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FDA discourages use of laparoscopic power morcellation for removal of uterus or uterine fibroids

April 18, 2014 Comments off

FDA discourages use of laparoscopic power morcellation for removal of uterus or uterine fibroids
Source: U.S. Food and Drug Administration

In a safety communication notice issued today, the U.S. Food and Drug Administration discouraged the use of laparoscopic power morcellation for the removal of the uterus (hysterectomy) or uterine fibroids (myomectomy) in women because, based on an analysis of currently available data, it poses a risk of spreading unsuspected cancerous tissue, notably uterine sarcomas, beyond the uterus.

Laparoscopic power morcellation is one of several available treatments for fibroids. It is a procedure that uses a medical device to divide the uterine tissue into smaller pieces or fragments so it can be removed through a small incision in the abdomen, such as during laparoscopy.

Uterine fibroids are non-cancerous growths that originate from the smooth muscle tissue in the wall of the uterus. According to the National Institutes of Health, most women will develop uterine fibroids at some point in their lives. While most uterine fibroids do not cause problems, they can cause symptoms, such as heavy or prolonged menstrual bleeding, pelvic pressure or pain, and frequent urination, sometimes requiring medical or surgical therapy.

Based on an analysis of currently available data, the FDA has determined that approximately 1 in 350 women who are undergoing hysterectomy or myomectomy for fibroids have an unsuspected type of uterine cancer called uterine sarcoma. If laparoscopic power morcellation is performed in these women, there is a risk that the procedure will spread the cancerous tissue within the abdomen and pelvis, significantly worsening the patient’s likelihood of long-term survival.

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Invasive Cancer Incidence — United States, 2010

March 31, 2014 Comments off

Invasive Cancer Incidence — United States, 2010
Source: Morbidity and Mortality Weekly Report

Cancer has many causes, some of which can, at least in part, be avoided through interventions known to reduce cancer risk (1). Healthy People 2020 objectives call for reducing colorectal cancer incidence to 38.6 per 100,000 persons, reducing late-stage breast cancer incidence to 41.0 per 100,000 women, and reducing cervical cancer incidence to 7.1 per 100,000 women (2). To assess progress toward reaching these Healthy People 2020 targets, CDC analyzed data from U.S. Cancer Statistics (USCS) for 2010. USCS includes incidence data from CDC’s National Program of Cancer Registries and the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program and mortality data from the National Vital Statistics System (3). In 2010, a total of 1,456,496 invasive cancers were reported to cancer registries in the United States (excluding Arkansas and Minnesota), an annual incidence rate of 446 cases per 100,000 persons, compared with 459 in 2009 (4). Cancer incidence rates were higher among men (503) than women (405), highest among blacks (455), and ranged by state from 380 to 511 per 100,000 persons. Many factors, including tobacco use, obesity, insufficient physical activity, and human papilloma virus (HPV) infection, contribute to the risk for developing cancer, and differences in cancer incidence indicate differences in the prevalence of these risk factors. These differences can be reduced through policy approaches such as the Affordable Care Act,* which could increase access for millions of persons to appropriate and timely cancer preventive services, including help with smoking cessation, cancer screening, and vaccination against HPV (5).

Invasive cancers include all cancers except in situ cancers (other than in the urinary bladder) and basal and squamous cell skin cancers.

Colorectal cancer statistics, 2014

March 27, 2014 Comments off

Colorectal cancer statistics, 2014
Source: CA: A Cancer Journal for Clinicians

Colorectal cancer is the third most common cancer and the third leading cause of cancer death in men and women in the United States. This article provides an overview of colorectal cancer statistics, including the most current data on incidence, survival, and mortality rates and trends. Incidence data were provided by the National Cancer Institute’s Surveillance, Epidemiology, and End Results program and the North American Association of Central Cancer Registries. Mortality data were provided by the National Center for Health Statistics. In 2014, an estimated 71,830 men and 65,000 women will be diagnosed with colorectal cancer and 26,270 men and 24,040 women will die of the disease. Greater than one-third of all deaths (29% in men and 43% in women) will occur in individuals aged 80 years and older. There is substantial variation in tumor location by age. For example, 26% of colorectal cancers in women aged younger than 50 years occur in the proximal colon, compared with 56% of cases in women aged 80 years and older. Incidence and death rates are highest in blacks and lowest in Asians/Pacific Islanders; among males during 2006 through 2010, death rates in blacks (29.4 per 100,000 population) were more than double those in Asians/Pacific Islanders (13.1) and 50% higher than those in non-Hispanic whites (19.2). Overall, incidence rates decreased by approximately 3% per year during the past decade (2001–2010). Notably, the largest drops occurred in adults aged 65 and older. For instance, rates for tumors located in the distal colon decreased by more than 5% per year. In contrast, rates increased during this time period among adults younger than 50 years. Colorectal cancer death rates declined by approximately 2% per year during the 1990s and by approximately 3% per year during the past decade. Progress in reducing colorectal cancer death rates can be accelerated by improving access to and use of screening and standard treatment in all populations.

