There is growing momentum to hold drug manufacturers accountable for the more than 400,000 US opioid overdose deaths that have occurred since 1999.¹ As state lawsuits against pharmaceutical manufacturers and distributors wind their way through the legal system, hospitals—which may benefit from settlement funds—have been paying close attention. Recently, former Governor John Kasich (R-Ohio), West Virginia University president E. Gordon Gee, and America’s Essential Hospitals argued that adequately compensating hospitals for the costs of being on the crisis’ “front lines” requires prioritizing them as settlement fund recipients.²

Hospitals should be laying the groundwork for how settlement funds might be used. They may consider enhancing some of the most promising, evidence-based services for individuals with opioid use disorders (OUDs), including improving treatment for commonly associated health conditions such as HIV and hepatitis C virus (HCV); expanding ambulatory long-term antibiotic treatment for endocarditis and other intravenous drug use–associated infections; more broadly adopting harm-reduction practices such as naloxone coprescribing; and applying best practices to caring for substance-exposed infants. They could also develop clinical services not already provided, including creating programs for OUD management during pregnancy and initiating medication for OUD in inpatient, emergency department, and ambulatory settings. In short, hospitals play a critical role in engaging people with OUD in treatment at every possible opportunity.³

When considering how to most effectively use opioid settlement funding, hospitals may consider adding or expanding these much-needed clinical services to address opioid-­related harms; however, their efforts should not stop there. Investments made outside hospital walls could have a significant effect on the public’s health, especially if they target social determinants of health. By tackling factors in the pathway to developing OUD, such as lack of meaningful employment, affordable housing, and mental health care, hospitals can move beyond treating the downstream consequences of addiction and toward preventing community-level opioid-related harms. To accomplish this daunting goal, hospitals will need to strengthen existing relationships with community partners and build new ones. Yet in a 2015 study, only 54% of nonprofit hospitals proposed a strategy to address the overdose crisis that involved community partnering.⁴

In this Perspective, we describe the following three strategies hospitals can use to multiply the reach of their opioid settlement funding by addressing root causes of opioid use through primary prevention: (1) supporting economic opportunities in their communities, (2) expanding affordable housing options in surrounding neighborhoods, and (3) building capacity in ambulatory practices and pharmacies to prevent OUD (Table).

Lack of economic opportunity is one of many root causes of opioid use. For example, a recent study found that automotive assembly plant closures were associated with increases in opioid overdose mortality.⁵ To tackle this complex issue, hospitals can play a crucial role in expanding employment and career advancement options for members of their local communities. Specifically, hospitals can do the following:

• Create jobs within the healthcare system and preferentially recruit and hire from surrounding neighborhoods
• Establish structured career development programs to build skills among entry-level healthcare employees
• Award contracts of varying sizes to locally owned businesses
• Employ individuals with lived experience with substance use disorders, such as peer recovery coaches⁶

To illustrate how health systems are investing in enhancing career opportunities for members of their communities, hundreds of institutions have implemented “School at Work,” a 6-month career development program for entry-level healthcare employees.⁷ The hospitals’ Human Resources department trains participants in communication skills, reading and writing, patient safety and satisfaction, medical terminology, and strategies for success and career advancement. Evaluations of this program have demonstrated improved employee outcomes and a favorable return on investment for hospitals.⁸

As “anchor institutions” and large employers in many communities, hospitals can simultaneously enhance their own workforce and offer employment opportunities that can help break the cycle of addiction that commonly traps individuals and families in communities affected by the overdose crisis.

Hospitals are increasingly supporting interventions that fall outside their traditional purview as they seek to improve population health, such as developing safe green outdoor spaces and increasing access to healthy food options by supporting local farmers markets and grocers.⁹ Stable, decent, and affordable housing is critically important to health and well-being,¹⁰ and there is a well-documented association of opioid use disorder and opioid misuse with housing instability.¹¹ Given evidence of improved outcomes with hospital-led housing interventions,¹² a growing number of hospitals are partnering with housing authorities and community groups to help do the following¹³:

• Contribute to supportive housing options
• Provide environmental health assessments, repairs, and renovations
• Buy or develop affordable housing units

Boston Medical Center, where one in four inpatients are experiencing homelessnes and one in three pediatric emergency department patients are housing insecure, provides an example of how a hospital has invested in housing.¹⁴ In 2017, the hospital began a 5-year, $6.5 million investment in community partnerships in surrounding neighborhoods. Instead of building housing units or acting as a landlord, the hospital chose to invest funding in creative ways to increase the pool of affordable housing. It invested $1 million to rehabilitate permanent, supportive housing units for individuals with mental health conditions in a nearby Boston neighborhood and in a housing stabilization program for people with complex medical issues including substance use disorder. It provided resources to a homeless shelter near the hospital and to the Boston Health Care for the Homeless Program, which provides healthcare to individuals with housing instability. It also funded a community wellness advocate based at the hospital, who received training in substance use disorders and served as a liaison between the hospital and the Boston Housing Authority.

Housing instability is just one of the social determinants of health that hospitals have the capacity to address as they consider where to invest their opioid settlement funds.

Finally, hospitals can partner with community ambulatory practices and pharmacies to prevent the progression to problematic opioid use and OUD. Specifically, hospitals can do as follows:

• Provide evidence-based training to community providers on safe prescribing practices for acute and chronic pain management, as well as postoperative, postprocedural, and postpartum pain management
• Support ambulatory providers in expanding office-based mental health treatment through direct care via telemedicine and in building mental health treatment capacity through consultation, continuing medical education, and telementorship (eg, Project ECHO¹⁵)
• Support ambulatory providers to implement risk reduction strategies to prevent initiation of problematic opioid use, particularly among adolescents and young adults
• Partner with local pharmacies to promote point-of-­prescription counseling on the risks and benefits of opioids

Hospitals bring key strengths and resources to these prevention-­oriented partnerships. First, they may have resources available for clinical research, implementation support, program evaluation, and quality improvement, bringing such expertise to partnerships with ambulatory practices and pharmacies. They likely have specific expertise among their staff, including areas such as pain management, obstetric care, pediatrics, and adolescent medicine, and can provide specialists for consultation services or telementoring initiatives. They also can organize continuing medical education and can offer in-service training at local practices and pharmacies.

Project ECHO is one example of telementoring to build capacity among community providers to manage chronic pain and address addiction and other related harms.¹⁶ The Project ECHO model includes virtual sessions with didactic content and case presentations during which specialists mentor community clinicians. Specific to primary prevention, telementoring has been shown to improve access to evidence-based treatment of chronic pain and mental health conditions,^17,18 which could prevent the development of OUD. By equipping community clinicians with tools to prevent the development of problematic opioid use, hospitals can help reduce the downstream burden of OUD and its associated morbidity, mortality, and costs.

The opioid crisis has devastated families, reduced life expectancy in certain communities,¹⁹ and had a substantial financial impact on hospitals—resulting in an estimated $11 billion in costs to US hospitals each year.²⁰ This ongoing crisis is only going to be compounded by the recent emergence of the SARS-CoV-2 virus. Hospital resources are being strained in unprecedented ways, which has required unprecedented responses in order to continue to serve their communities. Supporting economic opportunity, stable housing, and mental health treatment will be challenging in this new environment but has never been more urgently needed. If opioid settlement funds are targeted to US hospitals, they should be held accountable for where funds are spent because they have a unique opportunity to focus on primary prevention in their communities—confronting OUD before it begins.²¹ However, if hospitals use opioid settlement funding only to continue to provide services already offered, or fail to make bold investments in their communities, this public health crisis will continue to strain the resources of those providing clinical care on the front lines.

The authors wish to thank Hilary Peterson of the RAND Corporation for preparing the paper for submission. She was not compensated for her contribution.

The authors report being supported by grants from the National Institute on Drug Abuse of the National Institutes of Health under awards R21DA045212 (Dr Faherty), K23DA045085 (Dr Hadland), L40DA042434 (Dr Hadland), K23DA038720 (Dr Patrick), R01DA045729 (Dr Patrick), and P50DA046351 (Dr Stein). Dr Hadland also reports grant support from the Thrasher Research Fund and the Academic Pediatric Association. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

There is growing momentum to hold drug manufacturers accountable for the more than 400,000 US opioid overdose deaths that have occurred since 1999.¹ As state lawsuits against pharmaceutical manufacturers and distributors wind their way through the legal system, hospitals—which may benefit from settlement funds—have been paying close attention. Recently, former Governor John Kasich (R-Ohio), West Virginia University president E. Gordon Gee, and America’s Essential Hospitals argued that adequately compensating hospitals for the costs of being on the crisis’ “front lines” requires prioritizing them as settlement fund recipients.²

Hospitals should be laying the groundwork for how settlement funds might be used. They may consider enhancing some of the most promising, evidence-based services for individuals with opioid use disorders (OUDs), including improving treatment for commonly associated health conditions such as HIV and hepatitis C virus (HCV); expanding ambulatory long-term antibiotic treatment for endocarditis and other intravenous drug use–associated infections; more broadly adopting harm-reduction practices such as naloxone coprescribing; and applying best practices to caring for substance-exposed infants. They could also develop clinical services not already provided, including creating programs for OUD management during pregnancy and initiating medication for OUD in inpatient, emergency department, and ambulatory settings. In short, hospitals play a critical role in engaging people with OUD in treatment at every possible opportunity.³

When considering how to most effectively use opioid settlement funding, hospitals may consider adding or expanding these much-needed clinical services to address opioid-­related harms; however, their efforts should not stop there. Investments made outside hospital walls could have a significant effect on the public’s health, especially if they target social determinants of health. By tackling factors in the pathway to developing OUD, such as lack of meaningful employment, affordable housing, and mental health care, hospitals can move beyond treating the downstream consequences of addiction and toward preventing community-level opioid-related harms. To accomplish this daunting goal, hospitals will need to strengthen existing relationships with community partners and build new ones. Yet in a 2015 study, only 54% of nonprofit hospitals proposed a strategy to address the overdose crisis that involved community partnering.⁴

In this Perspective, we describe the following three strategies hospitals can use to multiply the reach of their opioid settlement funding by addressing root causes of opioid use through primary prevention: (1) supporting economic opportunities in their communities, (2) expanding affordable housing options in surrounding neighborhoods, and (3) building capacity in ambulatory practices and pharmacies to prevent OUD (Table).

Lack of economic opportunity is one of many root causes of opioid use. For example, a recent study found that automotive assembly plant closures were associated with increases in opioid overdose mortality.⁵ To tackle this complex issue, hospitals can play a crucial role in expanding employment and career advancement options for members of their local communities. Specifically, hospitals can do the following:

• Create jobs within the healthcare system and preferentially recruit and hire from surrounding neighborhoods
• Establish structured career development programs to build skills among entry-level healthcare employees
• Award contracts of varying sizes to locally owned businesses
• Employ individuals with lived experience with substance use disorders, such as peer recovery coaches⁶

To illustrate how health systems are investing in enhancing career opportunities for members of their communities, hundreds of institutions have implemented “School at Work,” a 6-month career development program for entry-level healthcare employees.⁷ The hospitals’ Human Resources department trains participants in communication skills, reading and writing, patient safety and satisfaction, medical terminology, and strategies for success and career advancement. Evaluations of this program have demonstrated improved employee outcomes and a favorable return on investment for hospitals.⁸

As “anchor institutions” and large employers in many communities, hospitals can simultaneously enhance their own workforce and offer employment opportunities that can help break the cycle of addiction that commonly traps individuals and families in communities affected by the overdose crisis.

Hospitals are increasingly supporting interventions that fall outside their traditional purview as they seek to improve population health, such as developing safe green outdoor spaces and increasing access to healthy food options by supporting local farmers markets and grocers.⁹ Stable, decent, and affordable housing is critically important to health and well-being,¹⁰ and there is a well-documented association of opioid use disorder and opioid misuse with housing instability.¹¹ Given evidence of improved outcomes with hospital-led housing interventions,¹² a growing number of hospitals are partnering with housing authorities and community groups to help do the following¹³:

• Contribute to supportive housing options
• Provide environmental health assessments, repairs, and renovations
• Buy or develop affordable housing units

Boston Medical Center, where one in four inpatients are experiencing homelessnes and one in three pediatric emergency department patients are housing insecure, provides an example of how a hospital has invested in housing.¹⁴ In 2017, the hospital began a 5-year, $6.5 million investment in community partnerships in surrounding neighborhoods. Instead of building housing units or acting as a landlord, the hospital chose to invest funding in creative ways to increase the pool of affordable housing. It invested $1 million to rehabilitate permanent, supportive housing units for individuals with mental health conditions in a nearby Boston neighborhood and in a housing stabilization program for people with complex medical issues including substance use disorder. It provided resources to a homeless shelter near the hospital and to the Boston Health Care for the Homeless Program, which provides healthcare to individuals with housing instability. It also funded a community wellness advocate based at the hospital, who received training in substance use disorders and served as a liaison between the hospital and the Boston Housing Authority.

Housing instability is just one of the social determinants of health that hospitals have the capacity to address as they consider where to invest their opioid settlement funds.

Finally, hospitals can partner with community ambulatory practices and pharmacies to prevent the progression to problematic opioid use and OUD. Specifically, hospitals can do as follows:

• Provide evidence-based training to community providers on safe prescribing practices for acute and chronic pain management, as well as postoperative, postprocedural, and postpartum pain management
• Support ambulatory providers in expanding office-based mental health treatment through direct care via telemedicine and in building mental health treatment capacity through consultation, continuing medical education, and telementorship (eg, Project ECHO¹⁵)
• Support ambulatory providers to implement risk reduction strategies to prevent initiation of problematic opioid use, particularly among adolescents and young adults
• Partner with local pharmacies to promote point-of-­prescription counseling on the risks and benefits of opioids

Hospitals bring key strengths and resources to these prevention-­oriented partnerships. First, they may have resources available for clinical research, implementation support, program evaluation, and quality improvement, bringing such expertise to partnerships with ambulatory practices and pharmacies. They likely have specific expertise among their staff, including areas such as pain management, obstetric care, pediatrics, and adolescent medicine, and can provide specialists for consultation services or telementoring initiatives. They also can organize continuing medical education and can offer in-service training at local practices and pharmacies.

Project ECHO is one example of telementoring to build capacity among community providers to manage chronic pain and address addiction and other related harms.¹⁶ The Project ECHO model includes virtual sessions with didactic content and case presentations during which specialists mentor community clinicians. Specific to primary prevention, telementoring has been shown to improve access to evidence-based treatment of chronic pain and mental health conditions,^17,18 which could prevent the development of OUD. By equipping community clinicians with tools to prevent the development of problematic opioid use, hospitals can help reduce the downstream burden of OUD and its associated morbidity, mortality, and costs.

The opioid crisis has devastated families, reduced life expectancy in certain communities,¹⁹ and had a substantial financial impact on hospitals—resulting in an estimated $11 billion in costs to US hospitals each year.²⁰ This ongoing crisis is only going to be compounded by the recent emergence of the SARS-CoV-2 virus. Hospital resources are being strained in unprecedented ways, which has required unprecedented responses in order to continue to serve their communities. Supporting economic opportunity, stable housing, and mental health treatment will be challenging in this new environment but has never been more urgently needed. If opioid settlement funds are targeted to US hospitals, they should be held accountable for where funds are spent because they have a unique opportunity to focus on primary prevention in their communities—confronting OUD before it begins.²¹ However, if hospitals use opioid settlement funding only to continue to provide services already offered, or fail to make bold investments in their communities, this public health crisis will continue to strain the resources of those providing clinical care on the front lines.

The authors wish to thank Hilary Peterson of the RAND Corporation for preparing the paper for submission. She was not compensated for her contribution.

The authors report being supported by grants from the National Institute on Drug Abuse of the National Institutes of Health under awards R21DA045212 (Dr Faherty), K23DA045085 (Dr Hadland), L40DA042434 (Dr Hadland), K23DA038720 (Dr Patrick), R01DA045729 (Dr Patrick), and P50DA046351 (Dr Stein). Dr Hadland also reports grant support from the Thrasher Research Fund and the Academic Pediatric Association. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

There is growing momentum to hold drug manufacturers accountable for the more than 400,000 US opioid overdose deaths that have occurred since 1999.¹ As state lawsuits against pharmaceutical manufacturers and distributors wind their way through the legal system, hospitals—which may benefit from settlement funds—have been paying close attention. Recently, former Governor John Kasich (R-Ohio), West Virginia University president E. Gordon Gee, and America’s Essential Hospitals argued that adequately compensating hospitals for the costs of being on the crisis’ “front lines” requires prioritizing them as settlement fund recipients.²

Hospitals should be laying the groundwork for how settlement funds might be used. They may consider enhancing some of the most promising, evidence-based services for individuals with opioid use disorders (OUDs), including improving treatment for commonly associated health conditions such as HIV and hepatitis C virus (HCV); expanding ambulatory long-term antibiotic treatment for endocarditis and other intravenous drug use–associated infections; more broadly adopting harm-reduction practices such as naloxone coprescribing; and applying best practices to caring for substance-exposed infants. They could also develop clinical services not already provided, including creating programs for OUD management during pregnancy and initiating medication for OUD in inpatient, emergency department, and ambulatory settings. In short, hospitals play a critical role in engaging people with OUD in treatment at every possible opportunity.³

When considering how to most effectively use opioid settlement funding, hospitals may consider adding or expanding these much-needed clinical services to address opioid-­related harms; however, their efforts should not stop there. Investments made outside hospital walls could have a significant effect on the public’s health, especially if they target social determinants of health. By tackling factors in the pathway to developing OUD, such as lack of meaningful employment, affordable housing, and mental health care, hospitals can move beyond treating the downstream consequences of addiction and toward preventing community-level opioid-related harms. To accomplish this daunting goal, hospitals will need to strengthen existing relationships with community partners and build new ones. Yet in a 2015 study, only 54% of nonprofit hospitals proposed a strategy to address the overdose crisis that involved community partnering.⁴

In this Perspective, we describe the following three strategies hospitals can use to multiply the reach of their opioid settlement funding by addressing root causes of opioid use through primary prevention: (1) supporting economic opportunities in their communities, (2) expanding affordable housing options in surrounding neighborhoods, and (3) building capacity in ambulatory practices and pharmacies to prevent OUD (Table).

Lack of economic opportunity is one of many root causes of opioid use. For example, a recent study found that automotive assembly plant closures were associated with increases in opioid overdose mortality.⁵ To tackle this complex issue, hospitals can play a crucial role in expanding employment and career advancement options for members of their local communities. Specifically, hospitals can do the following:

• Create jobs within the healthcare system and preferentially recruit and hire from surrounding neighborhoods
• Establish structured career development programs to build skills among entry-level healthcare employees
• Award contracts of varying sizes to locally owned businesses
• Employ individuals with lived experience with substance use disorders, such as peer recovery coaches⁶

To illustrate how health systems are investing in enhancing career opportunities for members of their communities, hundreds of institutions have implemented “School at Work,” a 6-month career development program for entry-level healthcare employees.⁷ The hospitals’ Human Resources department trains participants in communication skills, reading and writing, patient safety and satisfaction, medical terminology, and strategies for success and career advancement. Evaluations of this program have demonstrated improved employee outcomes and a favorable return on investment for hospitals.⁸

As “anchor institutions” and large employers in many communities, hospitals can simultaneously enhance their own workforce and offer employment opportunities that can help break the cycle of addiction that commonly traps individuals and families in communities affected by the overdose crisis.

