Imaging Tests for the Diagnosis and Staging of Pancreatic Adenocarcinoma (PDF)
Source: Agency for Healthcare Research and Quality
Our objectives were to synthesize the available information on the diagnostic accuracy and clinical utility of commonly used imaging tests for the diagnosis and staging of pancreatic adenocarcinoma , as well as screening for pancreatic adenocarcinoma in high risk individuals .
We searched Embase , MEDLINE, PubMed, and The Cochrane Library from 1980 through November 1, 2013 , for English – la nguage, full – length articles on the role of m ultidetector computed tomography ( MD CT), endoscopic ultrasound with fine – needle aspiration (EUS – FNA), magnetic resonance imaging (MRI), and positron emission tomography – computed tomography ( PET/CT ) in screening, diagnosis, and staging pancreatic adenocarcinoma. The searches identified 9, 776 citations; after screening against the inclusion criteria, we included 15 systematic reviews and 108 primary studies.
We extracted data from the included studies and constructed evidence tables. Comparative o utcomes of interest included diagnostic accuracy (sensitivity and specificity) , staging accuracy, screening accuracy, clinical management, quality of life, survival, and harms of imaging tests. For studies of a single imaging test, the key outcomes were accuracy and procedural harms. Where possible, we pooled the data using bivariate binomial regression models for comparative accuracy. For each pair of tests and each assessed aspect (e.g., determination of metastase s), we determined whether the evidence was sufficient to permit a conclusion of a difference, a conclusion of similar accuracy , or neither (i.e., insufficient ). We rated the risk of bias of individual studies using an internal validity instrument and grade d the overall strength of evidence of conclusions using Evidence – based Practic e Center methods . For dat a on single – test accuracy, procedural harms, patient tolerance, and screening accuracy, we tabulated the important information and summarized the evidenc e qualitatively.
We included 15 systematic reviews and 108 primary studies. Regarding comparative accuracy, the evidence was sufficient to conclude that MDCT and EUS – FNA have similar accuracy in assess ing resectability in patients whose disease is unstaged , and that EUS – FNA has a slight advantage over MDCT with respect to T (tumor) staging (specifically, a lower chance of undersizing the tumor) . Further, we concluded that MDCT and MRI are similarly accurate with respect to both diagnos ing and asses s ing vessel involvement. For PET/CT , evidence was generally inconclusive, but we f ound low – strength evidence to conclude that PET/CT is more accurate than MDCT in assessing distant metastases (slight advantages in both sensitivity and specificity) . No ne of the included studies reported comparative data on clinical management, survival, quality, or the impact on comparative accuracy of patient characteristics , tumor characteristics , or operator experience. Many studies have reported procedural harms, but har ms are generally rare and are different for different imaging modalities. In the screening of people at high risk of developing pancreatic adenocarcinoma , a vailable studies do not correlate the results of a given imagin g test to subsequent diagnoses.
Current evidence permits some tentative conclusions about the comparative assessment of imaging tests for diagnosing and staging pancreatic adenocarcinoma, but many gaps remain. The conclusions we did draw are as follows: MDCT and EUS – FNA have similar accuracy in assessing resectability in patients whose disease is unstaged ; EUS – FNA has a slight advantage over MDCT with respect to T (tumor) staging (specifically, a lower chance of undersizing the tumor) ; MDCT and MRI are similarly accurate with respect to both diagnos ing and assess ing vessel involvement ; and PET/CT is more accurate than MDCT in assessing distant metastases (slight advantages in both sensitivity and specificity). The prominent gaps include minimal information on MDCT angiography , impr ecis e data on other imaging techniques, a lack of comparative data on patient – oriented outco mes and factors that could influence comparative accuracy, and test – specific data on screening accuracy.
Transforming Cancer Care and the Role of Payment Reform
Source: Brookings Institution
According to the National Cancer Institute there are more than 13 million people living with cancer in the United States; it is the second leading cause of death in the U.S. It is expected that 41% of Americans will be diagnosed with cancer at some point during their lives. More than 1.6 million new cases of cancer will be diagnosed in 2014; a nearly 22% increase over the last decade.
Cancer care is also expensive. In 2010 it accounted for $125 billion in health care spending and is expected to cost at least $158 billion by 2020, due to population increase. In 2011 Medicare alone spent nearly $35 billion in fee-for-service (FFS) payments for cancer care, representing almost 9% of all Medicare FFS payments overall.
Broadly speaking, problems in complex clinical care fall into two categories: deficits in knowledge (for example, lack of any effective treatment for certain brain tumors) and deficits in execution (for example, failure to treat breast cancer with a standard-of-care protocol). Delivery reform seeks to find opportunity in the latter problem type. Considering cancer care through this lens, there are many opportunities to improve outcomes and potentially lower costs, including better coordination of care, eliminating duplication of services and reducing fragmentation of care. In addition, almost two-thirds of oncology revenue derives from drug sales, and pricing for drugs (calculated by the average sale price plus 6% profit for providers) may incentivize the use of the most expensive drugs rather than equally effective, lower-cost alternatives.
Promising approaches are being developed to deliver high quality care, improve the patient experience, and reduce costs for this condition and other chronic diseases. Care redesign strategies such as adopting team-based models, offering extended practice hours, providing triage to keep patients out of the emergency room, and implementing care pathways help providers address avoidable costs and maximize the value of care. Many of these strategies are not currently reimbursed in the FFS, volume-based payment system.