Mortality from road crashes in 193 countries: a comparison with other leading causes of death

February 26, 2014 Comments off

Mortality from road crashes in 193 countries: a comparison with other leading causes of death
Source: Transportation Research Institute (University of Michigan)

This study compared, for each country of the world, the fatalities per population from road crashes with fatalities per population from three leading causes of death (malignant neoplasm, ischaemic heart disease, and cerebrovascular disease), and from all causes. The data, applicable to 2008, came from the World Health Organization. The main findings are as follows:
(1) For the world, there are 18 fatalities from road crashes per 100,000 population, as compared with 113 for malignant neoplasm, 108 for ischaemic heart disease, and 91 for cerebrovascular disease. The highest fatality rate from road crashes is in Namibia (45) and the lowest in the Maldives (2).
(2) For the world, fatalities from road crashes represent 2.1% of fatalities from all causes. The highest percentage is in the United Arab Emirates (15.9%) and the lowest in the Marshall Islands (0.3%).
(3) For the world, fatalities from road crashes represent 15.9% of fatalities from malignant neoplasm. The highest percentage is in Namibia (153.9%) and the lowest in the Maldives (1.7%).
(4) For the world, fatalities from road crashes represent 16.7% of fatalities from ischaemic heart disease. The highest percentage is in Qatar (123.9%) and the lowest in Malta (1.9%).
(5) For the world, fatalities from road crashes represent 19.6% of fatalities from cerebrovascular disease. The highest percentage is in Qatar (529.7%) and the lowest in the Marshall Islands (2.3%). The appendixes list the rates and percentages for each individual country.

Disability Status as an Antecedent to Chronic Conditions: National Health Interview Survey, 2006–2012

February 24, 2014 Comments off

Disability Status as an Antecedent to Chronic Conditions: National Health Interview Survey, 2006–2012
Source: Preventing Chronic Disease (CDC)

Introduction
A strong relationship exists between disability and poor health. This relationship could exist as a result of disabilities emerging from chronic conditions; conversely, people with disabilities may be at increased risk of developing chronic conditions. Studying health in relation to age of disability onset can illuminate the extent to which disability may be a risk factor for future poor health.

Methods
We used data from the 2006–2012 National Health Interview Survey and conducted weighted logistic regression analyses to compare chronic conditions in adults with lifelong disabilities (n = 2,619) and adults with no limitations (n = 122,395).

Results
After adjusting for sociodemographic differences, adults with lifelong disabilities had increased odds of having the following chronic conditions compared with adults with no limitations: coronary heart disease (adjusted odds ratio [AOR] = 2.92; 95% confidence interval [CI], 2.33–3.66) cancer (AOR = 1.61; 95% CI, 1.34–1.94), diabetes (AOR = 2.57; 95% CI, 2.10–3.15), obesity (AOR = 1.81; 95% CI, 1.63–2.01), and hypertension (AOR = 2.18; 95% CI, 1.94–2.45). Subpopulations of people with lifelong disabilities (ie, physical, mental, intellectual/developmental, and sensory) experienced similar increased odds for chronic conditions compared with people with no limitations.

Conclusion
Adults with lifelong disabilities were more likely to have chronic conditions than adults with no limitations, indicating that disability likely increases risk of developing poor health. This distinction is critical in understanding how to prevent health risks for people with disabilities. Health promotion efforts that target people living with a disability are needed.

Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial

February 18, 2014 Comments off

Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial (PDF)
Source: British Medical Journal

Objective
To compare breast cancer incidence and mortality up to 25 years in women aged 40-59 who did or did not undergo mammography screening.

Design
Follow-up of randomised screening trial by centre coordinators, the study’s central office, and linkage to cancer registries and vital statistics databases.

Setting 15 screening centres in six Canadian provinces,1980-85 (Nova Scotia, Quebec, Ontario, Manitoba, Alberta, and British Columbia).

Participants 89 835 women, aged 40-59, randomly assigned to mammography (five annual mammography screens) or control (no mammography).

Interventions
Women aged 40-49 in the mammography arm and all women aged 50-59 in both arms received annual physical breast examinations. Women aged 40-49 in the control arm received a single examination followed by usual care in the community.

Main outcome measure
Deaths from breast cancer.