Hospitals are increasingly supporting interventions that fall outside their traditional purview as they seek to improve population health, such as developing safe green outdoor spaces and increasing access to healthy food options by supporting local farmers markets and grocers.⁹ Stable, decent, and affordable housing is critically important to health and well-being,¹⁰ and there is a well-documented association of opioid use disorder and opioid misuse with housing instability.¹¹ Given evidence of improved outcomes with hospital-led housing interventions,¹² a growing number of hospitals are partnering with housing authorities and community groups to help do the following¹³:

• Contribute to supportive housing options
• Provide environmental health assessments, repairs, and renovations
• Buy or develop affordable housing units

Boston Medical Center, where one in four inpatients are experiencing homelessnes and one in three pediatric emergency department patients are housing insecure, provides an example of how a hospital has invested in housing.¹⁴ In 2017, the hospital began a 5-year, $6.5 million investment in community partnerships in surrounding neighborhoods. Instead of building housing units or acting as a landlord, the hospital chose to invest funding in creative ways to increase the pool of affordable housing. It invested $1 million to rehabilitate permanent, supportive housing units for individuals with mental health conditions in a nearby Boston neighborhood and in a housing stabilization program for people with complex medical issues including substance use disorder. It provided resources to a homeless shelter near the hospital and to the Boston Health Care for the Homeless Program, which provides healthcare to individuals with housing instability. It also funded a community wellness advocate based at the hospital, who received training in substance use disorders and served as a liaison between the hospital and the Boston Housing Authority.

Housing instability is just one of the social determinants of health that hospitals have the capacity to address as they consider where to invest their opioid settlement funds.

Finally, hospitals can partner with community ambulatory practices and pharmacies to prevent the progression to problematic opioid use and OUD. Specifically, hospitals can do as follows:

• Provide evidence-based training to community providers on safe prescribing practices for acute and chronic pain management, as well as postoperative, postprocedural, and postpartum pain management
• Support ambulatory providers in expanding office-based mental health treatment through direct care via telemedicine and in building mental health treatment capacity through consultation, continuing medical education, and telementorship (eg, Project ECHO¹⁵)
• Support ambulatory providers to implement risk reduction strategies to prevent initiation of problematic opioid use, particularly among adolescents and young adults
• Partner with local pharmacies to promote point-of-­prescription counseling on the risks and benefits of opioids

Hospitals bring key strengths and resources to these prevention-­oriented partnerships. First, they may have resources available for clinical research, implementation support, program evaluation, and quality improvement, bringing such expertise to partnerships with ambulatory practices and pharmacies. They likely have specific expertise among their staff, including areas such as pain management, obstetric care, pediatrics, and adolescent medicine, and can provide specialists for consultation services or telementoring initiatives. They also can organize continuing medical education and can offer in-service training at local practices and pharmacies.

Project ECHO is one example of telementoring to build capacity among community providers to manage chronic pain and address addiction and other related harms.¹⁶ The Project ECHO model includes virtual sessions with didactic content and case presentations during which specialists mentor community clinicians. Specific to primary prevention, telementoring has been shown to improve access to evidence-based treatment of chronic pain and mental health conditions,^17,18 which could prevent the development of OUD. By equipping community clinicians with tools to prevent the development of problematic opioid use, hospitals can help reduce the downstream burden of OUD and its associated morbidity, mortality, and costs.

The opioid crisis has devastated families, reduced life expectancy in certain communities,¹⁹ and had a substantial financial impact on hospitals—resulting in an estimated $11 billion in costs to US hospitals each year.²⁰ This ongoing crisis is only going to be compounded by the recent emergence of the SARS-CoV-2 virus. Hospital resources are being strained in unprecedented ways, which has required unprecedented responses in order to continue to serve their communities. Supporting economic opportunity, stable housing, and mental health treatment will be challenging in this new environment but has never been more urgently needed. If opioid settlement funds are targeted to US hospitals, they should be held accountable for where funds are spent because they have a unique opportunity to focus on primary prevention in their communities—confronting OUD before it begins.²¹ However, if hospitals use opioid settlement funding only to continue to provide services already offered, or fail to make bold investments in their communities, this public health crisis will continue to strain the resources of those providing clinical care on the front lines.

The authors wish to thank Hilary Peterson of the RAND Corporation for preparing the paper for submission. She was not compensated for her contribution.

The authors report being supported by grants from the National Institute on Drug Abuse of the National Institutes of Health under awards R21DA045212 (Dr Faherty), K23DA045085 (Dr Hadland), L40DA042434 (Dr Hadland), K23DA038720 (Dr Patrick), R01DA045729 (Dr Patrick), and P50DA046351 (Dr Stein). Dr Hadland also reports grant support from the Thrasher Research Fund and the Academic Pediatric Association. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

The 1918 H1N1 influenza pandemic was the most severe pandemic in recent history. Fifty to 100 million individuals died worldwide, with approximately 675,000 deaths in the United States.^1-3 The fatality rate was approximately 2% and was highest during the second and third waves of the disease.⁴ At that time, there were no diagnostic tests for influenza infection, influenza vaccines, antiviral drugs, antibiotics to treat secondary bacterial infections, or mechanical ventilation. Some cities decided to close schools, limit public gatherings, self-isolate, and issue quarantine orders; the federal government took no central role.

The 1918 influenza pandemic seems far away in history, but my mother often tells me stories about her own grandmother who disliked shaking anyone’s hands and would worry when people coughed or sneezed around her. It sounded like she was overreacting. Now, we can better relate to her concerns. Life has changed dramatically.

In mid-February 2020, news spread that the coronavirus disease 2019 (COVID-19) had spread from Wuhan, China, to a number of countries in Asia and the Middle East. I was following the news with great sadness for those affected countries, especially for Iran, my country of origin, which had become an epicenter of COVID-19. We were not worried for ourselves in the United States. These infections seemed far away. However, once Italy became the new epicenter of COVID-19 with alarmingly high death rates, I grasped the inevitable reality: The novel coronavirus would not spare the United States and would not spare New York.

Then the virus arrived in New York City. On March 10, 2020, our hospital recommended using teledermatology instead of in-person visits in an attempt to keep patients safe in their own homes. Cases of COVID-19 were escalating, hospitals were filling up, health care workers were falling ill, and there was a shortage of health care staff and personal protective equipment (PPE). Dermatologists at various hospitals were asked to retrain to help care for COVID-19 patients.

On March 13, flights from Europe to the United States were suspended. A statewide stay-at-home order subsequently went into effect on March 22. It felt surreal. From March 23 on, various specialty physicians and nurses in our hospital volunteered to work as frontline staff in the newly prepared annex where patients with possible COVID-19 would arrive. My dermatology co-residents and I started working as frontline physicians. Everything we had heard from the countries affected first had become our reality. Our hospital, part of the largest public health care system in the nation, became a dedicated COVID-19 treatment center.

Large numbers of scared patients with symptoms of COVID-19 flooded the annex. We sent the majority of them home, unable to offer them even a diagnostic test, and advised them to stay isolated. We only had the capacity to test those who required hospital admission.

It broke my heart even more when my colleagues became patients. We often felt helpless, not being able to help every patient and not being able to help our infected colleagues.

Elective surgeries were suspended. Inpatient beds, including specialized intensive care unit beds, rapidly filled up with COVID-19 patients. To help with the surge of patients, our hospital added medical and intensive care unit beds. The hospital became surreal, the corridors eerily empty and silent while every bed was filled, and health care workers were rushing around the inpatient units.

Life quickly became filled with fears—worries about how sick the patients would be, how much we would be able to help them, whether we would have enough PPE, who among our friends or family might be infected next, and whether we might ourselves be next. As PPE became scarce, I desperately searched for some form of protective equipment. I hunted for protective masks, face shields, eye protection, and gowns. We had to reuse disposable N95 masks and face shields multiple times and disinfect them as best we could. Our attendings ordered any protective gear they could find for us. Nearly everything was sold out; the very few items remaining would not for arrive for months. I could have never imagined that I would be afraid of going to work, of not having the appropriate protective gear, and that any day might be my last because of my profession.

New York City had become the epicenter of COVID-19. The city, the country, and the world were in chaos. Hospitals were overflowing, and makeshift morgues were appearing outside of hospitals. Those who could fled the city. Despite warnings from experts, we were not prepared. The number of deaths was climbing rapidly. There was no clarity on who could be tested or how to get it done. It felt like a nightmare.

Social distancing was in place, nonessential businesses were shut down, street vendors disappeared, and people were advised to wear face coverings. People were afraid of each other, afraid of getting too close and catching the virus. New York City—The City That Never Sleeps—went into deep sleep. Every day brought ever greater numbers of infected patients and more deaths.

Every day at 7:00 pm, people in New York City started clapping from their windows to salute health care workers, bringing tears to my eyes—tears for the gratitude of people mixed with tears of fear for my life and the lives of my patients and colleagues. I made arrangements for the event of falling ill, including a list of names and contact details of my family and close friends so they could be reached in case I ended up in intensive care or died.

After around 2 months of lockdown, New York City passed its peak, and the epicenter moved on. The current death toll (ie, confirmed deaths due to COVID-19) in New York stands at 18,836, while the reported death toll in the United States is 143,868, according to the Centers for Disease Control and Prevention. New York City has started a phased reopening to a new normal. Elective care has resumed, and people are leaving their homes again, eager to bring some sense of normalcy back into their lives.

I fear for those who will contract the virus in the next wave. I wonder what we will have learned.

Acknowledgment
The author wishes to thank Steven R. Feldman, MD, PhD (Winston-Salem, North Carolina), for his friendship and invaluable assistance with the conception and editing of this manuscript.

The 1918 H1N1 influenza pandemic was the most severe pandemic in recent history. Fifty to 100 million individuals died worldwide, with approximately 675,000 deaths in the United States.^1-3 The fatality rate was approximately 2% and was highest during the second and third waves of the disease.⁴ At that time, there were no diagnostic tests for influenza infection, influenza vaccines, antiviral drugs, antibiotics to treat secondary bacterial infections, or mechanical ventilation. Some cities decided to close schools, limit public gatherings, self-isolate, and issue quarantine orders; the federal government took no central role.

The 1918 influenza pandemic seems far away in history, but my mother often tells me stories about her own grandmother who disliked shaking anyone’s hands and would worry when people coughed or sneezed around her. It sounded like she was overreacting. Now, we can better relate to her concerns. Life has changed dramatically.

In mid-February 2020, news spread that the coronavirus disease 2019 (COVID-19) had spread from Wuhan, China, to a number of countries in Asia and the Middle East. I was following the news with great sadness for those affected countries, especially for Iran, my country of origin, which had become an epicenter of COVID-19. We were not worried for ourselves in the United States. These infections seemed far away. However, once Italy became the new epicenter of COVID-19 with alarmingly high death rates, I grasped the inevitable reality: The novel coronavirus would not spare the United States and would not spare New York.

Then the virus arrived in New York City. On March 10, 2020, our hospital recommended using teledermatology instead of in-person visits in an attempt to keep patients safe in their own homes. Cases of COVID-19 were escalating, hospitals were filling up, health care workers were falling ill, and there was a shortage of health care staff and personal protective equipment (PPE). Dermatologists at various hospitals were asked to retrain to help care for COVID-19 patients.

On March 13, flights from Europe to the United States were suspended. A statewide stay-at-home order subsequently went into effect on March 22. It felt surreal. From March 23 on, various specialty physicians and nurses in our hospital volunteered to work as frontline staff in the newly prepared annex where patients with possible COVID-19 would arrive. My dermatology co-residents and I started working as frontline physicians. Everything we had heard from the countries affected first had become our reality. Our hospital, part of the largest public health care system in the nation, became a dedicated COVID-19 treatment center.

Large numbers of scared patients with symptoms of COVID-19 flooded the annex. We sent the majority of them home, unable to offer them even a diagnostic test, and advised them to stay isolated. We only had the capacity to test those who required hospital admission.

It broke my heart even more when my colleagues became patients. We often felt helpless, not being able to help every patient and not being able to help our infected colleagues.

Elective surgeries were suspended. Inpatient beds, including specialized intensive care unit beds, rapidly filled up with COVID-19 patients. To help with the surge of patients, our hospital added medical and intensive care unit beds. The hospital became surreal, the corridors eerily empty and silent while every bed was filled, and health care workers were rushing around the inpatient units.

Life quickly became filled with fears—worries about how sick the patients would be, how much we would be able to help them, whether we would have enough PPE, who among our friends or family might be infected next, and whether we might ourselves be next. As PPE became scarce, I desperately searched for some form of protective equipment. I hunted for protective masks, face shields, eye protection, and gowns. We had to reuse disposable N95 masks and face shields multiple times and disinfect them as best we could. Our attendings ordered any protective gear they could find for us. Nearly everything was sold out; the very few items remaining would not for arrive for months. I could have never imagined that I would be afraid of going to work, of not having the appropriate protective gear, and that any day might be my last because of my profession.

New York City had become the epicenter of COVID-19. The city, the country, and the world were in chaos. Hospitals were overflowing, and makeshift morgues were appearing outside of hospitals. Those who could fled the city. Despite warnings from experts, we were not prepared. The number of deaths was climbing rapidly. There was no clarity on who could be tested or how to get it done. It felt like a nightmare.

Social distancing was in place, nonessential businesses were shut down, street vendors disappeared, and people were advised to wear face coverings. People were afraid of each other, afraid of getting too close and catching the virus. New York City—The City That Never Sleeps—went into deep sleep. Every day brought ever greater numbers of infected patients and more deaths.

Every day at 7:00 pm, people in New York City started clapping from their windows to salute health care workers, bringing tears to my eyes—tears for the gratitude of people mixed with tears of fear for my life and the lives of my patients and colleagues. I made arrangements for the event of falling ill, including a list of names and contact details of my family and close friends so they could be reached in case I ended up in intensive care or died.

After around 2 months of lockdown, New York City passed its peak, and the epicenter moved on. The current death toll (ie, confirmed deaths due to COVID-19) in New York stands at 18,836, while the reported death toll in the United States is 143,868, according to the Centers for Disease Control and Prevention. New York City has started a phased reopening to a new normal. Elective care has resumed, and people are leaving their homes again, eager to bring some sense of normalcy back into their lives.

I fear for those who will contract the virus in the next wave. I wonder what we will have learned.

Acknowledgment
The author wishes to thank Steven R. Feldman, MD, PhD (Winston-Salem, North Carolina), for his friendship and invaluable assistance with the conception and editing of this manuscript.

The 1918 H1N1 influenza pandemic was the most severe pandemic in recent history. Fifty to 100 million individuals died worldwide, with approximately 675,000 deaths in the United States.^1-3 The fatality rate was approximately 2% and was highest during the second and third waves of the disease.⁴ At that time, there were no diagnostic tests for influenza infection, influenza vaccines, antiviral drugs, antibiotics to treat secondary bacterial infections, or mechanical ventilation. Some cities decided to close schools, limit public gatherings, self-isolate, and issue quarantine orders; the federal government took no central role.

The 1918 influenza pandemic seems far away in history, but my mother often tells me stories about her own grandmother who disliked shaking anyone’s hands and would worry when people coughed or sneezed around her. It sounded like she was overreacting. Now, we can better relate to her concerns. Life has changed dramatically.

In mid-February 2020, news spread that the coronavirus disease 2019 (COVID-19) had spread from Wuhan, China, to a number of countries in Asia and the Middle East. I was following the news with great sadness for those affected countries, especially for Iran, my country of origin, which had become an epicenter of COVID-19. We were not worried for ourselves in the United States. These infections seemed far away. However, once Italy became the new epicenter of COVID-19 with alarmingly high death rates, I grasped the inevitable reality: The novel coronavirus would not spare the United States and would not spare New York.

Then the virus arrived in New York City. On March 10, 2020, our hospital recommended using teledermatology instead of in-person visits in an attempt to keep patients safe in their own homes. Cases of COVID-19 were escalating, hospitals were filling up, health care workers were falling ill, and there was a shortage of health care staff and personal protective equipment (PPE). Dermatologists at various hospitals were asked to retrain to help care for COVID-19 patients.

On March 13, flights from Europe to the United States were suspended. A statewide stay-at-home order subsequently went into effect on March 22. It felt surreal. From March 23 on, various specialty physicians and nurses in our hospital volunteered to work as frontline staff in the newly prepared annex where patients with possible COVID-19 would arrive. My dermatology co-residents and I started working as frontline physicians. Everything we had heard from the countries affected first had become our reality. Our hospital, part of the largest public health care system in the nation, became a dedicated COVID-19 treatment center.

Large numbers of scared patients with symptoms of COVID-19 flooded the annex. We sent the majority of them home, unable to offer them even a diagnostic test, and advised them to stay isolated. We only had the capacity to test those who required hospital admission.

It broke my heart even more when my colleagues became patients. We often felt helpless, not being able to help every patient and not being able to help our infected colleagues.

Elective surgeries were suspended. Inpatient beds, including specialized intensive care unit beds, rapidly filled up with COVID-19 patients. To help with the surge of patients, our hospital added medical and intensive care unit beds. The hospital became surreal, the corridors eerily empty and silent while every bed was filled, and health care workers were rushing around the inpatient units.

Life quickly became filled with fears—worries about how sick the patients would be, how much we would be able to help them, whether we would have enough PPE, who among our friends or family might be infected next, and whether we might ourselves be next. As PPE became scarce, I desperately searched for some form of protective equipment. I hunted for protective masks, face shields, eye protection, and gowns. We had to reuse disposable N95 masks and face shields multiple times and disinfect them as best we could. Our attendings ordered any protective gear they could find for us. Nearly everything was sold out; the very few items remaining would not for arrive for months. I could have never imagined that I would be afraid of going to work, of not having the appropriate protective gear, and that any day might be my last because of my profession.

New York City had become the epicenter of COVID-19. The city, the country, and the world were in chaos. Hospitals were overflowing, and makeshift morgues were appearing outside of hospitals. Those who could fled the city. Despite warnings from experts, we were not prepared. The number of deaths was climbing rapidly. There was no clarity on who could be tested or how to get it done. It felt like a nightmare.

Social distancing was in place, nonessential businesses were shut down, street vendors disappeared, and people were advised to wear face coverings. People were afraid of each other, afraid of getting too close and catching the virus. New York City—The City That Never Sleeps—went into deep sleep. Every day brought ever greater numbers of infected patients and more deaths.

Every day at 7:00 pm, people in New York City started clapping from their windows to salute health care workers, bringing tears to my eyes—tears for the gratitude of people mixed with tears of fear for my life and the lives of my patients and colleagues. I made arrangements for the event of falling ill, including a list of names and contact details of my family and close friends so they could be reached in case I ended up in intensive care or died.

After around 2 months of lockdown, New York City passed its peak, and the epicenter moved on. The current death toll (ie, confirmed deaths due to COVID-19) in New York stands at 18,836, while the reported death toll in the United States is 143,868, according to the Centers for Disease Control and Prevention. New York City has started a phased reopening to a new normal. Elective care has resumed, and people are leaving their homes again, eager to bring some sense of normalcy back into their lives.

I fear for those who will contract the virus in the next wave. I wonder what we will have learned.

Acknowledgment
The author wishes to thank Steven R. Feldman, MD, PhD (Winston-Salem, North Carolina), for his friendship and invaluable assistance with the conception and editing of this manuscript.

Early testing for actionable genomic alterations is now recommended for metastatic pancreatic cancer patients who progress on therapy or experience intolerable toxicity and who are potential candidates for additional treatment after first-line therapy, according to an American Society of Clinical Oncology guideline update.

