1, 3582 KE, Utrecht, The Netherlands
| | - S G Elias
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Universiteitsweg 100, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.
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Ko JJ, Kennecke HF, Lim HJ, Renouf DJ, Gill S, Woods R, Speers C, Cheung WY. Reasons for Underuse of Adjuvant Chemotherapy in Elderly Patients With Stage III Colon Cancer. Clin Colorectal Cancer 2015; 15:179-85. [PMID: 26520019 DOI: 10.1016/j.clcc.2015.09.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 09/17/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Undertreatment has been frequently reported in the elderly cancer patient population. For this reason, we aimed to characterize adjuvant chemotherapy (AC) use among elderly patients (EPs) with stage III colon cancer (CC) and to identify potential reasons for undertreatment. PATIENTS AND METHODS Patients diagnosed with stage III CC between 2008 and 2010 were included in this review. Multivariate Cox regression models were constructed to evaluate the associations between AC and cancer-specific, disease-free, and overall survival and to determine whether these were modified by age. RESULTS We identified 810 patients: 423 (52%) men, 423 (52%) young patients (YPs), and 603 (74%) received AC. Compared with YPs, EPs were less likely to receive AC (57% vs. 91%; P < .01), particularly 5-fluorouracil and oxaliplatin (FOLFOX) (32% vs. 74%, P < .01). Frequent reasons for nontreatment included age, comorbidities, and perceived minimal benefit from AC. When AC was given, EPs had similar rates of treatment discontinuations (34% vs. 26%; P > .05) and dose reductions (63% vs. 61%; P > .05) as YPs. Reasons for treatment interruptions included side effects, progressive disease, and patient choice. Receipt of either FOLFOX or capecitabine was correlated with improved cancer-specific survival, disease-free survival, and overall survival compared with surgery alone; this effect was not modified by age. CONCLUSION Elderly patients with stage III CC frequently received either no AC or capecitabine monotherapy because of advanced age and comorbidities. The effect of AC on survival was similar across age groups, with comparable side effects and rates of treatment modifications. AC should not be withheld because of advanced age alone.
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Affiliation(s)
- Jenny J Ko
- Division of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Hagen F Kennecke
- Division of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Howard J Lim
- Division of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Daniel J Renouf
- Division of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Sharlene Gill
- Division of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Ryan Woods
- Cancer Control Research, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Caroline Speers
- Cancer Control Research, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Winson Y Cheung
- Cancer Control Research, British Columbia Cancer Agency, Vancouver, British Columbia, Canada.
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Engebretson A, Matrisian L, Thompson C. Pancreatic cancer: Patient and caregiver perceptions on diagnosis, psychological impact, and importance of support. Pancreatology 2015; 15:701-7. [PMID: 26092655 DOI: 10.1016/j.pan.2015.05.471] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 04/21/2015] [Accepted: 05/18/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Pancreatic cancer (PC) can have an enormous psychological toll on those affected by it. This study evaluated patient and caregiver perceptions about diagnosis and daily life with PC. METHODS The Pancreatic Cancer Action Network (PanCAN) administered a 25-min online survey (funded by Celgene) between July 30 and September 18, 2013 to patients with PC and caregivers whose loved ones were alive or had died within the past 6 months. RESULTS There were 397 respondents (all in the US) including 184 patients (81 with metastatic disease) and 213 caregivers (145 with loved ones with metastatic disease); 80% of patients reported having a primary caregiver. Over 90% reported symptoms before diagnosis, the most common of which being acute abdominal pain, pain radiating into the back, and fatigue. Gastroenterologists were the diagnosing physician in 36.3% of cases. The mean duration from symptom onset to diagnosis was 2.4 months. The most common action taken by diagnosing physicians was referral to another physician (57.7%). No treatments were offered for 9% of patients with nonmetastatic disease and 17% of patients with metastatic disease. The most commonly reported caregiver roles were providing support on treatment days and talking to physicians. A greater percentage of caregivers than patients recognized the various roles played by caregivers. Patients aware of the PanCAN Patient and Liaison Services (PALS) program reported fewer negative emotions than PALS-unaware patients. CONCLUSIONS This study provides insights into the issues patients and caregivers in the US face and the importance of support services for both.
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