Results
During the five year screening period, 666 invasive breast cancers were diagnosed in the mammography arm (n=44 925 participants) and 524 in the controls (n=44 910), and of these, 180 women in the mammography arm and 171 women in the control arm died of breast cancer during the 25 year follow-up period. The overall hazard ratio for death from breast cancer diagnosed during the screening period associated with mammography was 1.05 (95% confidence interval 0.85 to 1.30). The findings for women aged 40-49 and 50-59 were almost identical. During the entire study period, 3250 women in the mammography arm and 3133 in the control arm had a diagnosis of breast cancer, and 500 and 505, respectively, died of breast cancer. Thus the cumulative mortality from breast cancer was similar between women in the mammography arm and in the control arm (hazard ratio 0.99, 95% confidence interval 0.88 to 1.12). After 15 years of follow-up a residual excess of 106 cancers was observed in the mammography arm, attributable to over-diagnosis.

Conclusion
Annual mammography in women aged 40-59 does not reduce mortality from breast cancer beyond that of physical examination or usual care when adjuvant therapy for breast cancer is freely available. Overall, 22% (106/484) of screen detected invasive breast cancers were over-diagnosed, representing one over-diagnosed breast cancer for every 424 women who received mammography screening in the trial.

Cervical Screening at Age 50–64 Years and the Risk of Cervical Cancer at Age 65 Years and Older: Population-Based Case Control Study

January 17, 2014 Comments off

Cervical Screening at Age 50–64 Years and the Risk of Cervical Cancer at Age 65 Years and Older: Population-Based Case Control Study
Source: PLoS Medicine

Background
There is little consensus, and minimal evidence, regarding the age at which to stop cervical screening. We studied the association between screening at age 50–64 y and cervical cancer at age 65–83 y.

Methods and Findings
Cases were women (n = 1,341) diagnosed with cervical cancer at age 65–83 y between 1 April 2007 and 31 March 2012 in England and Wales; age-matched controls (n = 2,646) were randomly selected from population registers. Screening details from 1988 onwards were extracted from national databases. We calculated the odds ratios (OR) for different screening histories and subsequent cervical cancer. Women with adequate negative screening at age 65 y (288 cases, 1,395 controls) were at lowest risk of cervical cancer (20-y risk: 8 cancers per 10,000 women) compared with those (532 cases, 429 controls) not screened at age 50–64 y (20-y risk: 49 cancers per 10,000 women, with OR = 0.16, 95% CI 0.13–0.19). ORs depended on the age mix of women because of the weakening association with time since last screen: OR = 0.11, 95% CI 0.08–0.14 at 2.5 to 7.5 y since last screen; OR = 0.27, 95% CI 0.20–0.36 at 12.5 to 17.5 y since last screen. Screening at least every 5.5 y between the ages 50 and 64 y was associated with a 75% lower risk of cervical cancer between the ages 65 and 79 y (OR = 0.25, 95% CI 0.21–0.30), and the attributable risk was such that in the absence of screening, cervical cancer rates in women aged 65+ would have been 2.4 (95% CI 2.1–2.7) times higher. In women aged 80–83 y the association was weaker (OR = 0.49, 95% CI 0.28–0.83) than in those aged 65–69 y (OR = 0.12, 95% CI 0.09–0.17). This study was limited by an absence of data on confounding factors; additionally, findings based on cytology may not generalise to human papillomavirus testing.

Conclusions
Women with adequate negative screening at age 50–64 y had one-sixth of the risk of cervical cancer at age 65–83 y compared with women who were not screened. Stopping screening between ages 60 and 69 y in women with adequate negative screening seems sensible, but further screening may be justifiable as life expectancy increases.

Lung Cancer Incidence Trends Among Men and Women — United States, 2005–2009

January 14, 2014 Comments off

Lung Cancer Incidence Trends Among Men and Women — United States, 2005–2009
Source: Morbidity and Mortality Weekly Report (CDC)

Lung cancer is the leading cause of cancer death and the second most commonly diagnosed cancer (excluding skin cancer) among men and women in the United States (1,2). Although lung cancer can be caused by environmental exposures, most efforts to prevent lung cancer emphasize tobacco control because 80%–90% of lung cancers are attributed to cigarette smoking and secondhand smoke (1). One sentinel health consequence of tobacco use is lung cancer (1,2), and one way to measure the impact of tobacco control is by examining trends in lung cancer incidence rates, particularly among younger adults (3). Changes in lung cancer rates among younger adults likely reflect recent changes in risk exposure (3). To assess lung cancer incidence and trends among men and women by age group, CDC used data from the National Program of Cancer Registries (NPCR) and the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program for the period 2005–2009, the most recent data available. During the study period, lung cancer incidence decreased among men in all age groups except <35 years and decreased among women aged 35–44 years and 54–64 years. Lung cancer incidence decreased more rapidly among men than among women and more rapidly among adults aged 35–44 years than among other age groups. To further reduce lung cancer incidence in the United States, proven population-based tobacco prevention and control strategies should receive sustained attention and support (4).