Both germline and somatic testing, including for microsatellite instability/mismatch repair deficiency, BRCA mutations with known significance, and NTRK gene fusions, are recommended in this population, reported Davendra P.S. Sohal, MD, MPH, of the University of Cincinnati, and colleagues on ASCO’s expert panel. The update was published online Aug. 5 in the Journal of Clinical Oncology.

The ASCO guideline on clinical decision making for patients with metastatic pancreatic cancer was first published in 2016 to address initial assessment and first- and second-line treatment options, supportive care, and follow-up and was updated in 2018. The current update is based on new evidence of benefit with targeted therapy options after first-line therapy or as maintenance therapy.

The phase 3 POLO trial, for example, showed significantly improved progression-free survival with the poly (ADP-ribose) polymerase (PARP) inhibitor olaparib for maintenance therapy after first-line treatment in patients with a germline BRCA1 or BRCA2 mutation and metastatic pancreatic cancer that had not progressed during first-line platinum-based chemotherapy. An integrated analysis of three studies showed that entrectinib, a potent inhibitor of tropomyosin receptor kinase (TRK) A, B, and C, safely induced durable and clinically meaningful responses in patients with NTRK fusion-positive solid tumors, and a phase 1-2 study showed that the highly selective TRK inhibitor larotrectinib had marked and durable antitumor activity in both children and adults with TRK fusion-positive solid tumors.

With respect to the new recommendation endorsing early testing for actionable genomic alterations (Recommendation 1.5), the authors noted that the results of testing can lead to treatment with PARP inhibitors, programmed death-1 (PD-1) checkpoint inhibitor therapy, TRK fusion inhibitors, and clinical trials of targeted therapies.

“Genomic testing is recommended as part of an initial assessment to ensure that the results of testing are available at the time of treatment decision where applicable after first-line therapy,” the new recommendation states.

A “qualifying statement” further notes that the decision to test should “involve a discussion between the patient and physician regarding the frequency of actionable findings, treatment implications of testing results, and genetic counseling related to germline testing.”

Recommendation 1.5 is rated by the panel as “strong” and is based on informal consensus.

The panel also added two recommendations on treatment options after first-line therapy:

• Recommendation 3.1 calls for treatment with larotrectinib or entrectinib in patient with tumors harboring NTRK fusions.
• Recommendation 3.3 states that patients with a germline BRCA1 or BCA2 mutation who have received first-line platinum-based chemotherapy without disease progression for at least 16 weeks can receive chemotherapy or PARP inhibition with olaparib.

The relevant evidence for these two recommendations is of low quality, but shows that the benefits outweigh the harms; the strength of both recommendations is “moderate.”

A qualifying statement for the latter notes that “the decision to continue treatment with chemotherapy or proceed to maintenance therapy with olaparib should be based on a discussion between the patient and the oncologist, including consideration of whether a maximum response and plateau in response to chemotherapy have been achieved, the level of cumulative toxicities associated with chemotherapy treatment, patient preference, convenience, toxicity, goals of care, cost, and clinical evidence, including a lack of overall survival benefit demonstrated in the POLO randomized controlled trial.”

This focused update includes minor modifications to three existing recommendations:

• In addition to capecitabine or erlotinib, nab-paclitaxel is now included in Recommendation 2.3 as another possible add-on to gemcitabine alone for patients with either an Eastern Cooperative Oncology Group (ECOG) performance score of 2 or a comorbidity profile that precludes more aggressive regimens. The recommendation was also updated to encourage proactive dose and schedule adjustments to minimize toxicities.
• Recommendation 3.5 now includes patients treated previously with a gemcitabine-based regimen in the criteria for the preferred second-line treatment combination of fluorouracil plus nanoliposomal irinotecan or fluorouracil plus irinotecan “where the former is unavailable.”
• Recommendation 3.7 now includes nab-paclitaxel as an add-on option to gemcitabine, and nanoliposomal irinotecan as an add-on option to fluorouracil for second-line therapy – with proactive dose and schedule adjustments to minimize toxicities – in patients with ECOG performance score of 2 or a comorbidity profile that precludes more aggressive regimens.

These three minor modifications reflect new evidence in the first-line treatment setting, including from the FRAGRANCE trial, and are based on expert panel consensus. All other recommendations in the 2018 update are endorsed for the current update, which is available at the ASCO website.

Dr. Sohal reported honoraria from Foundation Medicine, and consulting or advisory roles with Perthera, Ability Pharma, and PierianDx. He reported research funding to his institution from Novartis, Celgene, OncoMed, Bayer, Genentech, Bristol Myers Squibb, Agios, Incyte, Loxo, and Rafael Pharmaceuticals.

sworcester@mdedge.com

SOURCE: Sohal D et al. J Clin Oncol. 2020 Aug 5. doi: 10.1200/JCO.20.01364.

Early testing for actionable genomic alterations is now recommended for metastatic pancreatic cancer patients who progress on therapy or experience intolerable toxicity and who are potential candidates for additional treatment after first-line therapy, according to an American Society of Clinical Oncology guideline update.

Both germline and somatic testing, including for microsatellite instability/mismatch repair deficiency, BRCA mutations with known significance, and NTRK gene fusions, are recommended in this population, reported Davendra P.S. Sohal, MD, MPH, of the University of Cincinnati, and colleagues on ASCO’s expert panel. The update was published online Aug. 5 in the Journal of Clinical Oncology.

The ASCO guideline on clinical decision making for patients with metastatic pancreatic cancer was first published in 2016 to address initial assessment and first- and second-line treatment options, supportive care, and follow-up and was updated in 2018. The current update is based on new evidence of benefit with targeted therapy options after first-line therapy or as maintenance therapy.

The phase 3 POLO trial, for example, showed significantly improved progression-free survival with the poly (ADP-ribose) polymerase (PARP) inhibitor olaparib for maintenance therapy after first-line treatment in patients with a germline BRCA1 or BRCA2 mutation and metastatic pancreatic cancer that had not progressed during first-line platinum-based chemotherapy. An integrated analysis of three studies showed that entrectinib, a potent inhibitor of tropomyosin receptor kinase (TRK) A, B, and C, safely induced durable and clinically meaningful responses in patients with NTRK fusion-positive solid tumors, and a phase 1-2 study showed that the highly selective TRK inhibitor larotrectinib had marked and durable antitumor activity in both children and adults with TRK fusion-positive solid tumors.

With respect to the new recommendation endorsing early testing for actionable genomic alterations (Recommendation 1.5), the authors noted that the results of testing can lead to treatment with PARP inhibitors, programmed death-1 (PD-1) checkpoint inhibitor therapy, TRK fusion inhibitors, and clinical trials of targeted therapies.

“Genomic testing is recommended as part of an initial assessment to ensure that the results of testing are available at the time of treatment decision where applicable after first-line therapy,” the new recommendation states.

A “qualifying statement” further notes that the decision to test should “involve a discussion between the patient and physician regarding the frequency of actionable findings, treatment implications of testing results, and genetic counseling related to germline testing.”

Recommendation 1.5 is rated by the panel as “strong” and is based on informal consensus.

The panel also added two recommendations on treatment options after first-line therapy:

• Recommendation 3.1 calls for treatment with larotrectinib or entrectinib in patient with tumors harboring NTRK fusions.
• Recommendation 3.3 states that patients with a germline BRCA1 or BCA2 mutation who have received first-line platinum-based chemotherapy without disease progression for at least 16 weeks can receive chemotherapy or PARP inhibition with olaparib.

The relevant evidence for these two recommendations is of low quality, but shows that the benefits outweigh the harms; the strength of both recommendations is “moderate.”

A qualifying statement for the latter notes that “the decision to continue treatment with chemotherapy or proceed to maintenance therapy with olaparib should be based on a discussion between the patient and the oncologist, including consideration of whether a maximum response and plateau in response to chemotherapy have been achieved, the level of cumulative toxicities associated with chemotherapy treatment, patient preference, convenience, toxicity, goals of care, cost, and clinical evidence, including a lack of overall survival benefit demonstrated in the POLO randomized controlled trial.”

This focused update includes minor modifications to three existing recommendations:

• In addition to capecitabine or erlotinib, nab-paclitaxel is now included in Recommendation 2.3 as another possible add-on to gemcitabine alone for patients with either an Eastern Cooperative Oncology Group (ECOG) performance score of 2 or a comorbidity profile that precludes more aggressive regimens. The recommendation was also updated to encourage proactive dose and schedule adjustments to minimize toxicities.
• Recommendation 3.5 now includes patients treated previously with a gemcitabine-based regimen in the criteria for the preferred second-line treatment combination of fluorouracil plus nanoliposomal irinotecan or fluorouracil plus irinotecan “where the former is unavailable.”
• Recommendation 3.7 now includes nab-paclitaxel as an add-on option to gemcitabine, and nanoliposomal irinotecan as an add-on option to fluorouracil for second-line therapy – with proactive dose and schedule adjustments to minimize toxicities – in patients with ECOG performance score of 2 or a comorbidity profile that precludes more aggressive regimens.

These three minor modifications reflect new evidence in the first-line treatment setting, including from the FRAGRANCE trial, and are based on expert panel consensus. All other recommendations in the 2018 update are endorsed for the current update, which is available at the ASCO website.

Dr. Sohal reported honoraria from Foundation Medicine, and consulting or advisory roles with Perthera, Ability Pharma, and PierianDx. He reported research funding to his institution from Novartis, Celgene, OncoMed, Bayer, Genentech, Bristol Myers Squibb, Agios, Incyte, Loxo, and Rafael Pharmaceuticals.

sworcester@mdedge.com

SOURCE: Sohal D et al. J Clin Oncol. 2020 Aug 5. doi: 10.1200/JCO.20.01364.

Early testing for actionable genomic alterations is now recommended for metastatic pancreatic cancer patients who progress on therapy or experience intolerable toxicity and who are potential candidates for additional treatment after first-line therapy, according to an American Society of Clinical Oncology guideline update.

Both germline and somatic testing, including for microsatellite instability/mismatch repair deficiency, BRCA mutations with known significance, and NTRK gene fusions, are recommended in this population, reported Davendra P.S. Sohal, MD, MPH, of the University of Cincinnati, and colleagues on ASCO’s expert panel. The update was published online Aug. 5 in the Journal of Clinical Oncology.

The ASCO guideline on clinical decision making for patients with metastatic pancreatic cancer was first published in 2016 to address initial assessment and first- and second-line treatment options, supportive care, and follow-up and was updated in 2018. The current update is based on new evidence of benefit with targeted therapy options after first-line therapy or as maintenance therapy.

The phase 3 POLO trial, for example, showed significantly improved progression-free survival with the poly (ADP-ribose) polymerase (PARP) inhibitor olaparib for maintenance therapy after first-line treatment in patients with a germline BRCA1 or BRCA2 mutation and metastatic pancreatic cancer that had not progressed during first-line platinum-based chemotherapy. An integrated analysis of three studies showed that entrectinib, a potent inhibitor of tropomyosin receptor kinase (TRK) A, B, and C, safely induced durable and clinically meaningful responses in patients with NTRK fusion-positive solid tumors, and a phase 1-2 study showed that the highly selective TRK inhibitor larotrectinib had marked and durable antitumor activity in both children and adults with TRK fusion-positive solid tumors.

With respect to the new recommendation endorsing early testing for actionable genomic alterations (Recommendation 1.5), the authors noted that the results of testing can lead to treatment with PARP inhibitors, programmed death-1 (PD-1) checkpoint inhibitor therapy, TRK fusion inhibitors, and clinical trials of targeted therapies.

“Genomic testing is recommended as part of an initial assessment to ensure that the results of testing are available at the time of treatment decision where applicable after first-line therapy,” the new recommendation states.

A “qualifying statement” further notes that the decision to test should “involve a discussion between the patient and physician regarding the frequency of actionable findings, treatment implications of testing results, and genetic counseling related to germline testing.”

Recommendation 1.5 is rated by the panel as “strong” and is based on informal consensus.

The panel also added two recommendations on treatment options after first-line therapy:

• Recommendation 3.1 calls for treatment with larotrectinib or entrectinib in patient with tumors harboring NTRK fusions.
• Recommendation 3.3 states that patients with a germline BRCA1 or BCA2 mutation who have received first-line platinum-based chemotherapy without disease progression for at least 16 weeks can receive chemotherapy or PARP inhibition with olaparib.

The relevant evidence for these two recommendations is of low quality, but shows that the benefits outweigh the harms; the strength of both recommendations is “moderate.”

A qualifying statement for the latter notes that “the decision to continue treatment with chemotherapy or proceed to maintenance therapy with olaparib should be based on a discussion between the patient and the oncologist, including consideration of whether a maximum response and plateau in response to chemotherapy have been achieved, the level of cumulative toxicities associated with chemotherapy treatment, patient preference, convenience, toxicity, goals of care, cost, and clinical evidence, including a lack of overall survival benefit demonstrated in the POLO randomized controlled trial.”

This focused update includes minor modifications to three existing recommendations:

• In addition to capecitabine or erlotinib, nab-paclitaxel is now included in Recommendation 2.3 as another possible add-on to gemcitabine alone for patients with either an Eastern Cooperative Oncology Group (ECOG) performance score of 2 or a comorbidity profile that precludes more aggressive regimens. The recommendation was also updated to encourage proactive dose and schedule adjustments to minimize toxicities.
• Recommendation 3.5 now includes patients treated previously with a gemcitabine-based regimen in the criteria for the preferred second-line treatment combination of fluorouracil plus nanoliposomal irinotecan or fluorouracil plus irinotecan “where the former is unavailable.”
• Recommendation 3.7 now includes nab-paclitaxel as an add-on option to gemcitabine, and nanoliposomal irinotecan as an add-on option to fluorouracil for second-line therapy – with proactive dose and schedule adjustments to minimize toxicities – in patients with ECOG performance score of 2 or a comorbidity profile that precludes more aggressive regimens.

These three minor modifications reflect new evidence in the first-line treatment setting, including from the FRAGRANCE trial, and are based on expert panel consensus. All other recommendations in the 2018 update are endorsed for the current update, which is available at the ASCO website.

Dr. Sohal reported honoraria from Foundation Medicine, and consulting or advisory roles with Perthera, Ability Pharma, and PierianDx. He reported research funding to his institution from Novartis, Celgene, OncoMed, Bayer, Genentech, Bristol Myers Squibb, Agios, Incyte, Loxo, and Rafael Pharmaceuticals.

sworcester@mdedge.com

SOURCE: Sohal D et al. J Clin Oncol. 2020 Aug 5. doi: 10.1200/JCO.20.01364.

Second lung cancers occurring up to a decade after the first are on the rise, but their prognosis is similar – especially when detected early – which supports long-term surveillance in survivors, finds a large population-based study.

Although guidelines recommend continued annual low-dose CT scan surveillance extending beyond 4 years for this population based on expert consensus, long-term evidence of benefit is lacking.

Investigators led by John M. Varlotto, MD, a radiation oncologist at the University of Massachusetts Medical Center, Worcester, analyzed Surveillance, Epidemiology & End Results (SEER) data for more than 58,000 patients with first and sometimes second non–small cell lung cancers initially treated by surgical resection.

Study results reported in Lung Cancer showed that the age-adjusted incidence of second lung cancers occurring 4-10 years after the first lung cancer rose sharply during the 1985-2014 study period, driven by a large uptick in women patients.

Among all patients, second lung cancers had similar overall survival as first lung cancers, but poorer lung cancer–specific survival. However, among the subset of patients having early-stage resectable disease (tumors measuring less than 4 cm with negative nodes), both outcomes were statistically indistinguishable.

“Because our investigation noted that the overall survival of patients undergoing a second lung cancer operation was similar to those patients undergoing a first operation, and because there is a rising rate of second lung cancer in lung cancer survivors, we feel that continued surveillance beyond the 4-year interval as recommended by the American Association for Thoracic Surgery as well as the [National Comprehensive Cancer Network] guidelines would be beneficial to long-term survivors of early-stage lung cancer,” Dr. Varlotto and coinvestigators wrote.

“The recent results from recent lung cancer screening studies demonstrate that females may benefit preferentially from screening … and our study suggests that these preferential benefits of increased CT scan surveillance may extend to females who are long-term survivors of lung cancer as well,” they added.
 

Findings in context

“As this is an observational study, it is challenging to understand what is driving the rise in prevalence of second lung cancers,” Mara Antonoff, MD, of The University of Texas MD Anderson Cancer Center in Houston commented in an interview.

“Overall, the findings are very important, as they suggest that we should continue to perform surveillance imaging for patients beyond recommended guidelines, which may allow us to achieve better survival outcomes for those individuals who develop a second lung cancer years after the first lung cancer,” she agreed.

“Just as lung cancer screening is important to identifying lung cancers at an earlier stage when they are more easily treatable and more likely to be cured, surveillance after an initial treatment for lung cancer would allow a diagnosis of second lung cancers at an earlier stage, so the patients can again achieve durable cure,” Dr. Antonoff concluded.

Study details

For the study, Dr. Varlotto and coinvestigators used data from SEER-13 and SEER-18 to identify patients with a lung cancer diagnosis during 1998-2013, and data from SEER-9, covering the years 1985-2014, to calculate rates of second cancers occurring 4-10 years after a first lung cancer.

Analyses were based on 58,758 patients with a surgically resected first primary lung cancer (55.9% with early-stage disease) and 384 patients with a surgically resected second primary lung cancer (77.6% with early-stage disease). Median follow-up was 76 months for the former and 46 months for the latter.

Results showed that in the 4-10 years after a first lung cancer diagnosis, the age-adjusted incidence of second lung cancers rose by study year but remained less than that of all other second cancers combined until the mid-2000s. Among women, incidence started rising sharply in 2001 and significantly exceeded that of all other second cancers starting in 2005.

In the entire population of study patients, propensity-adjusted analyses showed that second lung cancers were similar to first lung cancers on overall survival (P = .1726) but had worse lung cancer–specific survival (P = .0143). However, in the subset of patients with early-stage resectable disease, second and first lung cancers were similar on both overall survival (P = .3872) and lung cancer–specific survival (P = .1276).

Dr. Varlotto disclosed that he had no conflicts of interest. The study was funded by the Department of Radiation Oncology, University of Massachusetts. Dr. Antonoff disclosed that she had no relevant conflicts of interest.

SOURCE: Varlotto JM et al. Lung Cancer. 2020;147:115-122.

Second lung cancers occurring up to a decade after the first are on the rise, but their prognosis is similar – especially when detected early – which supports long-term surveillance in survivors, finds a large population-based study.

Although guidelines recommend continued annual low-dose CT scan surveillance extending beyond 4 years for this population based on expert consensus, long-term evidence of benefit is lacking.

Investigators led by John M. Varlotto, MD, a radiation oncologist at the University of Massachusetts Medical Center, Worcester, analyzed Surveillance, Epidemiology & End Results (SEER) data for more than 58,000 patients with first and sometimes second non–small cell lung cancers initially treated by surgical resection.

Study results reported in Lung Cancer showed that the age-adjusted incidence of second lung cancers occurring 4-10 years after the first lung cancer rose sharply during the 1985-2014 study period, driven by a large uptick in women patients.

Among all patients, second lung cancers had similar overall survival as first lung cancers, but poorer lung cancer–specific survival. However, among the subset of patients having early-stage resectable disease (tumors measuring less than 4 cm with negative nodes), both outcomes were statistically indistinguishable.

“Because our investigation noted that the overall survival of patients undergoing a second lung cancer operation was similar to those patients undergoing a first operation, and because there is a rising rate of second lung cancer in lung cancer survivors, we feel that continued surveillance beyond the 4-year interval as recommended by the American Association for Thoracic Surgery as well as the [National Comprehensive Cancer Network] guidelines would be beneficial to long-term survivors of early-stage lung cancer,” Dr. Varlotto and coinvestigators wrote.