Consequently, much policy attention is focusing on payment reform. On the heels of the Affordable Care Act (ACA), and numerous quality and payment focused initiatives in the private sector, health care organizations need to enhance the competitiveness and efficiency of their system in the marketplace. Alternative payment models (APMs) such as Accountable Care Organizations (ACOs), bundled payments, and patient-centered oncology medical homes (PCOMH) are just a few of the initiatives supported by public and private payers to align care redesign and payment reform and encourage continuous improvement. This paper provides a comprehensive overview of the complex care associated with oncology and the alternate payment models which help support optimal care and encourage continuous improvement.
Use of Sunscreen and Indoor Tanning Devices Among a Nationally Representative Sample of High School Students, 2001–2011
Use of Sunscreen and Indoor Tanning Devices Among a Nationally Representative Sample of High School Students, 2001–2011
Source: Preventing Chronic Disease (CDC)
Adolescents are particularly vulnerable to engaging in poor skin-protection behaviors. The objective of this study was to examine use of sunscreen and indoor tanning devices among a nationally representative sample of high school students during a 10-year period (2001–2011) using data from the Youth Risk Behavior Surveillance System. The percentage of youth who reported using sunscreen declined from 67.7% in 2001 to 56.1% in 2011. The prevalence of using indoor tanning devices was highest among white females: 37.4% in 2009 and 29.3% in 2011. These findings indicate the need for prevention efforts aimed at adolescents to reduce risks for skin cancer.
New GAO Report
Source: Government Accountability Office
World Trade Center Health Program: Approach Used to Add Cancers to List of Covered Conditions Was Reasonable, but Could Be Improved. GAO-14-606, July 23.
Highlights – http://www.gao.gov/assets/670/664962.pdf
Understanding CAM Natural Health Products: Implications of Use Among Cancer Patients and Survivors
Source: Journal of the Advanced Practitioner in Oncology
Herbs, vitamins, and other natural health products are being used by cancer patients and survivors with increasing prevalence in the United States. These complementary and alternative medicine (CAM) products, which are also referred to as natural health products in Canada and abroad, are used during cancer treatment and the survivorship period to ease the burden of symptoms such as pain, fatigue, insomnia, anxiety, and depression and hence improve overall quality of life. Data indicate that while patients choose these products for self-treatment, they often do not inform their health-care providers, thereby presenting the potential for negative interactions. This article gives an overview of CAM natural health products, including discussion of herbs, vitamins, and other supplements such as minerals, enzymes, and more. Related research is presented, and implications for advanced practitioners are discussed. Insights into guiding safe and effective use among patients as well as appropriate decision-making strategies are explored.
Review of the Formaldehyde Assessment in the National Toxicology Program 12th Report on Carcinogens
Source: National Research Council
Many people in the United States are exposed to formaldehyde. Exposure can occur from environmental sources (for example, combustion processes, building materials, and tobacco smoke) or in occupational settings (for example, the furniture, textile, and construction industries). Formaldehyde exposure also has endogenous sources–it is produced intracellularly as a component of the one carbon pool intermediary metabolism pathway. Scientists have studied formaldehyde for decades to determine whether exogenous formaldehyde exposure may be associated with cancer in humans. In 1981, The National Toxicology Program (NTP) first listed formaldehyde in the 2nd Report on Carcinogens as “reasonably anticipated to be a human carcinogen”. In 2011, NTP upgraded the listing of formaldehyde to “known to be a human carcinogen”. Following the new listing, Congress directed the Department of Health and Human Services to arrange for the National Academy of Sciences to independently review formaldehyde’s substance profile and listing. This report presents the findings and conclusions of the committee formed in response to the congressional request.
Review of the Formaldehyde Assessment in the National Toxicology Program 12th Report on Carcinogens concurs with NTP that there is sufficient evidence in studies that had adequate characterization of relevant exposure metrics to enable a strong conclusion about the association between formaldehyde exposure and cancer in humans. Additionally, the authoring committee independently reviewed the scientific evidence from studies in humans, experimental animals, and other studies relevant to the mechanisms of carcinogenesis and made level-of-evidence conclusions. This report finds clear and convincing epidemiologic evidence of an association between formaldehyde exposure and nasopharyngeal and sinonasal cancers in humans.
FDA takes steps to help ensure the reliability of certain diagnostic tests
Source: U.S. Food and Drug Administration
Today, the U.S. Food and Drug Administration took important steps to ensure that certain tests used by health care professionals to help diagnose and treat patients provide accurate, consistent and reliable results.
First, the FDA is issuing a final guidance on the development, review and approval or clearance of companion diagnostics, which are tests used to identify patients who will benefit from or be harmed by treatment with a certain drug. Companion diagnostic tests are intended to aid physicians in selecting appropriate therapies for individual patients. These tests are commonly used to detect certain types of gene-based cancers.
Second, consistent with the requirements of the Food and Drug Administration Safety and Innovation Act of 2012 (FDASIA), the agency is notifying Congress of its intention to publish a proposed risk-based oversight framework for laboratory developed tests (LDTs), which are designed, manufactured and used within a single laboratory. They include some genetic tests and tests that are used by health care professionals to guide medical treatment for their patients. The FDA already oversees direct-to-consumer tests regardless of whether they are LDTs or traditional diagnostics.