Vitamin and Mineral Supplements in the Primary Prevention of Cardiovascular Disease and Cancer: An Updated Systematic Evidence Review for the U.S. Preventive Services Task Force

December 18, 2013 Comments off

Vitamin and Mineral Supplements in the Primary Prevention of Cardiovascular Disease and Cancer: An Updated Systematic Evidence Review for the U.S. Preventive Services Task Force
Source: Annals of Internal Medicine

Background: Vitamin and mineral supplements are commonly used to prevent chronic diseases.

Purpose: To systematically review evidence for the benefit and harms of vitamin and mineral supplements in community-dwelling, nutrient-sufficient adults for the primary prevention of cardiovascular disease (CVD) and cancer.

Data Sources: MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews of Effects were searched from January 2005 to 29 January 2013, with manual searches of reference lists and gray literature.

Study Selection: Two investigators independently selected and reviewed fair- and good-quality trials for benefit and fair- and good-quality trials and observational studies for harms.

Data Extraction: Dual quality assessments and data abstraction.

Data Synthesis: Two large trials (n = 27 658) reported lower cancer incidence in men taking a multivitamin for more than 10 years (pooled unadjusted relative risk, 0.93 [95% CI, 0.87 to 0.99]). The study that included women showed no effect in that group. High-quality studies (k = 24; n = 324 653) of single and paired nutrients (such as vitamins A, C, or D; folic acid; selenium; or calcium) were scant and heterogeneous and showed no clear evidence of benefit or harm. Neither vitamin E nor β-carotene prevented CVD or cancer, and β-carotene increased lung cancer risk in smokers.

Limitations: The analysis included only primary prevention studies in adults without known nutritional deficiencies. Studies were conducted in older individuals and included various supplements and doses under the set upper tolerable limits. Duration of most studies was less than 10 years.

Conclusion: Limited evidence supports any benefit from vitamin and mineral supplementation for the prevention of cancer or CVD. Two trials found a small, borderline-significant benefit from multivitamin supplements on cancer in men only and no effect on CVD.

Evaluation of exposure to contaminated drinking water and specific birth defects and childhood cancers at Marine Corps Base Camp Lejeune, North Carolina: a case–control study

December 9, 2013 Comments off

<strong>Evaluation of exposure to contaminated drinking water and specific birth defects and childhood cancers at Marine Corps Base Camp Lejeune, North Carolina: a case–control study
Source: Environmental Health (CDC)

Background
Drinking water supplies at Marine Corps Base Camp Lejeune were contaminated with trichloroethylene, tetrachloroethylene, benzene, vinyl chloride and trans-1,2-dichloroethylene during 1968 through 1985.

Methods
We conducted a case control study to determine if children born during 1968–1985 to mothers with residential exposure to contaminated drinking water at Camp Lejeune during pregnancy were more likely to have childhood hematopoietic cancers, neural tube defects (NTDs), or oral clefts. For cancers, exposures during the first year of life were also evaluated. Cases and controls were identified through a survey of parents residing on base during pregnancy and confirmed by medical records. Controls were randomly sampled from surveyed participants who had a live birth without a major birth defect or childhood cancer. Groundwater contaminant fate and transport and distribution system models provided estimates of monthly levels of drinking water contaminants at mothers’ residences. Magnitude of odds ratios (ORs) was used to assess associations. Confidence intervals (CIs) were used to indicate precision of ORs. We evaluated parental characteristics and pregnancy history to assess potential confounding.

Results
Confounding was negligible so unadjusted results were presented. For NTDs and average 1st trimester exposures, ORs for any benzene exposure and for trichloroethylene above 5 parts per billion were 4.1 (95% CI: 1.4-12.0) and 2.4 (95% CI: 0.6-9.6), respectively. For trichloroethylene, a monotonic exposure response relationship was observed. For childhood cancers and average 1st trimester exposures, ORs for any tetrachloroethylene exposure and any vinyl chloride exposure were 1.6 (95% CI: 0.5-4.8), and 1.6 (95% CI: 0.5-4.7), respectively. The study found no evidence suggesting any other associations between outcomes and exposures.

Conclusion
Although CIs were wide, ORs suggested associations between drinking water contaminants and NTDs. ORs suggested weaker associations with childhood hematopoietic cancers.