“The recent results from recent lung cancer screening studies demonstrate that females may benefit preferentially from screening … and our study suggests that these preferential benefits of increased CT scan surveillance may extend to females who are long-term survivors of lung cancer as well,” they added.
 

Findings in context

“As this is an observational study, it is challenging to understand what is driving the rise in prevalence of second lung cancers,” Mara Antonoff, MD, of The University of Texas MD Anderson Cancer Center in Houston commented in an interview.

“Overall, the findings are very important, as they suggest that we should continue to perform surveillance imaging for patients beyond recommended guidelines, which may allow us to achieve better survival outcomes for those individuals who develop a second lung cancer years after the first lung cancer,” she agreed.

“Just as lung cancer screening is important to identifying lung cancers at an earlier stage when they are more easily treatable and more likely to be cured, surveillance after an initial treatment for lung cancer would allow a diagnosis of second lung cancers at an earlier stage, so the patients can again achieve durable cure,” Dr. Antonoff concluded.

Study details

For the study, Dr. Varlotto and coinvestigators used data from SEER-13 and SEER-18 to identify patients with a lung cancer diagnosis during 1998-2013, and data from SEER-9, covering the years 1985-2014, to calculate rates of second cancers occurring 4-10 years after a first lung cancer.

Analyses were based on 58,758 patients with a surgically resected first primary lung cancer (55.9% with early-stage disease) and 384 patients with a surgically resected second primary lung cancer (77.6% with early-stage disease). Median follow-up was 76 months for the former and 46 months for the latter.

Results showed that in the 4-10 years after a first lung cancer diagnosis, the age-adjusted incidence of second lung cancers rose by study year but remained less than that of all other second cancers combined until the mid-2000s. Among women, incidence started rising sharply in 2001 and significantly exceeded that of all other second cancers starting in 2005.

In the entire population of study patients, propensity-adjusted analyses showed that second lung cancers were similar to first lung cancers on overall survival (P = .1726) but had worse lung cancer–specific survival (P = .0143). However, in the subset of patients with early-stage resectable disease, second and first lung cancers were similar on both overall survival (P = .3872) and lung cancer–specific survival (P = .1276).

Dr. Varlotto disclosed that he had no conflicts of interest. The study was funded by the Department of Radiation Oncology, University of Massachusetts. Dr. Antonoff disclosed that she had no relevant conflicts of interest.

SOURCE: Varlotto JM et al. Lung Cancer. 2020;147:115-122.

Second lung cancers occurring up to a decade after the first are on the rise, but their prognosis is similar – especially when detected early – which supports long-term surveillance in survivors, finds a large population-based study.

Although guidelines recommend continued annual low-dose CT scan surveillance extending beyond 4 years for this population based on expert consensus, long-term evidence of benefit is lacking.

Investigators led by John M. Varlotto, MD, a radiation oncologist at the University of Massachusetts Medical Center, Worcester, analyzed Surveillance, Epidemiology & End Results (SEER) data for more than 58,000 patients with first and sometimes second non–small cell lung cancers initially treated by surgical resection.

Study results reported in Lung Cancer showed that the age-adjusted incidence of second lung cancers occurring 4-10 years after the first lung cancer rose sharply during the 1985-2014 study period, driven by a large uptick in women patients.

Among all patients, second lung cancers had similar overall survival as first lung cancers, but poorer lung cancer–specific survival. However, among the subset of patients having early-stage resectable disease (tumors measuring less than 4 cm with negative nodes), both outcomes were statistically indistinguishable.

“Because our investigation noted that the overall survival of patients undergoing a second lung cancer operation was similar to those patients undergoing a first operation, and because there is a rising rate of second lung cancer in lung cancer survivors, we feel that continued surveillance beyond the 4-year interval as recommended by the American Association for Thoracic Surgery as well as the [National Comprehensive Cancer Network] guidelines would be beneficial to long-term survivors of early-stage lung cancer,” Dr. Varlotto and coinvestigators wrote.

“The recent results from recent lung cancer screening studies demonstrate that females may benefit preferentially from screening … and our study suggests that these preferential benefits of increased CT scan surveillance may extend to females who are long-term survivors of lung cancer as well,” they added.
 

Findings in context

“As this is an observational study, it is challenging to understand what is driving the rise in prevalence of second lung cancers,” Mara Antonoff, MD, of The University of Texas MD Anderson Cancer Center in Houston commented in an interview.

“Overall, the findings are very important, as they suggest that we should continue to perform surveillance imaging for patients beyond recommended guidelines, which may allow us to achieve better survival outcomes for those individuals who develop a second lung cancer years after the first lung cancer,” she agreed.

“Just as lung cancer screening is important to identifying lung cancers at an earlier stage when they are more easily treatable and more likely to be cured, surveillance after an initial treatment for lung cancer would allow a diagnosis of second lung cancers at an earlier stage, so the patients can again achieve durable cure,” Dr. Antonoff concluded.

Study details

For the study, Dr. Varlotto and coinvestigators used data from SEER-13 and SEER-18 to identify patients with a lung cancer diagnosis during 1998-2013, and data from SEER-9, covering the years 1985-2014, to calculate rates of second cancers occurring 4-10 years after a first lung cancer.

Analyses were based on 58,758 patients with a surgically resected first primary lung cancer (55.9% with early-stage disease) and 384 patients with a surgically resected second primary lung cancer (77.6% with early-stage disease). Median follow-up was 76 months for the former and 46 months for the latter.

Results showed that in the 4-10 years after a first lung cancer diagnosis, the age-adjusted incidence of second lung cancers rose by study year but remained less than that of all other second cancers combined until the mid-2000s. Among women, incidence started rising sharply in 2001 and significantly exceeded that of all other second cancers starting in 2005.

In the entire population of study patients, propensity-adjusted analyses showed that second lung cancers were similar to first lung cancers on overall survival (P = .1726) but had worse lung cancer–specific survival (P = .0143). However, in the subset of patients with early-stage resectable disease, second and first lung cancers were similar on both overall survival (P = .3872) and lung cancer–specific survival (P = .1276).

Dr. Varlotto disclosed that he had no conflicts of interest. The study was funded by the Department of Radiation Oncology, University of Massachusetts. Dr. Antonoff disclosed that she had no relevant conflicts of interest.

SOURCE: Varlotto JM et al. Lung Cancer. 2020;147:115-122.

Have you ever wished you could prescribe dog training classes to any of the parents of your pediatric patients? As one of the myriad people adopting a dog during COVID-19 quarantine, I have had the amusing and poignant chance to relive the principles basic to effective parenting of young children that I have been coaching about for decades.

Courtesy Dr. Barbara J. Howard

Managing a dog instead of a child strips away layers that obfuscate parenting (e.g. child from unwanted pregnancy, fears about health issues, hopes for Harvard, wishes for the other gender, projection of expectations based on relatives, etc.) thereby making the lessons crystal clear. Unlike our perceptions for children, dog behavior does not mean anything (dog aficionados who differ, please allow poetic license). When a dog is hyper it indicates time to play or eat, not intentional defiance. Understanding this, we tend to respond more rationally.

With a dog of any age post weaning, one starts with the same basic learning abilities that will ever be present. An infant soaks up one’s caregiving for months before much training can begin, lulling parents into a mindset of having perfect skills that later requires a wrenching transition and new techniques when toddlerhood strikes.

Without expressive language feedback from a dog, we are forced to observe closely, and consciously use behavior modification techniques to get the desired behavior, but we have the advantage of seeing the effects of our management in days, not years later as for children!
 

Get her attention

It becomes obvious that to teach something, we need to get a dog’s attention first. A smell, appearance of a rabbit during a walk, a raindrop on the dog’s head all need to pass before a verbal command has a chance. Somehow the fact that children from toddler age on understand language (most of the time) makes parents forget that something else may be more interesting at the moment. We understand we need to teach a dog in a nondistracting environment without judging them for this requirement. In fact, trying to see what is engaging a dog or a toddler can enhance our appreciation of the world. But we stay curious about a dog’s distraction – not expecting to sense all a dog can – yet we may label a child’s repeated distraction as a flaw. Not being dogs ourselves allows us to give them the gift of being nonjudgmental.

Humans are inclined to talk to their young from birth, and, in general, the more talk the better for the child’s long-term development. Dogs can readily learn some human language but dog trainers all instruct us, when trying to teach a command, to give a single word instruction once, the same way each time, maintaining the animal’s attention, then waiting for at least a partially correct response (shaping) before rewarding. Inherent in this method is consistency and avoiding messages that are confusing because of extraneous words or emotions. While providing complex language that includes emotions is important for children overall, parents often do not differentiate times when they are actually giving an instruction from general banter, yet are upset when the child fails to follow through.
 

Be positive

Rather than relying on words to teach, using routines is the secret to desirable behavior in dogs. Dogs quickly develop habits (such as pooping on a certain rug) that can take many repetitions of humans supplying an alternative acceptable routine (pooping only in part of the yard) to change. Supplying an approximate alternative (rag toy instead of shoelaces), particularly if it is more exciting by being relatively novel and unavailable at other times, is far more effective than saying “No.” In fact, yelling at or hitting a dog is rarely effective because of short memory and lack of causal thinking and, in addition, can result in anxiety, shying away from interacting, or aggression; all consequences of harsh punishment in children as well.

Reinforcement works

Whatever your beliefs about dogs loving their humans, dogs understand only a small human vocabulary and are instead reinforced mainly by our attention to them that has become strongly associated with getting food or treats through instrumental conditioning. Because dogs have short memories, the most effective tools in changing their behavior are immediate attention, praise, and treats; this is also is true for children. The opposite of attention – ignoring – is very powerful in extinguishing an undesired behavior. We are told to wait at least 2 minutes after an undesired dog behavior before re-engaging. Why does this not seem to work in child rearing? Actually, it works well but is very hard for parents to do as our hearts go out to the begging child, who is part of our soul and closest kin. Soft-hearted dog owners have the same problem and often create obnoxious barking, begging, and nipping dogs as a result. These are all behaviors that could otherwise be extinguished.

Consistency is key

Behavior management works best and fastest if all the humans agree on the rules and follow them. This kind of consistency can be difficult for people training dogs as well as raising children, for many reasons. Most often there is a failure to take the time to explicitly decide on the rules; in other cases, it is lower thresholds for being annoyed and an inability to ignore a behavior. There may have been past experiences with being harshly punished, ignored, or coddled that people are are trying to overcome or reproduce; covert disagreements or desires to undermine a plan whether for the dog, the child, or the relationship; or even a desire for the dog or child to favor them by giving more treats. Sound familiar in pediatrics? With animals, objectivity and agreement may be easier to achieve because unwanted animal behavior is immediately more obviously related to training consistency than for children and may include big disincentives for humans such as barking, biting, or defecating. When these overt or covert disagreements occur in parenting children, our pediatric counseling or even family therapy may be needed. A similar acceleration plan may be available for people and their dogs (but not covered by insurance)!

While a dog may run down the stairs after a ball or a treat day after day, having forgotten that he will inevitably end up being locked in the basement for the night, we are taking advantage of the fact that dogs generally do not anticipate consequences. Yet, parents often scold even young children for a similar level of comprehension: “Didn’t you know that would break?” Fortunately, talking about consequences is educational over time for children but it needs to be done kindly with the understanding that, as with dogs, doing the same undesirable thing repeatedly is not necessarily defiance in young children but failure of our teaching. If behavior is not what you hoped for, look at what you are doing to promote it.

Much of what we call temperament is genetic in children as well as dogs. People know what to expect adopting a Jack Russell Terrier vs. a Labrador Retriever. With children we just don’t get to pick. Acceptance of what we got will make the journey easier.

We have much to cherish about dogs and children. If we lose it over the location of their poop, their forgiveness is quick. There is no such thing as too much affection. And joy is always available from both.

So why do I wish I could recommend dog training? Besides all the principles above, raising a dog together allows adults to discover mismatches in behavior management philosophies and to have a chance to see if they can negotiate a plan acceptable to both. Maybe it should be a premarital recommendation.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

Have you ever wished you could prescribe dog training classes to any of the parents of your pediatric patients? As one of the myriad people adopting a dog during COVID-19 quarantine, I have had the amusing and poignant chance to relive the principles basic to effective parenting of young children that I have been coaching about for decades.

Courtesy Dr. Barbara J. Howard

Managing a dog instead of a child strips away layers that obfuscate parenting (e.g. child from unwanted pregnancy, fears about health issues, hopes for Harvard, wishes for the other gender, projection of expectations based on relatives, etc.) thereby making the lessons crystal clear. Unlike our perceptions for children, dog behavior does not mean anything (dog aficionados who differ, please allow poetic license). When a dog is hyper it indicates time to play or eat, not intentional defiance. Understanding this, we tend to respond more rationally.

With a dog of any age post weaning, one starts with the same basic learning abilities that will ever be present. An infant soaks up one’s caregiving for months before much training can begin, lulling parents into a mindset of having perfect skills that later requires a wrenching transition and new techniques when toddlerhood strikes.

Without expressive language feedback from a dog, we are forced to observe closely, and consciously use behavior modification techniques to get the desired behavior, but we have the advantage of seeing the effects of our management in days, not years later as for children!
 

Get her attention

It becomes obvious that to teach something, we need to get a dog’s attention first. A smell, appearance of a rabbit during a walk, a raindrop on the dog’s head all need to pass before a verbal command has a chance. Somehow the fact that children from toddler age on understand language (most of the time) makes parents forget that something else may be more interesting at the moment. We understand we need to teach a dog in a nondistracting environment without judging them for this requirement. In fact, trying to see what is engaging a dog or a toddler can enhance our appreciation of the world. But we stay curious about a dog’s distraction – not expecting to sense all a dog can – yet we may label a child’s repeated distraction as a flaw. Not being dogs ourselves allows us to give them the gift of being nonjudgmental.

Humans are inclined to talk to their young from birth, and, in general, the more talk the better for the child’s long-term development. Dogs can readily learn some human language but dog trainers all instruct us, when trying to teach a command, to give a single word instruction once, the same way each time, maintaining the animal’s attention, then waiting for at least a partially correct response (shaping) before rewarding. Inherent in this method is consistency and avoiding messages that are confusing because of extraneous words or emotions. While providing complex language that includes emotions is important for children overall, parents often do not differentiate times when they are actually giving an instruction from general banter, yet are upset when the child fails to follow through.
 

Be positive

Rather than relying on words to teach, using routines is the secret to desirable behavior in dogs. Dogs quickly develop habits (such as pooping on a certain rug) that can take many repetitions of humans supplying an alternative acceptable routine (pooping only in part of the yard) to change. Supplying an approximate alternative (rag toy instead of shoelaces), particularly if it is more exciting by being relatively novel and unavailable at other times, is far more effective than saying “No.” In fact, yelling at or hitting a dog is rarely effective because of short memory and lack of causal thinking and, in addition, can result in anxiety, shying away from interacting, or aggression; all consequences of harsh punishment in children as well.

Reinforcement works

Whatever your beliefs about dogs loving their humans, dogs understand only a small human vocabulary and are instead reinforced mainly by our attention to them that has become strongly associated with getting food or treats through instrumental conditioning. Because dogs have short memories, the most effective tools in changing their behavior are immediate attention, praise, and treats; this is also is true for children. The opposite of attention – ignoring – is very powerful in extinguishing an undesired behavior. We are told to wait at least 2 minutes after an undesired dog behavior before re-engaging. Why does this not seem to work in child rearing? Actually, it works well but is very hard for parents to do as our hearts go out to the begging child, who is part of our soul and closest kin. Soft-hearted dog owners have the same problem and often create obnoxious barking, begging, and nipping dogs as a result. These are all behaviors that could otherwise be extinguished.

Consistency is key

Behavior management works best and fastest if all the humans agree on the rules and follow them. This kind of consistency can be difficult for people training dogs as well as raising children, for many reasons. Most often there is a failure to take the time to explicitly decide on the rules; in other cases, it is lower thresholds for being annoyed and an inability to ignore a behavior. There may have been past experiences with being harshly punished, ignored, or coddled that people are are trying to overcome or reproduce; covert disagreements or desires to undermine a plan whether for the dog, the child, or the relationship; or even a desire for the dog or child to favor them by giving more treats. Sound familiar in pediatrics? With animals, objectivity and agreement may be easier to achieve because unwanted animal behavior is immediately more obviously related to training consistency than for children and may include big disincentives for humans such as barking, biting, or defecating. When these overt or covert disagreements occur in parenting children, our pediatric counseling or even family therapy may be needed. A similar acceleration plan may be available for people and their dogs (but not covered by insurance)!

While a dog may run down the stairs after a ball or a treat day after day, having forgotten that he will inevitably end up being locked in the basement for the night, we are taking advantage of the fact that dogs generally do not anticipate consequences. Yet, parents often scold even young children for a similar level of comprehension: “Didn’t you know that would break?” Fortunately, talking about consequences is educational over time for children but it needs to be done kindly with the understanding that, as with dogs, doing the same undesirable thing repeatedly is not necessarily defiance in young children but failure of our teaching. If behavior is not what you hoped for, look at what you are doing to promote it.

Much of what we call temperament is genetic in children as well as dogs. People know what to expect adopting a Jack Russell Terrier vs. a Labrador Retriever. With children we just don’t get to pick. Acceptance of what we got will make the journey easier.

We have much to cherish about dogs and children. If we lose it over the location of their poop, their forgiveness is quick. There is no such thing as too much affection. And joy is always available from both.

So why do I wish I could recommend dog training? Besides all the principles above, raising a dog together allows adults to discover mismatches in behavior management philosophies and to have a chance to see if they can negotiate a plan acceptable to both. Maybe it should be a premarital recommendation.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

Have you ever wished you could prescribe dog training classes to any of the parents of your pediatric patients? As one of the myriad people adopting a dog during COVID-19 quarantine, I have had the amusing and poignant chance to relive the principles basic to effective parenting of young children that I have been coaching about for decades.

Courtesy Dr. Barbara J. Howard

Managing a dog instead of a child strips away layers that obfuscate parenting (e.g. child from unwanted pregnancy, fears about health issues, hopes for Harvard, wishes for the other gender, projection of expectations based on relatives, etc.) thereby making the lessons crystal clear. Unlike our perceptions for children, dog behavior does not mean anything (dog aficionados who differ, please allow poetic license). When a dog is hyper it indicates time to play or eat, not intentional defiance. Understanding this, we tend to respond more rationally.

With a dog of any age post weaning, one starts with the same basic learning abilities that will ever be present. An infant soaks up one’s caregiving for months before much training can begin, lulling parents into a mindset of having perfect skills that later requires a wrenching transition and new techniques when toddlerhood strikes.

Without expressive language feedback from a dog, we are forced to observe closely, and consciously use behavior modification techniques to get the desired behavior, but we have the advantage of seeing the effects of our management in days, not years later as for children!
 

Get her attention

It becomes obvious that to teach something, we need to get a dog’s attention first. A smell, appearance of a rabbit during a walk, a raindrop on the dog’s head all need to pass before a verbal command has a chance. Somehow the fact that children from toddler age on understand language (most of the time) makes parents forget that something else may be more interesting at the moment. We understand we need to teach a dog in a nondistracting environment without judging them for this requirement. In fact, trying to see what is engaging a dog or a toddler can enhance our appreciation of the world. But we stay curious about a dog’s distraction – not expecting to sense all a dog can – yet we may label a child’s repeated distraction as a flaw. Not being dogs ourselves allows us to give them the gift of being nonjudgmental.