ESMO Press Release: Untreated Cancer Pain a ‘Scandal of Global Proportions,’ Survey Shows

December 2, 2013 Comments off

ESMO Press Release: Untreated Cancer Pain a ‘Scandal of Global Proportions,’ Survey Shows
Source: European Society for Medical Oncology

A ground-breaking international collaborative survey, published today in Annals of Oncology, shows that more than half of the world’s population live in countries where regulations that aim to stem drug misuse leave cancer patients without access to opioid medicines for managing cancer pain.

The results from the Global Opioid Policy Initiative (GOPI) project show that more than 4 billion people live in countries where regulations leave cancer patients suffering excruciating pain. National governments must take urgent action to improve access to these medicines, says the European Society for Medical Oncology, leader of a group of 22 partners that have launched the first global survey to evaluate the availability and accessibility of opioids for cancer pain management.

The study conducted in Africa, Asia, Latin America & the Caribbean and the Middle East assessed the availability of the seven opioid medications considered to be essential for the relief of cancer pain by the WHO Model List of Essential Medicines and the International Association for Hospice and Palliative Care. Those essential medications include codeine, oral oxycodone, transdermal fentanyl, immediate and slow release oral morphine, as well as injectable morphine, and oral methadone.

While there are problems with the supply of these medicines in many countries, the main problem is over-regulation that makes it difficult for healthcare professionals to prescribe and administer them for legitimate medical use, the authors say.

Medicare Contractors Nationwide Overpaid Millions to Providers for Full Vials of Herceptin

December 2, 2013 Comments off

Medicare Contractors Nationwide Overpaid Millions to Providers for Full Vials of Herceptin
Source: U.S Department of Health and Human Services, Office of Inspector General

This report summarizes the results of our individual reviews related to incorrect billings for full vials of Herceptin and evaluates the effectiveness of the Herceptin-specific edit that was implemented after our audit period. Herceptin (trastuzumab) is a Medicare-covered drug used to treat breast cancer that has spread to other parts of the body.

Most payments that Medicare contractors made to providers for full vials of Herceptin were incorrect. Specifically, of the 26,042 line items reviewed, 19,954 (77 percent) were incorrect and included overpayments of about $24.2 million, or more than one-third of total dollars reviewed. These providers had not identified or refunded these payments by the beginning of our reviews. Prior to our audit work, and not as a result of our audit, providers had refunded overpayments on 1,484 line items totaling approximately $1.9 million. The 4,604 remaining line items were correct.

On nearly all of the 19,954 incorrect line items, the providers reported the units of service for the entire content of 1 or more vial(s), each containing 440 milligrams of Herceptin, rather than reporting the units of service for the amount actually administered. The providers attributed the incorrect payments to clerical errors and to billing systems that could not prevent or detect the incorrect billing of units of service. Medicare contractors made these incorrect payments because neither the Fiscal Intermediary Standard System nor the Common Working File had sufficient edits in place during our audit period to prevent or detect the overpayments. During our audit period, there was no specific edit to identify Herceptin claims incorrectly billed as full vials.

Identifying and Addressing the Needs of Adolescents and Young Adults with Cancer: Workshop Summary

November 14, 2013 Comments off

Identifying and Addressing the Needs of Adolescents and Young Adults with Cancer: Workshop Summary
Source: Institute of Medicine

Identifying and Addressing the Needs of Adolescents and Young Adults with Cancer is the summary of a workshop convened by the Institute of Medicine’s National Cancer Policy Forum in July 2013 to facilitate discussion about gaps and challenges in caring for adolescent and young adult cancer patients and potential strategies and actions to improve the quality of their care. The workshop featured invited presentations from clinicians and other advocates working to improve the care and outcomes for the adolescent and young adult population with cancer.

Cancer is the leading disease-related cause of death in adolescents and young adults. Each year nearly 70,000 people between the ages of 15 and 39 are diagnosed with cancer, approximately 8 times more than children under age 15. This population faces a variety of unique short- and long-term health and psychosocial issues, such as difficulty reentering school, the workforce, or the dating scene; problems with infertility; cardiac, pulmonary, or other treatment repercussions; and secondary malignancies. Survivors are also at increased risk for psychiatric conditions such as anxiety, depression, substance abuse, and suicide and may have difficulty acquiring health insurance and paying for needed care. Identifying and Addressing the Needs of Adolescents and Young Adults with Cancer discusses a variety of topics important to adolescent and young adult patients with cancer, including the ways in which cancers affecting this group differ from cancers in other age groups and what that implies about the best treatments for these cancer patients. This report identifies gaps and challenges in providing optimal care to adolescent and young adult patients with cancer and to discuss potential strategies and actions to address them.