Humans are inclined to talk to their young from birth, and, in general, the more talk the better for the child’s long-term development. Dogs can readily learn some human language but dog trainers all instruct us, when trying to teach a command, to give a single word instruction once, the same way each time, maintaining the animal’s attention, then waiting for at least a partially correct response (shaping) before rewarding. Inherent in this method is consistency and avoiding messages that are confusing because of extraneous words or emotions. While providing complex language that includes emotions is important for children overall, parents often do not differentiate times when they are actually giving an instruction from general banter, yet are upset when the child fails to follow through.
 

Be positive

Rather than relying on words to teach, using routines is the secret to desirable behavior in dogs. Dogs quickly develop habits (such as pooping on a certain rug) that can take many repetitions of humans supplying an alternative acceptable routine (pooping only in part of the yard) to change. Supplying an approximate alternative (rag toy instead of shoelaces), particularly if it is more exciting by being relatively novel and unavailable at other times, is far more effective than saying “No.” In fact, yelling at or hitting a dog is rarely effective because of short memory and lack of causal thinking and, in addition, can result in anxiety, shying away from interacting, or aggression; all consequences of harsh punishment in children as well.

Reinforcement works

Whatever your beliefs about dogs loving their humans, dogs understand only a small human vocabulary and are instead reinforced mainly by our attention to them that has become strongly associated with getting food or treats through instrumental conditioning. Because dogs have short memories, the most effective tools in changing their behavior are immediate attention, praise, and treats; this is also is true for children. The opposite of attention – ignoring – is very powerful in extinguishing an undesired behavior. We are told to wait at least 2 minutes after an undesired dog behavior before re-engaging. Why does this not seem to work in child rearing? Actually, it works well but is very hard for parents to do as our hearts go out to the begging child, who is part of our soul and closest kin. Soft-hearted dog owners have the same problem and often create obnoxious barking, begging, and nipping dogs as a result. These are all behaviors that could otherwise be extinguished.

Consistency is key

Behavior management works best and fastest if all the humans agree on the rules and follow them. This kind of consistency can be difficult for people training dogs as well as raising children, for many reasons. Most often there is a failure to take the time to explicitly decide on the rules; in other cases, it is lower thresholds for being annoyed and an inability to ignore a behavior. There may have been past experiences with being harshly punished, ignored, or coddled that people are are trying to overcome or reproduce; covert disagreements or desires to undermine a plan whether for the dog, the child, or the relationship; or even a desire for the dog or child to favor them by giving more treats. Sound familiar in pediatrics? With animals, objectivity and agreement may be easier to achieve because unwanted animal behavior is immediately more obviously related to training consistency than for children and may include big disincentives for humans such as barking, biting, or defecating. When these overt or covert disagreements occur in parenting children, our pediatric counseling or even family therapy may be needed. A similar acceleration plan may be available for people and their dogs (but not covered by insurance)!

While a dog may run down the stairs after a ball or a treat day after day, having forgotten that he will inevitably end up being locked in the basement for the night, we are taking advantage of the fact that dogs generally do not anticipate consequences. Yet, parents often scold even young children for a similar level of comprehension: “Didn’t you know that would break?” Fortunately, talking about consequences is educational over time for children but it needs to be done kindly with the understanding that, as with dogs, doing the same undesirable thing repeatedly is not necessarily defiance in young children but failure of our teaching. If behavior is not what you hoped for, look at what you are doing to promote it.

Much of what we call temperament is genetic in children as well as dogs. People know what to expect adopting a Jack Russell Terrier vs. a Labrador Retriever. With children we just don’t get to pick. Acceptance of what we got will make the journey easier.

We have much to cherish about dogs and children. If we lose it over the location of their poop, their forgiveness is quick. There is no such thing as too much affection. And joy is always available from both.

So why do I wish I could recommend dog training? Besides all the principles above, raising a dog together allows adults to discover mismatches in behavior management philosophies and to have a chance to see if they can negotiate a plan acceptable to both. Maybe it should be a premarital recommendation.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

In women with extremely dense breasts, digital breast tomosynthesis (DBT) does not outperform digital mammography (DM) after the baseline exam, according to a review of nearly 1.6 million screenings.

At baseline, DBT improved recall and cancer detection rates for all women. On subsequent exams, differences in screening performance between DBT and DM varied by age and density subgroups. However, there were no significant differences in recall or cancer detection rates among women with extremely dense breasts in any age group.

Kathryn Lowry, MD, of the University of Washington in Seattle, and colleagues reported these findings in JAMA Network Open.

“Our findings suggest that density likely should not be used as a criterion to triage use of DBT for routine screening in settings where DBT is not universally available, as has been reported in physician surveys,” the authors wrote. “The largest absolute improvements of DBT screening were achieved on the baseline screening examination, suggesting that women presenting for their first screening examination are particularly important to prioritize for DBT,” regardless of breast density or age.
 

Study details

Dr. Lowry and colleagues reviewed 1,584,079 screenings in women aged 40-79 years. The exams were done from January 2010 to April 2018 at Breast Cancer Surveillance Consortium facilities across the United States.

Sixty-five percent of the exams were in White, non-Hispanic women, 25.2% were in women younger than 50 years, and 42.4% were in women with heterogeneously dense or extremely dense breasts. Subjects had no history of breast cancer, mastectomy, or breast augmentation.

The investigators compared the performance of 1,273,492 DMs with 310,587 DBTs across the four Breast Imaging Reporting and Database System density types: almost entirely fatty, scattered fibroglandular density, heterogeneously dense, and extremely dense.

Findings were adjusted for race, family breast cancer history, and other potential confounders.
 

Recall and cancer detection rates

At baseline, recall and cancer detection rates were better with DBT than with DM, regardless of breast density subtype or patient age.

For instance, in women aged 50-59 years, screening recalls per 1,000 exams dropped from 241 with DM to 204 with DBT (relative risk, 0.84; 95% confidence interval, 0.73-0.98). Cancer detection rates per 1,000 exams in this age group increased from 5.9 with DM to 8.8 with DBT (RR, 1.50; 95% CI, 1.10-2.08).

On follow-up exams, recall rates were lower with DBT for women with scattered fibroglandular density and heterogeneously dense breasts in all age groups, as well as in women with almost entirely fatty breasts aged 50-79 years.

“By contrast, there were no significant differences in recall rates in women with extremely dense breasts in any age group,” the authors wrote.

Cancer detection rates on follow-up exams varied by age and breast density.

Cancer detection rates were higher with DBT than with DM in women with heterogeneously dense breasts in all age groups and in women with scattered fibroglandular density at 50-59 years of age and 60-79 years of age. However, cancer detection rates were not significantly different with DBT or DM for women with almost entirely fatty breasts or extremely dense breasts of any age.
 

Implications and next steps

Dr. Lowry and colleagues noted that use of DBT has increased steadily since it was approved by the Food and Drug Administration in 2011, driven by studies demonstrating, among other things, earlier detection of invasive cancers.

The problem has been that previous investigations “largely dichotomized dense (heterogeneously dense and extremely dense) and nondense (almost entirely fat and scattered fibroglandular densities) categories,” the authors wrote. Therefore, the nuance of benefit across density subtypes hasn’t been clear.

The finding that “screening benefits of DBT differ for women with heterogeneously dense breasts [versus] extremely dense breasts is especially important in the current landscape of density legislation and demand for supplemental screening tests beyond mammography. To date, most state mandates and ... proposed federal legislation have uniformly grouped women with heterogeneously dense breasts and those with extremely dense breasts as a single population,” the authors wrote.

As the new findings suggest, “there are important differences in performance that may not be appreciated by combining density categories,” the authors added.

The results “suggest that women with extremely dense breast tissue may benefit more from additional screening than women with heterogeneously dense breasts who undergo tomosynthesis mammography,” Catherine Tuite, MD, of Fox Chase Cancer Center in Philadelphia, and colleagues wrote in a related editorial.

“Research to determine density and risk-specific outcomes for supplemental screening methods, such as magnetic resonance imaging ... molecular breast imaging, or ultrasonography is necessary to understand which screening method beyond DBT is best for average-risk women with heterogeneous or extremely dense breasts,” the editorialists wrote.

This research was funded by the National Cancer Institute and the Patient-Centered Outcomes Research Institute through the Breast Cancer Surveillance Consortium. Dr. Lowry reported grants from GE Healthcare outside the submitted work. The editorialists didn’t have any disclosures.

aotto@mdedge.com

SOURCE: Lowry K et al. JAMA Netw Open. 2020 Jul 1;3(7):e2011792.

In women with extremely dense breasts, digital breast tomosynthesis (DBT) does not outperform digital mammography (DM) after the baseline exam, according to a review of nearly 1.6 million screenings.

At baseline, DBT improved recall and cancer detection rates for all women. On subsequent exams, differences in screening performance between DBT and DM varied by age and density subgroups. However, there were no significant differences in recall or cancer detection rates among women with extremely dense breasts in any age group.

Kathryn Lowry, MD, of the University of Washington in Seattle, and colleagues reported these findings in JAMA Network Open.

“Our findings suggest that density likely should not be used as a criterion to triage use of DBT for routine screening in settings where DBT is not universally available, as has been reported in physician surveys,” the authors wrote. “The largest absolute improvements of DBT screening were achieved on the baseline screening examination, suggesting that women presenting for their first screening examination are particularly important to prioritize for DBT,” regardless of breast density or age.
 

Study details

Dr. Lowry and colleagues reviewed 1,584,079 screenings in women aged 40-79 years. The exams were done from January 2010 to April 2018 at Breast Cancer Surveillance Consortium facilities across the United States.

Sixty-five percent of the exams were in White, non-Hispanic women, 25.2% were in women younger than 50 years, and 42.4% were in women with heterogeneously dense or extremely dense breasts. Subjects had no history of breast cancer, mastectomy, or breast augmentation.

The investigators compared the performance of 1,273,492 DMs with 310,587 DBTs across the four Breast Imaging Reporting and Database System density types: almost entirely fatty, scattered fibroglandular density, heterogeneously dense, and extremely dense.

Findings were adjusted for race, family breast cancer history, and other potential confounders.
 

Recall and cancer detection rates

At baseline, recall and cancer detection rates were better with DBT than with DM, regardless of breast density subtype or patient age.

For instance, in women aged 50-59 years, screening recalls per 1,000 exams dropped from 241 with DM to 204 with DBT (relative risk, 0.84; 95% confidence interval, 0.73-0.98). Cancer detection rates per 1,000 exams in this age group increased from 5.9 with DM to 8.8 with DBT (RR, 1.50; 95% CI, 1.10-2.08).

On follow-up exams, recall rates were lower with DBT for women with scattered fibroglandular density and heterogeneously dense breasts in all age groups, as well as in women with almost entirely fatty breasts aged 50-79 years.

“By contrast, there were no significant differences in recall rates in women with extremely dense breasts in any age group,” the authors wrote.

Cancer detection rates on follow-up exams varied by age and breast density.

Cancer detection rates were higher with DBT than with DM in women with heterogeneously dense breasts in all age groups and in women with scattered fibroglandular density at 50-59 years of age and 60-79 years of age. However, cancer detection rates were not significantly different with DBT or DM for women with almost entirely fatty breasts or extremely dense breasts of any age.
 

Implications and next steps

Dr. Lowry and colleagues noted that use of DBT has increased steadily since it was approved by the Food and Drug Administration in 2011, driven by studies demonstrating, among other things, earlier detection of invasive cancers.

The problem has been that previous investigations “largely dichotomized dense (heterogeneously dense and extremely dense) and nondense (almost entirely fat and scattered fibroglandular densities) categories,” the authors wrote. Therefore, the nuance of benefit across density subtypes hasn’t been clear.

The finding that “screening benefits of DBT differ for women with heterogeneously dense breasts [versus] extremely dense breasts is especially important in the current landscape of density legislation and demand for supplemental screening tests beyond mammography. To date, most state mandates and ... proposed federal legislation have uniformly grouped women with heterogeneously dense breasts and those with extremely dense breasts as a single population,” the authors wrote.

As the new findings suggest, “there are important differences in performance that may not be appreciated by combining density categories,” the authors added.

The results “suggest that women with extremely dense breast tissue may benefit more from additional screening than women with heterogeneously dense breasts who undergo tomosynthesis mammography,” Catherine Tuite, MD, of Fox Chase Cancer Center in Philadelphia, and colleagues wrote in a related editorial.

“Research to determine density and risk-specific outcomes for supplemental screening methods, such as magnetic resonance imaging ... molecular breast imaging, or ultrasonography is necessary to understand which screening method beyond DBT is best for average-risk women with heterogeneous or extremely dense breasts,” the editorialists wrote.

This research was funded by the National Cancer Institute and the Patient-Centered Outcomes Research Institute through the Breast Cancer Surveillance Consortium. Dr. Lowry reported grants from GE Healthcare outside the submitted work. The editorialists didn’t have any disclosures.

aotto@mdedge.com

SOURCE: Lowry K et al. JAMA Netw Open. 2020 Jul 1;3(7):e2011792.

In women with extremely dense breasts, digital breast tomosynthesis (DBT) does not outperform digital mammography (DM) after the baseline exam, according to a review of nearly 1.6 million screenings.

At baseline, DBT improved recall and cancer detection rates for all women. On subsequent exams, differences in screening performance between DBT and DM varied by age and density subgroups. However, there were no significant differences in recall or cancer detection rates among women with extremely dense breasts in any age group.

Kathryn Lowry, MD, of the University of Washington in Seattle, and colleagues reported these findings in JAMA Network Open.

“Our findings suggest that density likely should not be used as a criterion to triage use of DBT for routine screening in settings where DBT is not universally available, as has been reported in physician surveys,” the authors wrote. “The largest absolute improvements of DBT screening were achieved on the baseline screening examination, suggesting that women presenting for their first screening examination are particularly important to prioritize for DBT,” regardless of breast density or age.
 

Study details

Dr. Lowry and colleagues reviewed 1,584,079 screenings in women aged 40-79 years. The exams were done from January 2010 to April 2018 at Breast Cancer Surveillance Consortium facilities across the United States.

Sixty-five percent of the exams were in White, non-Hispanic women, 25.2% were in women younger than 50 years, and 42.4% were in women with heterogeneously dense or extremely dense breasts. Subjects had no history of breast cancer, mastectomy, or breast augmentation.

The investigators compared the performance of 1,273,492 DMs with 310,587 DBTs across the four Breast Imaging Reporting and Database System density types: almost entirely fatty, scattered fibroglandular density, heterogeneously dense, and extremely dense.

Findings were adjusted for race, family breast cancer history, and other potential confounders.
 

Recall and cancer detection rates

At baseline, recall and cancer detection rates were better with DBT than with DM, regardless of breast density subtype or patient age.

For instance, in women aged 50-59 years, screening recalls per 1,000 exams dropped from 241 with DM to 204 with DBT (relative risk, 0.84; 95% confidence interval, 0.73-0.98). Cancer detection rates per 1,000 exams in this age group increased from 5.9 with DM to 8.8 with DBT (RR, 1.50; 95% CI, 1.10-2.08).

On follow-up exams, recall rates were lower with DBT for women with scattered fibroglandular density and heterogeneously dense breasts in all age groups, as well as in women with almost entirely fatty breasts aged 50-79 years.

“By contrast, there were no significant differences in recall rates in women with extremely dense breasts in any age group,” the authors wrote.

Cancer detection rates on follow-up exams varied by age and breast density.

Cancer detection rates were higher with DBT than with DM in women with heterogeneously dense breasts in all age groups and in women with scattered fibroglandular density at 50-59 years of age and 60-79 years of age. However, cancer detection rates were not significantly different with DBT or DM for women with almost entirely fatty breasts or extremely dense breasts of any age.
 

Implications and next steps

Dr. Lowry and colleagues noted that use of DBT has increased steadily since it was approved by the Food and Drug Administration in 2011, driven by studies demonstrating, among other things, earlier detection of invasive cancers.

The problem has been that previous investigations “largely dichotomized dense (heterogeneously dense and extremely dense) and nondense (almost entirely fat and scattered fibroglandular densities) categories,” the authors wrote. Therefore, the nuance of benefit across density subtypes hasn’t been clear.

The finding that “screening benefits of DBT differ for women with heterogeneously dense breasts [versus] extremely dense breasts is especially important in the current landscape of density legislation and demand for supplemental screening tests beyond mammography. To date, most state mandates and ... proposed federal legislation have uniformly grouped women with heterogeneously dense breasts and those with extremely dense breasts as a single population,” the authors wrote.

As the new findings suggest, “there are important differences in performance that may not be appreciated by combining density categories,” the authors added.

The results “suggest that women with extremely dense breast tissue may benefit more from additional screening than women with heterogeneously dense breasts who undergo tomosynthesis mammography,” Catherine Tuite, MD, of Fox Chase Cancer Center in Philadelphia, and colleagues wrote in a related editorial.

“Research to determine density and risk-specific outcomes for supplemental screening methods, such as magnetic resonance imaging ... molecular breast imaging, or ultrasonography is necessary to understand which screening method beyond DBT is best for average-risk women with heterogeneous or extremely dense breasts,” the editorialists wrote.

This research was funded by the National Cancer Institute and the Patient-Centered Outcomes Research Institute through the Breast Cancer Surveillance Consortium. Dr. Lowry reported grants from GE Healthcare outside the submitted work. The editorialists didn’t have any disclosures.

aotto@mdedge.com

SOURCE: Lowry K et al. JAMA Netw Open. 2020 Jul 1;3(7):e2011792.

Primary care screening in several key areas including maternal depression and developmental delay increased significantly after practices implemented a quality improvement (QI) program, according to data from 19 pediatric primary care practices in 12 states.

FatCamera/Getty Images

Screening for developmental delay, maternal depression, and autism spectrum disorder are recommended by the American Academy of Pediatrics; screening for social-emotional problems and social determinants of health also are recommended. However, “Practices face challenges in implementing recommended screenings simultaneously,” wrote Kori B. Flower, MD, MPH, of the University of North Carolina at Chapel Hill, and colleagues in Pediatrics.

To support practices in screening, the researchers developed a national QI collaborative. “Aims were to improve screening processes, including screening, discussion, referral, and follow-up,” the researchers wrote.

In the study published in Pediatrics, the researchers reviewed data from 19 pediatric practices in 12 states, including independent, academic, hospital-affiliated, and multispecialty group practices and community health centers for diversity in type, size, location, and patient population.

The improvement program included two full-day sessions of in-person learning, separated by a 9-month action period that included virtual learning through webinars and online resources, monthly data collection to assess progress, and coaching. “Coaches used reports to guide virtual learning content and provide individual feedback to practices,” the researchers said.

Overall, after a year, the largest screening increases from baseline occurred for maternal depression (from 27% to 87%) and social determinants of health (from 26% to 76%). Screening also increased significantly for developmental delays (from 60% to 93%), and autism spectrum disorder (from 74% to 95%).

Statistically significant increases in discussion of screening results occurred for all screening areas: developmental delays (from 63% to 97%), autism spectrum disorder (from 51% to 93%), maternal depression (from 46% to 90%), and social determinants of health (from 19% to 73%).

In addition, significant increases in referrals were seen for development (from 53% to 86%) and maternal depression (from 23% to 100%).
 

EHR packages deficiencies seen as barrier

“Standard EHR packages often lack features for documenting and tracking screenings, and this was a persistent barrier to screening improvement,” Dr. Flower and associates noted. However, the percentage of practices citing EHR challenges as a barrier to screening decreased from 41% at baseline to 24% after the intervention.