Vital Signs: Colorectal Cancer Screening Test Use — United States, 2012

November 8, 2013 Comments off

Vital Signs: Colorectal Cancer Screening Test Use — United States, 2012
Source: Morbidity and Mortality Weekly Report (CDC)

Background:
Strong evidence exists that screening with fecal occult blood testing (FOBT), sigmoidoscopy, or colonoscopy reduces the number of deaths from colorectal cancer (CRC). The percentage of the population up-to-date with recommended CRC screening increased from 54% in 2002 to 65% in 2010, primarily through increased use of colonoscopy.

Methods:
Data from the 2012 Behavioral Risk Factor Surveillance System survey were analyzed to estimate percentages of adults aged 50–75 years who reported CRC screening participation consistent with United States Preventive Services Task Force recommendations.

Results:
In 2012, 65.1% of U.S. adults were up-to-date with CRC screening, and 27.7% had never been screened. The proportion of respondents who had never been screened was greater among those without insurance (55.0%) and without a regular care provider (61.0%) than among those with health insurance (24.0%) and a regular care provider (23.5%). Colonoscopy was the most commonly used screening test (61.7%), followed by FOBT (10.4%). Colonoscopy was used by more than 53% of the population in every state. The percentages of blacks and whites up-to-date with CRC screening were equivalent. Compared with whites, a higher percentage of blacks across all income and education levels used FOBT.

Conclusions:
Many age-eligible adults did not use any type of CRC screening test as recommended. Organized, population-based approaches might increase CRC screening among those who have never been screened. Promoting both FOBT and colonoscopy as viable screening test options might increase CRC screening rates and reduce health disparities.

Mortality and cancer incidence in a pooled cohort of US firefighters from San Francisco, Chicago and Philadelphia (1950− 2009)

November 7, 2013 Comments off

Mortality and cancer incidence in a pooled cohort of US firefighters from San Francisco, Chicago and Philadelphia (1950− 2009) (PDF)
Source: Occupational and Environmental Medicine (via CDC)

OBJECTIVES:
To examine mortality patterns and cancer incidence in a pooled cohort of 29 993 US career firefighters employed since 1950 and followed through 2009.

METHODS:
Mortality and cancer incidence were evaluated by life table methods with the US population referent. Standardised mortality (SMR) and incidence (SIR) ratios were determined for 92 causes of death and 41 cancer incidence groupings. Analyses focused on 15 outcomes of a priori interest. Sensitivity analyses were conducted to examine the potential for significant bias.

RESULTS:
Person-years at risk totalled 858 938 and 403 152 for mortality and incidence analyses, respectively. All-cause mortality was at expectation (SMR=0.99, 95% CI 0.97 to 1.01, n=12 028). There was excess cancer mortality (SMR=1.14, 95% CI 1.10 to 1.18, n=3285) and incidence (SIR=1.09, 95% CI 1.06 to 1.12, n=4461) comprised mainly of digestive (SMR=1.26, 95% CI 1.18 to 1.34, n=928; SIR=1.17, 95% CI 1.10 to 1.25, n=930) and respiratory (SMR=1.10, 95% CI 1.04 to 1.17, n=1096; SIR=1.16, 95% CI 1.08 to 1.24, n=813) cancers. Consistent with previous reports, modest elevations were observed in several solid cancers; however, evidence of excess lymphatic or haematopoietic cancers was lacking. This study is the first to report excess malignant mesothelioma (SMR=2.00, 95% CI 1.03 to 3.49, n=12; SIR=2.29, 95% CI 1.60 to 3.19, n=35) among US firefighters. Results appeared robust under differing assumptions and analytic techniques.

CONCLUSIONS:
Our results provide evidence of a relation between firefighting and cancer. The new finding of excess malignant mesothelioma is noteworthy, given that asbestos exposure is a known hazard of firefighting.

Investigating Suspected Cancer Clusters and Responding to Community Concerns: Guidelines from CDC and the Council of State and Territorial Epidemiologists

October 4, 2013 Comments off

Investigating Suspected Cancer Clusters and Responding to Community Concerns: Guidelines from CDC and the Council of State and Territorial Epidemiologists
Source: Morbidity and Mortality Weekly Report (CDC)

This report augments guidelines published in 1990 for investigating clusters of health events (CDC. Guidelines for investigating clusters of health events. MMWR 1990;39[No. RR-11]). The 1990 Guidelines considered any noninfectious disease cluster, injuries, birth defects, and previously unrecognized syndromes or illnesses. These new guidelines focus on cancer clusters. State and local health departments can use these guidelines to develop a systematic approach to responding to community concerns regarding cancer clusters. The guidelines are intended to apply to situations in which a health department responds to an inquiry about a suspected cancer cluster in a residential or community setting only. Occupational or medical treatment-related clusters are not included in this report. Since 1990, many improvements have occurred in data resources, investigative techniques, and analytic/statistical methods, and much has been learned from both large- and small-scale cancer cluster investigations. These improvements and lessons have informed these updated guidelines.

These guidelines utilize a four-step approach (initial response, assessment, major feasibility study, and etiologic investigation) as a tool for managing a reported cluster. Even if a cancer cluster is identified, there is no guarantee that a common cause or an environmental contaminant will be implicated. Identification of a common cause or an implicated contaminant might be an expected outcome for the concerned community. Therefore, during all parts of an inquiry, responders should be transparent, communicate clearly, and explain their decisions to the community.

Core Needle and Open Surgical Biopsy for Diagnosis of Breast Lesions–An Update to the 2009 Report

September 26, 2013 Comments off

Core Needle and Open Surgical Biopsy for Diagnosis of Breast Lesions–An Update to the 2009 Report
Source: Agency for Healthcare Research and Quality

Among women in the United States, breast cancer is the second most common malignancy (after skin cancer), and the second most common cause of cancer death (after lung cancer).1 Approximately 1 in 8 U.S. women will develop breast cancer during their lifetime, and an estimated 2.7 million women had a current or past diagnosis of breast cancer as of 2009.2 The American Cancer Society estimates that 232,340 new cases of invasive breast cancer and 64,640 new cases of noninvasive breast cancer will be diagnosed in 2013, and 39,620 women will die of breast cancer.3

During the earliest stages of breast cancer, there are usually no symptoms. The process of breast cancer diagnosis is initiated by detection of an abnormality through self-examination, physical examination by a clinician, or screening mammography. Data from the Behavioral Risk Factor Surveillance System show that, in 2010, 75.4 percent of U.S. women aged ≥40 years and 79.7% of women aged 50 to 74 years reported having a mammogram within the past 2 years.4 If initial assessment suggests that the abnormality may be breast cancer, the woman may be referred for a biopsy, which is a sampling of cells or tissue from the suspicious lesion. Among women screened annually for 10 years, approximately 50 percent will need additional imaging tests, and a large proportion will have biopsies.5,6 More than a million women have breast biopsies each year in the United States. There are currently three techniques for obtaining samples from suspicious breast lesions: fine-needle aspiration, biopsy with a hollow core needle, or open surgical excision of tissue. Fine-needle aspiration, which retrieves a sample of cells, is generally considered less sensitive than both core-needle and open biopsy methods.7 Core-needle biopsy, which retrieves a sample of tissue, and open surgical procedures are, therefore, the most frequently used procedures.

Samples obtained by any of these methods are evaluated by pathologists and classified into histological categories with the primary goal of determining whether the lesion is benign or malignant. Because a core-needle biopsy often samples only part of the breast abnormality, there is the risk that a lesion will be classified as benign or as high risk (e.g., atypical ductal hyperplasia [ADH]) or noninvasive (e.g., ductal carcinoma in situ [DCIS]) when invasive cancer is in fact present in unsampled areas. In contrast, open surgical biopsy often samples most or the entire lesion, and it is thought that there is a much smaller risk of misdiagnosis. However, while open surgical biopsy methods are considered to be the most accurate, they also appear to carry a higher risk of complications, such as bleeding or infection, when compared with core-needle biopsy.8 Therefore, if core-needle biopsy is also highly accurate, women and their clinicians may prefer some type of core-needle biopsy to open surgical biopsy.

Core-needle biopsy may be carried out using a range of techniques. If the breast lesion to be biopsied is not palpable, an imaging method (i.e., stereotactic mammography, ultrasound, or magnetic resonance imaging [MRI]) may be used to locate the lesion. The biopsy may be carried out with needles of varying diameters, and one or more samples of tissue may be taken. Sometimes a vacuum device is used to assist in removing the tissue sample through the needle. It is thought that these and other variations in how a core-needle biopsy is performed may affect the accuracy and rate of complications of the biopsy. However, the impact aspects of biopsy technique have on test performance and safety are not clear.

In 2009, the ECRI Evidence-based Practice Center (EPC) conducted a comparative effectiveness review for core-needle versus open surgical biopsy on behalf of the Agency for Health Care Research and Quality (AHRQ).9,10 The review assessed the diagnostic test performance and harms of multiple core-needle biopsy techniques and tools, when compared with open surgical biopsy, and also evaluated differences between open biopsy and core-needle biopsy with regard to patient preference, costs, availability, and other factors. The conclusions were that core-needle biopsies were almost as accurate as open surgical biopsies, had a lower risk of severe complications, and were associated with fewer subsequent surgical procedures.10 The need for an update of the 2009 review was assessed in 2010 by the RAND EPC.11 Several high-impact general medical and specialty journals were searched, a panel of experts in the field was consulted, and an overall assessment of the need to update the review was produced. The conclusion of the updated Surveillance Report was that additional studies and changes in practice render some conclusions of the original report possibly out of date. Specifically, the Surveillance Report noted the following:

New studies are available that could be included in the updated report regarding the following topics:

  • The underestimation rate of stereotactically-guided vacuum-assisted core-needle biopsy for DCIS
  • The test performance of MRI-guided core-needle biopsy
  • The test performance of freehand automated-device core-needle technology
  • New studies on the test performance of core-needle biopsy may include additional information allowing the exploration of the heterogeneity for test performance or harm outcomes.