Parents also reported increased discussion of screening and referrals, but “[o]n overall rating of care, the percentage of parents rating care as above average or best did not change,” but parents were not asked reasons for their care rating, the researchers wrote.

The study findings were limited by several factors including limited data quality control and insufficient data to assess the effects of screening interventions on other preventive services or other office-based factors such as revenue, the researchers noted. However, the results suggest that shared learning can help primary care practices increase screening.

“Careful attention to integrating screenings in visit flow and emphasizing their potential impact on child health can make implementation possible in multiple screening areas,” Dr. Flower and colleagues concluded.

Making measurable, meaningful practice change

Barbara J. Howard, MD, commented: “It is clear that using validated tools to screen have benefits in accuracy, equity, efficiency, and income. Increasingly, practices are being judged and paid based on ‘value,’ which is especially difficult to measure in pediatrics with its low rates of serious chronic conditions to assess. We pediatricians will be judged on use of proven methods instead, and screening is a major criterion and also, fortunately, one that is within our power to change.

“However, as this study shows, a great deal of effort and teamwork is needed to shift office workflows to incorporate screening, discussions, referral, and follow-up – all necessary processes for screening to be of value. It is broadly recognized in all industries, not just health care, that use of QI processes is a major force in facilitating change in standard practices. The American Board of Pediatrics, as well as the American Academy of Pediatrics, recognizes this need and has been assisting as well as requiring use of QI methods.

“This study specifically selected a range of practices characteristic of U.S. providers to demonstrate that both screening for multiple child health risk factors simultaneously and use of methods of QI can be feasible and effective for measurable and meaningful practice change. This should give all pediatricians encouragement to move forward in implementing changes in screening,” Dr. Howard, of Johns Hopkins University, Baltimore, said in an interview.

This study not only showed the effectiveness of change management, but also detailed the effort it required, including:

• Use of monthly team meetings.
• Collecting data from patients and team members.
• Soliciting parent feedback.
• Implementing new templates for care.
• Use of tool translations or translator support.
• Involving colocated professionals, residents, and students.
• Assembling resources.
• Attempting to invoke change in EHR vendor.

“There were expert coaches involved of national prominence and extensive QI experience. Even with all this support and effort, it should be noted that 74% of practices had participated in QI efforts previously, which should have made this project easier, and even then it took 6-7 months before measurable change in practice could be documented. In spite of the fact that actually getting help for problems identified is the goal, referrals were only marginally improved, and the tracking of referrals was not significantly improved even with all this effort,” Dr. Howard noted.

“Of note, the practices reported at the end of the project that fewer practices reported lack of time or resources for screening and referral. As a result of this publication, a slimmed down set of practice report measures might be chosen to make future QI efforts work and be measurable in meaningful ways. Instead of paper chart reviews, data from electronic screening could be automatically collected in the course of care. Referral processes could likewise be made electronic and automated, including tracking their success, not just those through a local EHR. Integration of Software as a Service with EHRs could make this data collection – that is essential to both QI and actual good care – seamless. Templates and checklists, as well as more incidental knowledge gained from this and other QI projects in pediatric practices, should be shared. While each practice operates somewhat differently, the differences are not that great and, in some cases, traditional ways of doing things would be fruitfully discarded,” suggested Dr. Howard, who was not involved in the study.

“While the pediatricians participated in the QI sessions, it is clear that the QI processes depend on the entire practice team, and generally, the team members more critical to success are not the doctor but the front desk receptionist, medical assistants, and the practice managers – as these individuals conduct or oversee workflow activities. Future QI interventions might include reinforcement and acknowledgment of these team members through inclusion in parallel continuing education activities from the American Association of Medical Assistants and the Medical Group Management Association continuing education credits,” she said.

Dr. Howard continued, “Of note, these studies were completed prior to the pandemic-related workflow changes including telehealth visits and requirements to minimize waiting room time and activities for the safety of patients and staff. These disruptive forces and the likelihood that telehealth alternatives will persist in primary care suggest that the traditional paper waiting room questionnaires are likely to have to give way to electronic alternatives. Using all electronic [approaches] will be the best unified workflow.”

The study was supported by the JPB Foundation through support to the American Academy of Pediatrics. The researchers had no financial conflicts to disclose. Dr. Howard is a pediatric founder of CHADIS, an online screening, decision support, patient education, and referral/tracking system in use nationally and implemented using QI processes. CHADIS is distributed by Total Child Health, of which Dr. Howard is president. Use of CHADIS for Part 4 Maintenance of Certification QI programs is under the ABMS portfolio sponsorship of the nonprofit Center for Promotion of Child Development through Primary Care, directed by her husband, Raymond Sturner, MD.

SOURCE: Flower KB et al. Pediatrics. 2020 Aug 7. doi: 10.1542/peds.2019-2328.

Primary care screening in several key areas including maternal depression and developmental delay increased significantly after practices implemented a quality improvement (QI) program, according to data from 19 pediatric primary care practices in 12 states.

FatCamera/Getty Images

Screening for developmental delay, maternal depression, and autism spectrum disorder are recommended by the American Academy of Pediatrics; screening for social-emotional problems and social determinants of health also are recommended. However, “Practices face challenges in implementing recommended screenings simultaneously,” wrote Kori B. Flower, MD, MPH, of the University of North Carolina at Chapel Hill, and colleagues in Pediatrics.

To support practices in screening, the researchers developed a national QI collaborative. “Aims were to improve screening processes, including screening, discussion, referral, and follow-up,” the researchers wrote.

In the study published in Pediatrics, the researchers reviewed data from 19 pediatric practices in 12 states, including independent, academic, hospital-affiliated, and multispecialty group practices and community health centers for diversity in type, size, location, and patient population.

The improvement program included two full-day sessions of in-person learning, separated by a 9-month action period that included virtual learning through webinars and online resources, monthly data collection to assess progress, and coaching. “Coaches used reports to guide virtual learning content and provide individual feedback to practices,” the researchers said.

Overall, after a year, the largest screening increases from baseline occurred for maternal depression (from 27% to 87%) and social determinants of health (from 26% to 76%). Screening also increased significantly for developmental delays (from 60% to 93%), and autism spectrum disorder (from 74% to 95%).

Statistically significant increases in discussion of screening results occurred for all screening areas: developmental delays (from 63% to 97%), autism spectrum disorder (from 51% to 93%), maternal depression (from 46% to 90%), and social determinants of health (from 19% to 73%).

In addition, significant increases in referrals were seen for development (from 53% to 86%) and maternal depression (from 23% to 100%).
 

EHR packages deficiencies seen as barrier

“Standard EHR packages often lack features for documenting and tracking screenings, and this was a persistent barrier to screening improvement,” Dr. Flower and associates noted. However, the percentage of practices citing EHR challenges as a barrier to screening decreased from 41% at baseline to 24% after the intervention.

Parents also reported increased discussion of screening and referrals, but “[o]n overall rating of care, the percentage of parents rating care as above average or best did not change,” but parents were not asked reasons for their care rating, the researchers wrote.

The study findings were limited by several factors including limited data quality control and insufficient data to assess the effects of screening interventions on other preventive services or other office-based factors such as revenue, the researchers noted. However, the results suggest that shared learning can help primary care practices increase screening.

“Careful attention to integrating screenings in visit flow and emphasizing their potential impact on child health can make implementation possible in multiple screening areas,” Dr. Flower and colleagues concluded.

Making measurable, meaningful practice change

Barbara J. Howard, MD, commented: “It is clear that using validated tools to screen have benefits in accuracy, equity, efficiency, and income. Increasingly, practices are being judged and paid based on ‘value,’ which is especially difficult to measure in pediatrics with its low rates of serious chronic conditions to assess. We pediatricians will be judged on use of proven methods instead, and screening is a major criterion and also, fortunately, one that is within our power to change.

“However, as this study shows, a great deal of effort and teamwork is needed to shift office workflows to incorporate screening, discussions, referral, and follow-up – all necessary processes for screening to be of value. It is broadly recognized in all industries, not just health care, that use of QI processes is a major force in facilitating change in standard practices. The American Board of Pediatrics, as well as the American Academy of Pediatrics, recognizes this need and has been assisting as well as requiring use of QI methods.

“This study specifically selected a range of practices characteristic of U.S. providers to demonstrate that both screening for multiple child health risk factors simultaneously and use of methods of QI can be feasible and effective for measurable and meaningful practice change. This should give all pediatricians encouragement to move forward in implementing changes in screening,” Dr. Howard, of Johns Hopkins University, Baltimore, said in an interview.

This study not only showed the effectiveness of change management, but also detailed the effort it required, including:

• Use of monthly team meetings.
• Collecting data from patients and team members.
• Soliciting parent feedback.
• Implementing new templates for care.
• Use of tool translations or translator support.
• Involving colocated professionals, residents, and students.
• Assembling resources.
• Attempting to invoke change in EHR vendor.

“There were expert coaches involved of national prominence and extensive QI experience. Even with all this support and effort, it should be noted that 74% of practices had participated in QI efforts previously, which should have made this project easier, and even then it took 6-7 months before measurable change in practice could be documented. In spite of the fact that actually getting help for problems identified is the goal, referrals were only marginally improved, and the tracking of referrals was not significantly improved even with all this effort,” Dr. Howard noted.

“Of note, the practices reported at the end of the project that fewer practices reported lack of time or resources for screening and referral. As a result of this publication, a slimmed down set of practice report measures might be chosen to make future QI efforts work and be measurable in meaningful ways. Instead of paper chart reviews, data from electronic screening could be automatically collected in the course of care. Referral processes could likewise be made electronic and automated, including tracking their success, not just those through a local EHR. Integration of Software as a Service with EHRs could make this data collection – that is essential to both QI and actual good care – seamless. Templates and checklists, as well as more incidental knowledge gained from this and other QI projects in pediatric practices, should be shared. While each practice operates somewhat differently, the differences are not that great and, in some cases, traditional ways of doing things would be fruitfully discarded,” suggested Dr. Howard, who was not involved in the study.

“While the pediatricians participated in the QI sessions, it is clear that the QI processes depend on the entire practice team, and generally, the team members more critical to success are not the doctor but the front desk receptionist, medical assistants, and the practice managers – as these individuals conduct or oversee workflow activities. Future QI interventions might include reinforcement and acknowledgment of these team members through inclusion in parallel continuing education activities from the American Association of Medical Assistants and the Medical Group Management Association continuing education credits,” she said.

Dr. Howard continued, “Of note, these studies were completed prior to the pandemic-related workflow changes including telehealth visits and requirements to minimize waiting room time and activities for the safety of patients and staff. These disruptive forces and the likelihood that telehealth alternatives will persist in primary care suggest that the traditional paper waiting room questionnaires are likely to have to give way to electronic alternatives. Using all electronic [approaches] will be the best unified workflow.”

The study was supported by the JPB Foundation through support to the American Academy of Pediatrics. The researchers had no financial conflicts to disclose. Dr. Howard is a pediatric founder of CHADIS, an online screening, decision support, patient education, and referral/tracking system in use nationally and implemented using QI processes. CHADIS is distributed by Total Child Health, of which Dr. Howard is president. Use of CHADIS for Part 4 Maintenance of Certification QI programs is under the ABMS portfolio sponsorship of the nonprofit Center for Promotion of Child Development through Primary Care, directed by her husband, Raymond Sturner, MD.

SOURCE: Flower KB et al. Pediatrics. 2020 Aug 7. doi: 10.1542/peds.2019-2328.

Primary care screening in several key areas including maternal depression and developmental delay increased significantly after practices implemented a quality improvement (QI) program, according to data from 19 pediatric primary care practices in 12 states.

FatCamera/Getty Images

Screening for developmental delay, maternal depression, and autism spectrum disorder are recommended by the American Academy of Pediatrics; screening for social-emotional problems and social determinants of health also are recommended. However, “Practices face challenges in implementing recommended screenings simultaneously,” wrote Kori B. Flower, MD, MPH, of the University of North Carolina at Chapel Hill, and colleagues in Pediatrics.

To support practices in screening, the researchers developed a national QI collaborative. “Aims were to improve screening processes, including screening, discussion, referral, and follow-up,” the researchers wrote.

In the study published in Pediatrics, the researchers reviewed data from 19 pediatric practices in 12 states, including independent, academic, hospital-affiliated, and multispecialty group practices and community health centers for diversity in type, size, location, and patient population.

The improvement program included two full-day sessions of in-person learning, separated by a 9-month action period that included virtual learning through webinars and online resources, monthly data collection to assess progress, and coaching. “Coaches used reports to guide virtual learning content and provide individual feedback to practices,” the researchers said.

Overall, after a year, the largest screening increases from baseline occurred for maternal depression (from 27% to 87%) and social determinants of health (from 26% to 76%). Screening also increased significantly for developmental delays (from 60% to 93%), and autism spectrum disorder (from 74% to 95%).

Statistically significant increases in discussion of screening results occurred for all screening areas: developmental delays (from 63% to 97%), autism spectrum disorder (from 51% to 93%), maternal depression (from 46% to 90%), and social determinants of health (from 19% to 73%).

In addition, significant increases in referrals were seen for development (from 53% to 86%) and maternal depression (from 23% to 100%).
 

EHR packages deficiencies seen as barrier

“Standard EHR packages often lack features for documenting and tracking screenings, and this was a persistent barrier to screening improvement,” Dr. Flower and associates noted. However, the percentage of practices citing EHR challenges as a barrier to screening decreased from 41% at baseline to 24% after the intervention.

Parents also reported increased discussion of screening and referrals, but “[o]n overall rating of care, the percentage of parents rating care as above average or best did not change,” but parents were not asked reasons for their care rating, the researchers wrote.

The study findings were limited by several factors including limited data quality control and insufficient data to assess the effects of screening interventions on other preventive services or other office-based factors such as revenue, the researchers noted. However, the results suggest that shared learning can help primary care practices increase screening.

“Careful attention to integrating screenings in visit flow and emphasizing their potential impact on child health can make implementation possible in multiple screening areas,” Dr. Flower and colleagues concluded.

Making measurable, meaningful practice change

Barbara J. Howard, MD, commented: “It is clear that using validated tools to screen have benefits in accuracy, equity, efficiency, and income. Increasingly, practices are being judged and paid based on ‘value,’ which is especially difficult to measure in pediatrics with its low rates of serious chronic conditions to assess. We pediatricians will be judged on use of proven methods instead, and screening is a major criterion and also, fortunately, one that is within our power to change.

“However, as this study shows, a great deal of effort and teamwork is needed to shift office workflows to incorporate screening, discussions, referral, and follow-up – all necessary processes for screening to be of value. It is broadly recognized in all industries, not just health care, that use of QI processes is a major force in facilitating change in standard practices. The American Board of Pediatrics, as well as the American Academy of Pediatrics, recognizes this need and has been assisting as well as requiring use of QI methods.

“This study specifically selected a range of practices characteristic of U.S. providers to demonstrate that both screening for multiple child health risk factors simultaneously and use of methods of QI can be feasible and effective for measurable and meaningful practice change. This should give all pediatricians encouragement to move forward in implementing changes in screening,” Dr. Howard, of Johns Hopkins University, Baltimore, said in an interview.

This study not only showed the effectiveness of change management, but also detailed the effort it required, including:

• Use of monthly team meetings.
• Collecting data from patients and team members.
• Soliciting parent feedback.
• Implementing new templates for care.
• Use of tool translations or translator support.
• Involving colocated professionals, residents, and students.
• Assembling resources.
• Attempting to invoke change in EHR vendor.

“There were expert coaches involved of national prominence and extensive QI experience. Even with all this support and effort, it should be noted that 74% of practices had participated in QI efforts previously, which should have made this project easier, and even then it took 6-7 months before measurable change in practice could be documented. In spite of the fact that actually getting help for problems identified is the goal, referrals were only marginally improved, and the tracking of referrals was not significantly improved even with all this effort,” Dr. Howard noted.

“Of note, the practices reported at the end of the project that fewer practices reported lack of time or resources for screening and referral. As a result of this publication, a slimmed down set of practice report measures might be chosen to make future QI efforts work and be measurable in meaningful ways. Instead of paper chart reviews, data from electronic screening could be automatically collected in the course of care. Referral processes could likewise be made electronic and automated, including tracking their success, not just those through a local EHR. Integration of Software as a Service with EHRs could make this data collection – that is essential to both QI and actual good care – seamless. Templates and checklists, as well as more incidental knowledge gained from this and other QI projects in pediatric practices, should be shared. While each practice operates somewhat differently, the differences are not that great and, in some cases, traditional ways of doing things would be fruitfully discarded,” suggested Dr. Howard, who was not involved in the study.

“While the pediatricians participated in the QI sessions, it is clear that the QI processes depend on the entire practice team, and generally, the team members more critical to success are not the doctor but the front desk receptionist, medical assistants, and the practice managers – as these individuals conduct or oversee workflow activities. Future QI interventions might include reinforcement and acknowledgment of these team members through inclusion in parallel continuing education activities from the American Association of Medical Assistants and the Medical Group Management Association continuing education credits,” she said.

Dr. Howard continued, “Of note, these studies were completed prior to the pandemic-related workflow changes including telehealth visits and requirements to minimize waiting room time and activities for the safety of patients and staff. These disruptive forces and the likelihood that telehealth alternatives will persist in primary care suggest that the traditional paper waiting room questionnaires are likely to have to give way to electronic alternatives. Using all electronic [approaches] will be the best unified workflow.”

The study was supported by the JPB Foundation through support to the American Academy of Pediatrics. The researchers had no financial conflicts to disclose. Dr. Howard is a pediatric founder of CHADIS, an online screening, decision support, patient education, and referral/tracking system in use nationally and implemented using QI processes. CHADIS is distributed by Total Child Health, of which Dr. Howard is president. Use of CHADIS for Part 4 Maintenance of Certification QI programs is under the ABMS portfolio sponsorship of the nonprofit Center for Promotion of Child Development through Primary Care, directed by her husband, Raymond Sturner, MD.

SOURCE: Flower KB et al. Pediatrics. 2020 Aug 7. doi: 10.1542/peds.2019-2328.

The start of a new school year is usually a time of excitement and return to routine, structure, and consistency for children, teenagers, and families. With the current COVID-19 pandemic, this year is anything but typical. Face masks, hand washing, physical distancing, remote learning, and restrictions on extracurricular activities are just a few of the changes experienced by children in schools. At home, the disruptions and uncertainty for families are equally dramatic with loss of employment, limited child care, risk of eviction and foreclosure, food insecurity, and growing numbers of families directly impacted by loss of health and life due to the coronavirus.

kali9/Getty Images

While every family is impacted by the current global pandemic, the realities of the pandemic have thrown increasing light on the racial, social, and structural injustices in our system. People of color are much more likely to be infected, have more severe disease, and die from COVID-19; they are more likely to experience the socioeconomic impacts.¹ Centuries of racial injustice and inequity have been highlighted not just by this pandemic but by ongoing differential treatment of people of color in our education, health, justice, economic, and housing systems. The murders of George Floyd, Breonna Taylor, Ahmaud Arbery, and too many others are just one source of the constant stress facing children and families of color.

While each family and individual currently faces a distinct combination of stressors and adversity, no one has been spared from these disruptions. International, national, and local communities all need to continue efforts to overcome the current pandemic and systemic racism. As providers, we have a profound opportunity and responsibility to engage both in advocacy for our communities and the individual care of children and families. We are aware of the negative impacts of acute and chronic stress on long-term health outcomes but are equally familiar with the power of resilience.