On the basis of the Surveillance Report findings, an updated review of the published literature was considered necessary to synthesize all evidence on currently available methods for core-needle and open surgical breast biopsy.

Sodium Intake in Populations: Assessment of Evidence

September 17, 2013 Comments off

Sodium Intake in Populations: Assessment of Evidence
Source: Institute of Medicine

Despite efforts over the past several decades to reduce sodium intake in the United States, adults still consume an average of 3,400 mg of sodium every day. A number of scientific bodies and professional health organizations, including the American Heart Association, the American Medical Association, and the American Public Health Association, support reducing dietary sodium intake. These organizations support a common goal to reduce daily sodium intake to less than 2,300 milligrams and further reduce intake to 1,500 mg among persons who are 51 years of age and older and those of any age who are African-American or have hypertension, diabetes, or chronic kidney disease.

A substantial body of evidence supports these efforts to reduce sodium intake. This evidence links excessive dietary sodium to high blood pressure, a surrogate marker for cardiovascular disease (CVD), stroke, and cardiac-related mortality. However, concerns have been raised that a low sodium intake may adversely affect certain risk factors, including blood lipids and insulin resistance, and thus potentially increase risk of heart disease and stroke. In fact, several recent reports have challenged sodium reduction in the population as a strategy to reduce this risk.

Sodium Intake in Populations recognizes the limitations of the available evidence, and explains that there is no consistent evidence to support an association between sodium intake and either a beneficial or adverse effect on most direct health outcomes other than some CVD outcomes (including stroke and CVD mortality) and all-cause mortality. Some evidence suggested that decreasing sodium intake could possibly reduce the risk of gastric cancer. However, the evidence was too limited to conclude the converse—that higher sodium intake could possibly increase the risk of gastric cancer. Interpreting these findings was particularly challenging because most studies were conducted outside the United States in populations consuming much higher levels of sodium than those consumed in this country. Sodium Intake in Populations is a summary of the findings and conclusions on evidence for associations between sodium intake and risk of CVD-related events and mortality.

Trends in Cancer Care Near the End of Life

September 12, 2013 Comments off

Trends in Cancer Care Near the End of Life
Source: Robert Wood Johnson Foundation

Even though most patients with advanced cancer prefer care that minimizes symptoms, many still receive intense treatment and are not admitted into hospice care until their last three days of life, according to research from the Dartmouth Atlas Project. Although hospice care for Medicare patients with advanced cancer is increasing, so are the rates of treatment in intensive care units.

Since the last Dartmouth Atlas report, the trends in end-of-life cancer care across the country have been mixed. While patients are spending fewer days hospitalized in the last month of life, the number of days in ICUs has increased. Hospice days have also increased, but a growing proportion of patients begin receiving hospice services in the last three days of life, a time period often too short to provide patients the full benefit of hospice care.

Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis

September 10, 2013 Comments off

Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis
Source: Institute of Medicine

In the United States, approximately 14 million people have had cancer and more than 1.6 million new cases are diagnosed each year. By 2022, it is projected that there will be 18 million cancer survivors and, by 2030, cancer incidence is expected to rise to 2.3 million new diagnoses per year. However, more than a decade after the IOM first studied the quality of cancer care, the barriers to achieving excellent care for all cancer patients remain daunting. Therefore, the IOM convened a committee of experts to examine the quality of cancer care in the United States and formulate recommendations for improvement. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis presents the committee’s findings and recommendations.

The committee concluded that the cancer care delivery system is in crisis due to a growing demand for cancer care, increasing complexity of treatment, a shrinking workforce, and rising costs. Changes across the board are urgently needed to improve the quality of cancer care. All stakeholders – including cancer care teams, patients and their families, researchers, quality metrics developers, and payers, as well as HHS, other federal agencies, and industries – must reevaluate their current roles and responsibilities in cancer care and work together to develop a higher quality cancer care delivery system. Working toward the recommendations outlined in this report, the cancer care community can improve the quality of life and outcomes for people facing a cancer diagnosis.

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