Resilience has broadly been defined as the “process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress.”² Some have argued that resilience should be further defined to include an individual making a “conscious effort to move forward” after or during adversity.³ Another definition with particular utility in considering how to develop and promote resilience describes it as “a process to harness resources to sustain well-being.”³ This definition not only discusses the end result, but the need to reach beyond the current capacity of an individual by harnessing both internal and external resources. These resources may be as tangible as money, food, infrastructure, or treatment, but also can include relationships, social capital, and the lived experience of others. Social supports, mature mentors, and solid bonds with parents/caregivers are critical resources for the development of child and adolescent resilience.^4,5

As health care workers, we can help promote resilience in children and families during this universally difficult time by both being a resource and helping them harness other resources that can lead to physical, emotional, and relationship well-being. To do this, consider incorporating the following into your practice:

Help children and adolescents identify and reach out to positive supports

Research has shown the importance of a stable adult figure in the development of resilience in children.^4,5 Ideally, parents will be a major positive support to their children in times of crisis. When parents are not appropriate supports, teachers, coaches, mentors, grandparents, or other extended family members can provide the needed support for children to be resilient across educational, emotional, and relationship domains.⁴ To find out who your patients have as a stable adult figure, ask the following or a related question: “Who do you have in your life who you can talk to or get support from on a regular basis?”

Screen for substance use and mental health challenges

Do this for children, adolescents, AND adults. Then treat and refer to appropriate treatment as indicated. Rates of depression, anxiety, suicide, substance use, and overdose all have increased with recent events.⁶ Treating parents with mental health and substance use disorders will not only facilitate their ability to be a positive support and role model for their children and promote resilience, but it has been shown to decrease child psychopathology.⁷ Providing parents with referrals for substance use and mental health services as well as educating them on the importance of self-care is vital for helping the development of children.

Provide parents with resources on how to cope with ongoing stressors

These stressors may be related to the COVID-19 pandemic, racism, or both. By providing resources to parents, they can better help their children overcome stressors. Multiple organizations have free online collections to support parents and families including the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and many others (See below for a list of resources).

Encourage families to find and develop purpose and meaning during this time. Children and families have devoted their time to many activities, some more adaptive and health promoting than others. If we think of resilience as the process of “moving forward” then developing goals and plans to be productive can be helpful and “meaning-making.”³ Spending time together as families, developing skills, accomplishing goals, becoming involved in important social movements, or volunteering all can be ways that individuals and families can develop feelings of self-worth, purpose, and accomplishment.²
 

Dr. Heward is a child and adolescent psychiatrist at the University of Vermont, Burlington. He said he had no relevant financial disclosures. Email him at pdnews@mdedge.com.

Resources: Coping with COVID-19

1. American Academy of Pediatrics HealthyChildren.org page on COVID-19.

2. American Academy of Child and Adolescent Psychiatry COVID-19 Resources for Families.

3. American Psychiatric Association COVID-19 Resources for Families.

4. American Psychological Association COVID-19 Information and Resources.

Resources: Racism and discrimination

1. American Academy of Pediatrics Talking to Children About Racial Bias.

2. American Academy of Child and Adolescent Psychiatry Racism Resource Library.

3. American Psychological Association Bias, Discrimination, and Equity Resources.

References

1. “Double jeopardy: COVID-19 and behavioral health disparities for Black and Latino communities in the U.S.” Substance Abuse and Mental Health Services Administration. (Submitted by Office of Behavioral Health Equity).

2. “Building your resilience.” American Psychological Association.

3. Eur J Psychotraumatol. 2014 Oct 1. doi: 10.3402/ejpt.v5.25338.

4. Psychological and biological factors associated with resilience to stress and trauma, in “The Unbroken Soul: Tragedy, Trauma, and Human Resilience” (Lanham, Md.: Jason Aronson, 2008, pp.129-51).

5. Biol Psychiatry. 2019 Sep 15. doi: 10.1016/j.biopsych.2019.07.012.

6. MMWR Morb Mortal Wkly Rep. 2020;69:1049-57.

7. J Am Acad Child Adolesc Psychiatry. 2008 Apr;47(4):379-89.

The start of a new school year is usually a time of excitement and return to routine, structure, and consistency for children, teenagers, and families. With the current COVID-19 pandemic, this year is anything but typical. Face masks, hand washing, physical distancing, remote learning, and restrictions on extracurricular activities are just a few of the changes experienced by children in schools. At home, the disruptions and uncertainty for families are equally dramatic with loss of employment, limited child care, risk of eviction and foreclosure, food insecurity, and growing numbers of families directly impacted by loss of health and life due to the coronavirus.

kali9/Getty Images

While every family is impacted by the current global pandemic, the realities of the pandemic have thrown increasing light on the racial, social, and structural injustices in our system. People of color are much more likely to be infected, have more severe disease, and die from COVID-19; they are more likely to experience the socioeconomic impacts.¹ Centuries of racial injustice and inequity have been highlighted not just by this pandemic but by ongoing differential treatment of people of color in our education, health, justice, economic, and housing systems. The murders of George Floyd, Breonna Taylor, Ahmaud Arbery, and too many others are just one source of the constant stress facing children and families of color.

While each family and individual currently faces a distinct combination of stressors and adversity, no one has been spared from these disruptions. International, national, and local communities all need to continue efforts to overcome the current pandemic and systemic racism. As providers, we have a profound opportunity and responsibility to engage both in advocacy for our communities and the individual care of children and families. We are aware of the negative impacts of acute and chronic stress on long-term health outcomes but are equally familiar with the power of resilience.

Resilience has broadly been defined as the “process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress.”² Some have argued that resilience should be further defined to include an individual making a “conscious effort to move forward” after or during adversity.³ Another definition with particular utility in considering how to develop and promote resilience describes it as “a process to harness resources to sustain well-being.”³ This definition not only discusses the end result, but the need to reach beyond the current capacity of an individual by harnessing both internal and external resources. These resources may be as tangible as money, food, infrastructure, or treatment, but also can include relationships, social capital, and the lived experience of others. Social supports, mature mentors, and solid bonds with parents/caregivers are critical resources for the development of child and adolescent resilience.^4,5

As health care workers, we can help promote resilience in children and families during this universally difficult time by both being a resource and helping them harness other resources that can lead to physical, emotional, and relationship well-being. To do this, consider incorporating the following into your practice:

Help children and adolescents identify and reach out to positive supports

Research has shown the importance of a stable adult figure in the development of resilience in children.^4,5 Ideally, parents will be a major positive support to their children in times of crisis. When parents are not appropriate supports, teachers, coaches, mentors, grandparents, or other extended family members can provide the needed support for children to be resilient across educational, emotional, and relationship domains.⁴ To find out who your patients have as a stable adult figure, ask the following or a related question: “Who do you have in your life who you can talk to or get support from on a regular basis?”

Screen for substance use and mental health challenges

Do this for children, adolescents, AND adults. Then treat and refer to appropriate treatment as indicated. Rates of depression, anxiety, suicide, substance use, and overdose all have increased with recent events.⁶ Treating parents with mental health and substance use disorders will not only facilitate their ability to be a positive support and role model for their children and promote resilience, but it has been shown to decrease child psychopathology.⁷ Providing parents with referrals for substance use and mental health services as well as educating them on the importance of self-care is vital for helping the development of children.

Provide parents with resources on how to cope with ongoing stressors

These stressors may be related to the COVID-19 pandemic, racism, or both. By providing resources to parents, they can better help their children overcome stressors. Multiple organizations have free online collections to support parents and families including the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and many others (See below for a list of resources).

Encourage families to find and develop purpose and meaning during this time. Children and families have devoted their time to many activities, some more adaptive and health promoting than others. If we think of resilience as the process of “moving forward” then developing goals and plans to be productive can be helpful and “meaning-making.”³ Spending time together as families, developing skills, accomplishing goals, becoming involved in important social movements, or volunteering all can be ways that individuals and families can develop feelings of self-worth, purpose, and accomplishment.²
 

Dr. Heward is a child and adolescent psychiatrist at the University of Vermont, Burlington. He said he had no relevant financial disclosures. Email him at pdnews@mdedge.com.

Resources: Coping with COVID-19

1. American Academy of Pediatrics HealthyChildren.org page on COVID-19.

2. American Academy of Child and Adolescent Psychiatry COVID-19 Resources for Families.

3. American Psychiatric Association COVID-19 Resources for Families.

4. American Psychological Association COVID-19 Information and Resources.

Resources: Racism and discrimination

1. American Academy of Pediatrics Talking to Children About Racial Bias.

2. American Academy of Child and Adolescent Psychiatry Racism Resource Library.

3. American Psychological Association Bias, Discrimination, and Equity Resources.

References

1. “Double jeopardy: COVID-19 and behavioral health disparities for Black and Latino communities in the U.S.” Substance Abuse and Mental Health Services Administration. (Submitted by Office of Behavioral Health Equity).

2. “Building your resilience.” American Psychological Association.

3. Eur J Psychotraumatol. 2014 Oct 1. doi: 10.3402/ejpt.v5.25338.

4. Psychological and biological factors associated with resilience to stress and trauma, in “The Unbroken Soul: Tragedy, Trauma, and Human Resilience” (Lanham, Md.: Jason Aronson, 2008, pp.129-51).

5. Biol Psychiatry. 2019 Sep 15. doi: 10.1016/j.biopsych.2019.07.012.

6. MMWR Morb Mortal Wkly Rep. 2020;69:1049-57.

7. J Am Acad Child Adolesc Psychiatry. 2008 Apr;47(4):379-89.

The start of a new school year is usually a time of excitement and return to routine, structure, and consistency for children, teenagers, and families. With the current COVID-19 pandemic, this year is anything but typical. Face masks, hand washing, physical distancing, remote learning, and restrictions on extracurricular activities are just a few of the changes experienced by children in schools. At home, the disruptions and uncertainty for families are equally dramatic with loss of employment, limited child care, risk of eviction and foreclosure, food insecurity, and growing numbers of families directly impacted by loss of health and life due to the coronavirus.

kali9/Getty Images

While every family is impacted by the current global pandemic, the realities of the pandemic have thrown increasing light on the racial, social, and structural injustices in our system. People of color are much more likely to be infected, have more severe disease, and die from COVID-19; they are more likely to experience the socioeconomic impacts.¹ Centuries of racial injustice and inequity have been highlighted not just by this pandemic but by ongoing differential treatment of people of color in our education, health, justice, economic, and housing systems. The murders of George Floyd, Breonna Taylor, Ahmaud Arbery, and too many others are just one source of the constant stress facing children and families of color.

While each family and individual currently faces a distinct combination of stressors and adversity, no one has been spared from these disruptions. International, national, and local communities all need to continue efforts to overcome the current pandemic and systemic racism. As providers, we have a profound opportunity and responsibility to engage both in advocacy for our communities and the individual care of children and families. We are aware of the negative impacts of acute and chronic stress on long-term health outcomes but are equally familiar with the power of resilience.

Resilience has broadly been defined as the “process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress.”² Some have argued that resilience should be further defined to include an individual making a “conscious effort to move forward” after or during adversity.³ Another definition with particular utility in considering how to develop and promote resilience describes it as “a process to harness resources to sustain well-being.”³ This definition not only discusses the end result, but the need to reach beyond the current capacity of an individual by harnessing both internal and external resources. These resources may be as tangible as money, food, infrastructure, or treatment, but also can include relationships, social capital, and the lived experience of others. Social supports, mature mentors, and solid bonds with parents/caregivers are critical resources for the development of child and adolescent resilience.^4,5

As health care workers, we can help promote resilience in children and families during this universally difficult time by both being a resource and helping them harness other resources that can lead to physical, emotional, and relationship well-being. To do this, consider incorporating the following into your practice:

Help children and adolescents identify and reach out to positive supports

Research has shown the importance of a stable adult figure in the development of resilience in children.^4,5 Ideally, parents will be a major positive support to their children in times of crisis. When parents are not appropriate supports, teachers, coaches, mentors, grandparents, or other extended family members can provide the needed support for children to be resilient across educational, emotional, and relationship domains.⁴ To find out who your patients have as a stable adult figure, ask the following or a related question: “Who do you have in your life who you can talk to or get support from on a regular basis?”

Screen for substance use and mental health challenges

Do this for children, adolescents, AND adults. Then treat and refer to appropriate treatment as indicated. Rates of depression, anxiety, suicide, substance use, and overdose all have increased with recent events.⁶ Treating parents with mental health and substance use disorders will not only facilitate their ability to be a positive support and role model for their children and promote resilience, but it has been shown to decrease child psychopathology.⁷ Providing parents with referrals for substance use and mental health services as well as educating them on the importance of self-care is vital for helping the development of children.

Provide parents with resources on how to cope with ongoing stressors

These stressors may be related to the COVID-19 pandemic, racism, or both. By providing resources to parents, they can better help their children overcome stressors. Multiple organizations have free online collections to support parents and families including the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and many others (See below for a list of resources).

Encourage families to find and develop purpose and meaning during this time. Children and families have devoted their time to many activities, some more adaptive and health promoting than others. If we think of resilience as the process of “moving forward” then developing goals and plans to be productive can be helpful and “meaning-making.”³ Spending time together as families, developing skills, accomplishing goals, becoming involved in important social movements, or volunteering all can be ways that individuals and families can develop feelings of self-worth, purpose, and accomplishment.²
 

Dr. Heward is a child and adolescent psychiatrist at the University of Vermont, Burlington. He said he had no relevant financial disclosures. Email him at pdnews@mdedge.com.

Resources: Coping with COVID-19

1. American Academy of Pediatrics HealthyChildren.org page on COVID-19.

2. American Academy of Child and Adolescent Psychiatry COVID-19 Resources for Families.

3. American Psychiatric Association COVID-19 Resources for Families.

4. American Psychological Association COVID-19 Information and Resources.

Resources: Racism and discrimination

1. American Academy of Pediatrics Talking to Children About Racial Bias.

2. American Academy of Child and Adolescent Psychiatry Racism Resource Library.

3. American Psychological Association Bias, Discrimination, and Equity Resources.

References

1. “Double jeopardy: COVID-19 and behavioral health disparities for Black and Latino communities in the U.S.” Substance Abuse and Mental Health Services Administration. (Submitted by Office of Behavioral Health Equity).

2. “Building your resilience.” American Psychological Association.

3. Eur J Psychotraumatol. 2014 Oct 1. doi: 10.3402/ejpt.v5.25338.

4. Psychological and biological factors associated with resilience to stress and trauma, in “The Unbroken Soul: Tragedy, Trauma, and Human Resilience” (Lanham, Md.: Jason Aronson, 2008, pp.129-51).

5. Biol Psychiatry. 2019 Sep 15. doi: 10.1016/j.biopsych.2019.07.012.

6. MMWR Morb Mortal Wkly Rep. 2020;69:1049-57.

7. J Am Acad Child Adolesc Psychiatry. 2008 Apr;47(4):379-89.

The first few months of 2020 have shone a light on the challenges we face in this new decade as a health care industry and society. As the new decade dawned, we glimpsed at just the tip of the iceberg of social injustice and longstanding inequality in our society as the COVID-19 pandemic gripped our world. The evident health disparities revealed what we have always known: that our health care system is a microcosm of our society, and that this crisis laid bare the systematic bias present in our everyday lives.

The events of early 2020 have allowed hospitalists to take our rightful place among the few who can and will be the problem solvers of the most complex puzzles. Any discussion of the year 2020 would be incomplete without talking about COVID-19, the first modern pandemic. The rapid global spread, severity, and transmissibility of the novel coronavirus presented unique clinical and operational challenges.

Hospitalists in my communities not only stepped up to care for our most acutely ill, but also our critically ill COVID-19 patients. We were in lockstep with our emergency medicine and critical care medicine colleagues to ensure that patients – COVID-19 positive or negative – received the right care at the right time in the right place. We partnered with our disaster and emergency preparedness colleagues, some of us members or leaders within our hospital, system, regional, state, or national emergency operations centers.

As further evidence of health disparities emerged in the outcomes of care of patients with COVID-19 and the homicide of George Floyd raised the alarm (again) that racism is alive and well in this country, hospitalists grieved, kneeled, and then stood with our colleagues, patients, and fellow humans to advocate for change. At the front lines, we ensured that crisis standards of care action plans would not disadvantage any person for whom we may care during acute illness. Behind closed doors and in open forums, we spoke in defense of the most vulnerable and wrote about how each and every person can throw a wrench into the existing system of bias and discrimination to produce lasting, real change for the better.

I am proud to be a hospitalist, a member of this club, with game changers like Kimberly Manning, Samir Shah, Tracy Cardin, Jason Persoff, Charlie Wray, Chris Moriates, and Vineet Arora – to name just a few. Even more so, I am grateful to be a new member of the Society of Hospital Medicine’s board of directors, where I find myself in the company of admired colleagues as we chart the course of SHM into the new decade. With such a jarring launch, we face a daunting task. In the short term, the board must guide SHM in weathering the economic storm kicked off by COVID-19 and the new social distanced norms we all practice. In the long run, we have to stay the ambitious and steep course of excellence and accomplishment set by our founders.

If we as a community of hospitalists intend to lead our field – and health care in general – each one of us must individually commit to the following pursuits:

1. Maintaining excellence in our clinical practice. First and foremost, our impact on patients happens at the bedside. Honing our clinical skills, staying up to date on the latest, breaking changes in best practices in caring for hospitalized patients and establishing the kind of relationship with their patients that we would wish for ourselves must be a core function. With the staggering volume of knowledge and the rapidity with which new information is constantly added to that existing body, this may seem like an impossibly daunting task. Thankfully, SHM recognizes this vital need and provides resources to allow each one of us to succeed in this endeavor. The Journal of Hospital Medicine brings us the best and most relevant evidence for our practice, ensuring that studies are rigorously performed and reviewed and that the outcomes produced are the ones that we are after. We can maintain board certification with a focused practice in hospital medicine by utilizing the multimodal study tools available through Spark. And, when we are once again able to gather together as a community, the annual conference will provide the best education about hospital medicine available. In the meantime, feel free to explore HM20 Virtual, featuring select offerings from the original HM20 course schedule and the opportunity to earn CME.

2. Guide our future hospitalist colleagues to be 21st-century practitioners. Medical students and residents are entering our profession in a very dynamic time. The competencies they must have in order to succeed as hospitalists in 2020 and onward are different than they were when I went through training. COVID-19 has shown us that hospitalists must be “digital doctors” – they must be facile in utilizing virtual health tools, be capable of harnessing the power of health information technology in the electronic medical record to provide care, and also be able to incorporate and interpret the incredible amount of information in health care “big data.” It is our responsibility today to prepare and coach our trainees so that they may be successful tomorrow.

3. Change the system to ensure that each patient gets the safest, most equitable care we can provide. Each one of us can be at the top of our game, but if we practice in a health care system that has gaps, we may still fail in providing the safest, highest-quality care possible. It is each of our responsibility to use every patient interaction to discover the systemic forces, including the social and cultural biases, that can lead to patient harm. In that, it is our duty to protect the most vulnerable, to redesign systems such that every person can be healthy. Only through this work of improvement do we have hope to eliminate the health disparities that exist.

4. Advocate for our patients. We each have seen the incredible impact that the Affordable Care Act has had on health care delivery in the day-to-day interactions we have with our patients. Yet it is not enough. We still have room to improve the American health care system to allow better access to care, more timely provision of care, and better outcomes for our communities. Sometimes, this takes a change in policy. For each of us, it starts with being aware of how our state policy can impact how care is delivered to our patients. In addition to your own personal advocacy work, you can join forces with SHM’s Advocacy & Public Policy team to use our society to amplify your voice.

The year 2020 began with eye-opening crises that exposed the depth and breadth of the work we have before us in hospital medicine. We have an important role to play in the next decade – surely to be the most interesting time to be a hospitalist.

Dr. Tad-y is a hospitalist and director of GME quality and safety programs at the University of Colorado at Denver, Aurora. She is a member of the SHM board of directors.

The first few months of 2020 have shone a light on the challenges we face in this new decade as a health care industry and society. As the new decade dawned, we glimpsed at just the tip of the iceberg of social injustice and longstanding inequality in our society as the COVID-19 pandemic gripped our world. The evident health disparities revealed what we have always known: that our health care system is a microcosm of our society, and that this crisis laid bare the systematic bias present in our everyday lives.

The events of early 2020 have allowed hospitalists to take our rightful place among the few who can and will be the problem solvers of the most complex puzzles. Any discussion of the year 2020 would be incomplete without talking about COVID-19, the first modern pandemic. The rapid global spread, severity, and transmissibility of the novel coronavirus presented unique clinical and operational challenges.

Hospitalists in my communities not only stepped up to care for our most acutely ill, but also our critically ill COVID-19 patients. We were in lockstep with our emergency medicine and critical care medicine colleagues to ensure that patients – COVID-19 positive or negative – received the right care at the right time in the right place. We partnered with our disaster and emergency preparedness colleagues, some of us members or leaders within our hospital, system, regional, state, or national emergency operations centers.

As further evidence of health disparities emerged in the outcomes of care of patients with COVID-19 and the homicide of George Floyd raised the alarm (again) that racism is alive and well in this country, hospitalists grieved, kneeled, and then stood with our colleagues, patients, and fellow humans to advocate for change. At the front lines, we ensured that crisis standards of care action plans would not disadvantage any person for whom we may care during acute illness. Behind closed doors and in open forums, we spoke in defense of the most vulnerable and wrote about how each and every person can throw a wrench into the existing system of bias and discrimination to produce lasting, real change for the better.

I am proud to be a hospitalist, a member of this club, with game changers like Kimberly Manning, Samir Shah, Tracy Cardin, Jason Persoff, Charlie Wray, Chris Moriates, and Vineet Arora – to name just a few. Even more so, I am grateful to be a new member of the Society of Hospital Medicine’s board of directors, where I find myself in the company of admired colleagues as we chart the course of SHM into the new decade. With such a jarring launch, we face a daunting task. In the short term, the board must guide SHM in weathering the economic storm kicked off by COVID-19 and the new social distanced norms we all practice. In the long run, we have to stay the ambitious and steep course of excellence and accomplishment set by our founders.

If we as a community of hospitalists intend to lead our field – and health care in general – each one of us must individually commit to the following pursuits:

1. Maintaining excellence in our clinical practice. First and foremost, our impact on patients happens at the bedside. Honing our clinical skills, staying up to date on the latest, breaking changes in best practices in caring for hospitalized patients and establishing the kind of relationship with their patients that we would wish for ourselves must be a core function. With the staggering volume of knowledge and the rapidity with which new information is constantly added to that existing body, this may seem like an impossibly daunting task. Thankfully, SHM recognizes this vital need and provides resources to allow each one of us to succeed in this endeavor. The Journal of Hospital Medicine brings us the best and most relevant evidence for our practice, ensuring that studies are rigorously performed and reviewed and that the outcomes produced are the ones that we are after. We can maintain board certification with a focused practice in hospital medicine by utilizing the multimodal study tools available through Spark. And, when we are once again able to gather together as a community, the annual conference will provide the best education about hospital medicine available. In the meantime, feel free to explore HM20 Virtual, featuring select offerings from the original HM20 course schedule and the opportunity to earn CME.

2. Guide our future hospitalist colleagues to be 21st-century practitioners. Medical students and residents are entering our profession in a very dynamic time. The competencies they must have in order to succeed as hospitalists in 2020 and onward are different than they were when I went through training. COVID-19 has shown us that hospitalists must be “digital doctors” – they must be facile in utilizing virtual health tools, be capable of harnessing the power of health information technology in the electronic medical record to provide care, and also be able to incorporate and interpret the incredible amount of information in health care “big data.” It is our responsibility today to prepare and coach our trainees so that they may be successful tomorrow.

3. Change the system to ensure that each patient gets the safest, most equitable care we can provide. Each one of us can be at the top of our game, but if we practice in a health care system that has gaps, we may still fail in providing the safest, highest-quality care possible. It is each of our responsibility to use every patient interaction to discover the systemic forces, including the social and cultural biases, that can lead to patient harm. In that, it is our duty to protect the most vulnerable, to redesign systems such that every person can be healthy. Only through this work of improvement do we have hope to eliminate the health disparities that exist.

4. Advocate for our patients. We each have seen the incredible impact that the Affordable Care Act has had on health care delivery in the day-to-day interactions we have with our patients. Yet it is not enough. We still have room to improve the American health care system to allow better access to care, more timely provision of care, and better outcomes for our communities. Sometimes, this takes a change in policy. For each of us, it starts with being aware of how our state policy can impact how care is delivered to our patients. In addition to your own personal advocacy work, you can join forces with SHM’s Advocacy & Public Policy team to use our society to amplify your voice.

The year 2020 began with eye-opening crises that exposed the depth and breadth of the work we have before us in hospital medicine. We have an important role to play in the next decade – surely to be the most interesting time to be a hospitalist.

Dr. Tad-y is a hospitalist and director of GME quality and safety programs at the University of Colorado at Denver, Aurora. She is a member of the SHM board of directors.

The first few months of 2020 have shone a light on the challenges we face in this new decade as a health care industry and society. As the new decade dawned, we glimpsed at just the tip of the iceberg of social injustice and longstanding inequality in our society as the COVID-19 pandemic gripped our world. The evident health disparities revealed what we have always known: that our health care system is a microcosm of our society, and that this crisis laid bare the systematic bias present in our everyday lives.

The events of early 2020 have allowed hospitalists to take our rightful place among the few who can and will be the problem solvers of the most complex puzzles. Any discussion of the year 2020 would be incomplete without talking about COVID-19, the first modern pandemic. The rapid global spread, severity, and transmissibility of the novel coronavirus presented unique clinical and operational challenges.

Hospitalists in my communities not only stepped up to care for our most acutely ill, but also our critically ill COVID-19 patients. We were in lockstep with our emergency medicine and critical care medicine colleagues to ensure that patients – COVID-19 positive or negative – received the right care at the right time in the right place. We partnered with our disaster and emergency preparedness colleagues, some of us members or leaders within our hospital, system, regional, state, or national emergency operations centers.

As further evidence of health disparities emerged in the outcomes of care of patients with COVID-19 and the homicide of George Floyd raised the alarm (again) that racism is alive and well in this country, hospitalists grieved, kneeled, and then stood with our colleagues, patients, and fellow humans to advocate for change. At the front lines, we ensured that crisis standards of care action plans would not disadvantage any person for whom we may care during acute illness. Behind closed doors and in open forums, we spoke in defense of the most vulnerable and wrote about how each and every person can throw a wrench into the existing system of bias and discrimination to produce lasting, real change for the better.

I am proud to be a hospitalist, a member of this club, with game changers like Kimberly Manning, Samir Shah, Tracy Cardin, Jason Persoff, Charlie Wray, Chris Moriates, and Vineet Arora – to name just a few. Even more so, I am grateful to be a new member of the Society of Hospital Medicine’s board of directors, where I find myself in the company of admired colleagues as we chart the course of SHM into the new decade. With such a jarring launch, we face a daunting task. In the short term, the board must guide SHM in weathering the economic storm kicked off by COVID-19 and the new social distanced norms we all practice. In the long run, we have to stay the ambitious and steep course of excellence and accomplishment set by our founders.

If we as a community of hospitalists intend to lead our field – and health care in general – each one of us must individually commit to the following pursuits:

1. Maintaining excellence in our clinical practice. First and foremost, our impact on patients happens at the bedside. Honing our clinical skills, staying up to date on the latest, breaking changes in best practices in caring for hospitalized patients and establishing the kind of relationship with their patients that we would wish for ourselves must be a core function. With the staggering volume of knowledge and the rapidity with which new information is constantly added to that existing body, this may seem like an impossibly daunting task. Thankfully, SHM recognizes this vital need and provides resources to allow each one of us to succeed in this endeavor. The Journal of Hospital Medicine brings us the best and most relevant evidence for our practice, ensuring that studies are rigorously performed and reviewed and that the outcomes produced are the ones that we are after. We can maintain board certification with a focused practice in hospital medicine by utilizing the multimodal study tools available through Spark. And, when we are once again able to gather together as a community, the annual conference will provide the best education about hospital medicine available. In the meantime, feel free to explore HM20 Virtual, featuring select offerings from the original HM20 course schedule and the opportunity to earn CME.

2. Guide our future hospitalist colleagues to be 21st-century practitioners. Medical students and residents are entering our profession in a very dynamic time. The competencies they must have in order to succeed as hospitalists in 2020 and onward are different than they were when I went through training. COVID-19 has shown us that hospitalists must be “digital doctors” – they must be facile in utilizing virtual health tools, be capable of harnessing the power of health information technology in the electronic medical record to provide care, and also be able to incorporate and interpret the incredible amount of information in health care “big data.” It is our responsibility today to prepare and coach our trainees so that they may be successful tomorrow.

3. Change the system to ensure that each patient gets the safest, most equitable care we can provide. Each one of us can be at the top of our game, but if we practice in a health care system that has gaps, we may still fail in providing the safest, highest-quality care possible. It is each of our responsibility to use every patient interaction to discover the systemic forces, including the social and cultural biases, that can lead to patient harm. In that, it is our duty to protect the most vulnerable, to redesign systems such that every person can be healthy. Only through this work of improvement do we have hope to eliminate the health disparities that exist.

4. Advocate for our patients. We each have seen the incredible impact that the Affordable Care Act has had on health care delivery in the day-to-day interactions we have with our patients. Yet it is not enough. We still have room to improve the American health care system to allow better access to care, more timely provision of care, and better outcomes for our communities. Sometimes, this takes a change in policy. For each of us, it starts with being aware of how our state policy can impact how care is delivered to our patients. In addition to your own personal advocacy work, you can join forces with SHM’s Advocacy & Public Policy team to use our society to amplify your voice.

The year 2020 began with eye-opening crises that exposed the depth and breadth of the work we have before us in hospital medicine. We have an important role to play in the next decade – surely to be the most interesting time to be a hospitalist.

Dr. Tad-y is a hospitalist and director of GME quality and safety programs at the University of Colorado at Denver, Aurora. She is a member of the SHM board of directors.

Perioperative administration of the beta blocker propranolol and the COX2 inhibitor etodolac significantly improved biomarkers of malignancy and metastasis and was associated with a reduction in recurrence rates after colorectal tumor resection in a randomized, placebo-controlled study.

The study included 34 patients (median age, 58 years) who underwent colorectal tumor resection in Israel. It was published online June 13 in Cancer.

On intent-to-treat analysis, 3-year recurrence rates were 12.5% in the placebo group (n = 16) and 33.3% in the treatment group (n = 18). This difference was not statistically significant (P = .239). However, in protocol-compliant patients, the respective rates were 0% and 29.4% (P = .054), but the study was not powered to assess drug effects on recurrence and survival, the researchers note.

With regard to tumor molecular markers, results showed that the combination reduced epithelial-to-mesenchymal transition and tumor-infiltrating CD14-positive monocytes and CD19-positive B cells. There was an increase in tumor-infiltrating CD56-positive natural killer cells, Rita Haldar, MA, of Tel Aviv University, Israel, and her colleagues note.

Transcriptional activity analysis showed a favorable effect on 12 of 19 potential colorectal cancer–related transcription factors, with alterations that have previously been linked with improved outcomes.

In the trial, the patients in the treatment group received oral etodolac 400 mg twice daily for 20 perioperative days beginning 5 days before surgery and oral propranolol at twice-daily doses of 20 mg for the 5 days before surgery, 80 mg on the day of surgery, 40 mg on postoperative days 1 to 7, and 20 mg for the last 7 days.

The treatments were well tolerated. Minor complications occurred at similar rates in the treatment and placebo groups, note the researchers. No severe surgical complications occurred in the treatment group; one occurred in the placebo group.

The findings indicate that the treatment protocol is “empirically safe, easy to administer, and inexpensive and has overall favorable molecular impacts on tumor tissues,” the researchers conclude.

Data from the study provide a strong rationale for future trials powered to assess the impact of this combination on disease-free and overall survival in patients with colorectal cancer.

“Haldar et al should be applauded for their steadfast pursuit of repurposed drugs for the treatment of cancer,” Michael Low, MD, and his colleagues at Morningside Center for Innovative and Affordable Medicine at Emory University, Atlanta, Georgia, write in an accompanying editorial.

The concept of using perioperative interventions “to alter the deleterious effects of surgery” is not new, and evidence of potential benefit is abundant, the editorialists note.

The focus of the current study on beta-adrenergic blockade and COX2 inhibition is supported both by the agents’ known suppressive effects on relevant pathways and by preclinical data, the editorialists write.

The study is limited by several factors, including small sample size, patient-reported compliance, and a failure to account for use of chemotherapy. The editorialists emphasize that use of these agents in the perioperative period “is of paramount importance and may have long-lasting antitumoral effects.” They hope “that larger trials focusing on these and other agents will soon prove that to be true.”

The study was supported by an Israel Science Foundation grant. The authors and Lowe have disclosed no relevant financial relationships.
 

This article first appeared on Medscape.com.

Perioperative administration of the beta blocker propranolol and the COX2 inhibitor etodolac significantly improved biomarkers of malignancy and metastasis and was associated with a reduction in recurrence rates after colorectal tumor resection in a randomized, placebo-controlled study.

The study included 34 patients (median age, 58 years) who underwent colorectal tumor resection in Israel. It was published online June 13 in Cancer.

On intent-to-treat analysis, 3-year recurrence rates were 12.5% in the placebo group (n = 16) and 33.3% in the treatment group (n = 18). This difference was not statistically significant (P = .239). However, in protocol-compliant patients, the respective rates were 0% and 29.4% (P = .054), but the study was not powered to assess drug effects on recurrence and survival, the researchers note.

With regard to tumor molecular markers, results showed that the combination reduced epithelial-to-mesenchymal transition and tumor-infiltrating CD14-positive monocytes and CD19-positive B cells. There was an increase in tumor-infiltrating CD56-positive natural killer cells, Rita Haldar, MA, of Tel Aviv University, Israel, and her colleagues note.

Transcriptional activity analysis showed a favorable effect on 12 of 19 potential colorectal cancer–related transcription factors, with alterations that have previously been linked with improved outcomes.

In the trial, the patients in the treatment group received oral etodolac 400 mg twice daily for 20 perioperative days beginning 5 days before surgery and oral propranolol at twice-daily doses of 20 mg for the 5 days before surgery, 80 mg on the day of surgery, 40 mg on postoperative days 1 to 7, and 20 mg for the last 7 days.

The treatments were well tolerated. Minor complications occurred at similar rates in the treatment and placebo groups, note the researchers. No severe surgical complications occurred in the treatment group; one occurred in the placebo group.

The findings indicate that the treatment protocol is “empirically safe, easy to administer, and inexpensive and has overall favorable molecular impacts on tumor tissues,” the researchers conclude.

Data from the study provide a strong rationale for future trials powered to assess the impact of this combination on disease-free and overall survival in patients with colorectal cancer.

“Haldar et al should be applauded for their steadfast pursuit of repurposed drugs for the treatment of cancer,” Michael Low, MD, and his colleagues at Morningside Center for Innovative and Affordable Medicine at Emory University, Atlanta, Georgia, write in an accompanying editorial.

The concept of using perioperative interventions “to alter the deleterious effects of surgery” is not new, and evidence of potential benefit is abundant, the editorialists note.

The focus of the current study on beta-adrenergic blockade and COX2 inhibition is supported both by the agents’ known suppressive effects on relevant pathways and by preclinical data, the editorialists write.

The study is limited by several factors, including small sample size, patient-reported compliance, and a failure to account for use of chemotherapy. The editorialists emphasize that use of these agents in the perioperative period “is of paramount importance and may have long-lasting antitumoral effects.” They hope “that larger trials focusing on these and other agents will soon prove that to be true.”

The study was supported by an Israel Science Foundation grant. The authors and Lowe have disclosed no relevant financial relationships.
 

This article first appeared on Medscape.com.

Perioperative administration of the beta blocker propranolol and the COX2 inhibitor etodolac significantly improved biomarkers of malignancy and metastasis and was associated with a reduction in recurrence rates after colorectal tumor resection in a randomized, placebo-controlled study.

The study included 34 patients (median age, 58 years) who underwent colorectal tumor resection in Israel. It was published online June 13 in Cancer.

On intent-to-treat analysis, 3-year recurrence rates were 12.5% in the placebo group (n = 16) and 33.3% in the treatment group (n = 18). This difference was not statistically significant (P = .239). However, in protocol-compliant patients, the respective rates were 0% and 29.4% (P = .054), but the study was not powered to assess drug effects on recurrence and survival, the researchers note.

With regard to tumor molecular markers, results showed that the combination reduced epithelial-to-mesenchymal transition and tumor-infiltrating CD14-positive monocytes and CD19-positive B cells. There was an increase in tumor-infiltrating CD56-positive natural killer cells, Rita Haldar, MA, of Tel Aviv University, Israel, and her colleagues note.

Transcriptional activity analysis showed a favorable effect on 12 of 19 potential colorectal cancer–related transcription factors, with alterations that have previously been linked with improved outcomes.

In the trial, the patients in the treatment group received oral etodolac 400 mg twice daily for 20 perioperative days beginning 5 days before surgery and oral propranolol at twice-daily doses of 20 mg for the 5 days before surgery, 80 mg on the day of surgery, 40 mg on postoperative days 1 to 7, and 20 mg for the last 7 days.

The treatments were well tolerated. Minor complications occurred at similar rates in the treatment and placebo groups, note the researchers. No severe surgical complications occurred in the treatment group; one occurred in the placebo group.

The findings indicate that the treatment protocol is “empirically safe, easy to administer, and inexpensive and has overall favorable molecular impacts on tumor tissues,” the researchers conclude.

Data from the study provide a strong rationale for future trials powered to assess the impact of this combination on disease-free and overall survival in patients with colorectal cancer.

“Haldar et al should be applauded for their steadfast pursuit of repurposed drugs for the treatment of cancer,” Michael Low, MD, and his colleagues at Morningside Center for Innovative and Affordable Medicine at Emory University, Atlanta, Georgia, write in an accompanying editorial.

The concept of using perioperative interventions “to alter the deleterious effects of surgery” is not new, and evidence of potential benefit is abundant, the editorialists note.

The focus of the current study on beta-adrenergic blockade and COX2 inhibition is supported both by the agents’ known suppressive effects on relevant pathways and by preclinical data, the editorialists write.

The study is limited by several factors, including small sample size, patient-reported compliance, and a failure to account for use of chemotherapy. The editorialists emphasize that use of these agents in the perioperative period “is of paramount importance and may have long-lasting antitumoral effects.” They hope “that larger trials focusing on these and other agents will soon prove that to be true.”

The study was supported by an Israel Science Foundation grant. The authors and Lowe have disclosed no relevant financial relationships.
 

This article first appeared on Medscape.com.