User login
Children who have stem cell transplants need skin exams, sun protection
WASHINGTON – Children who have had a hematopoietic stem cell transplant (HSCT) have an increased risk of benign and atypical nevi, Dr. Johanna Sheu reported at the annual meeting of the American Academy of Dermatology.
These patients need to have routine skin exams and be educated about sun protection needs, she said. Based on her study, these needs are not routinely met.
At least 1 year after undergoing HSCT at Boston Children’s Hospital, 85 posttransplant patients had significantly more nevi and more atypical nevi than did 85 healthy controls who were matched by age, gender, and Fitzpatrick skin type. In addition, 41% of the transplant recipients had at least one actinic keratosis, a basal or squamous cell carcinoma, or a solar lentigo; 11% had at least one nevus spilus.
Moreover, “sun protection … and dermatology follow-up was poor” among the transplant recipients, said Dr. Sheu, of MassGeneral Hospital for Children, Boston. About 40% of the transplant recipients reported having a sunburn since their transplant, only 15% reported daily use of sunscreen, and 53% said they did not recall being told that sunburn could trigger graft-versus-host disease (GVHD).
About one-third of the patients had never seen a dermatologist; of those who had, two-thirds had only seen the dermatologist once, Dr. Sheu reported.
Late skin effects of HSCT are not as well described in children as they are in adults, she said. In adults, late skin effects include vitiligo, psoriasis, nonmelanoma skin cancers, and an increased nevi count.
The children in the study had undergone an HSCT between 1998 and 2013, at a median age of about 7 years (range was 1 month to 19 years). At the time of their skin exams, their mean age was 14 years, and they had been followed for a median of almost 4 years. Nevi were counted on the forearms, backs, legs, palms, and soles.
The median nevi count was 44 nevi, significantly more than the level seen in control subjects. Transplant recipients also had significantly more nevi in sun-exposed areas of the body, as well as on the palms and soles. Transplant recipients were more likely to have atypical nevi and to have nevi greater than 5 mm in diameter.
In addition to fair skin, factors associated with an increase in the overall nevi count included being older than age 10 at the time of the transplant and having total body irradiation, pretransplant chemotherapy, and myeloablative conditioning. Having had a sunburn since the transplant, reported by 40%, was also a risk factor.
Chronic GVHD and chronic GVHD of the skin were associated with the presence of atypical nevi; acute GVHD, the duration of immune suppression, and the use of topical steroids or calcineurin inhibitors were not associated with increased risk of atypical nevi.
She and her coinvestigators are currently analyzing the pathogenesis of these late effects in this population, and autoimmune skin conditions – vitiligo and alopecia – in 25% of the transplant recipients in the study.
In 2013, 1,100 children under aged 16 years in the United States underwent a bone marrow transplant, she noted.
Dr. Sheu had no disclosures.
WASHINGTON – Children who have had a hematopoietic stem cell transplant (HSCT) have an increased risk of benign and atypical nevi, Dr. Johanna Sheu reported at the annual meeting of the American Academy of Dermatology.
These patients need to have routine skin exams and be educated about sun protection needs, she said. Based on her study, these needs are not routinely met.
At least 1 year after undergoing HSCT at Boston Children’s Hospital, 85 posttransplant patients had significantly more nevi and more atypical nevi than did 85 healthy controls who were matched by age, gender, and Fitzpatrick skin type. In addition, 41% of the transplant recipients had at least one actinic keratosis, a basal or squamous cell carcinoma, or a solar lentigo; 11% had at least one nevus spilus.
Moreover, “sun protection … and dermatology follow-up was poor” among the transplant recipients, said Dr. Sheu, of MassGeneral Hospital for Children, Boston. About 40% of the transplant recipients reported having a sunburn since their transplant, only 15% reported daily use of sunscreen, and 53% said they did not recall being told that sunburn could trigger graft-versus-host disease (GVHD).
About one-third of the patients had never seen a dermatologist; of those who had, two-thirds had only seen the dermatologist once, Dr. Sheu reported.
Late skin effects of HSCT are not as well described in children as they are in adults, she said. In adults, late skin effects include vitiligo, psoriasis, nonmelanoma skin cancers, and an increased nevi count.
The children in the study had undergone an HSCT between 1998 and 2013, at a median age of about 7 years (range was 1 month to 19 years). At the time of their skin exams, their mean age was 14 years, and they had been followed for a median of almost 4 years. Nevi were counted on the forearms, backs, legs, palms, and soles.
The median nevi count was 44 nevi, significantly more than the level seen in control subjects. Transplant recipients also had significantly more nevi in sun-exposed areas of the body, as well as on the palms and soles. Transplant recipients were more likely to have atypical nevi and to have nevi greater than 5 mm in diameter.
In addition to fair skin, factors associated with an increase in the overall nevi count included being older than age 10 at the time of the transplant and having total body irradiation, pretransplant chemotherapy, and myeloablative conditioning. Having had a sunburn since the transplant, reported by 40%, was also a risk factor.
Chronic GVHD and chronic GVHD of the skin were associated with the presence of atypical nevi; acute GVHD, the duration of immune suppression, and the use of topical steroids or calcineurin inhibitors were not associated with increased risk of atypical nevi.
She and her coinvestigators are currently analyzing the pathogenesis of these late effects in this population, and autoimmune skin conditions – vitiligo and alopecia – in 25% of the transplant recipients in the study.
In 2013, 1,100 children under aged 16 years in the United States underwent a bone marrow transplant, she noted.
Dr. Sheu had no disclosures.
WASHINGTON – Children who have had a hematopoietic stem cell transplant (HSCT) have an increased risk of benign and atypical nevi, Dr. Johanna Sheu reported at the annual meeting of the American Academy of Dermatology.
These patients need to have routine skin exams and be educated about sun protection needs, she said. Based on her study, these needs are not routinely met.
At least 1 year after undergoing HSCT at Boston Children’s Hospital, 85 posttransplant patients had significantly more nevi and more atypical nevi than did 85 healthy controls who were matched by age, gender, and Fitzpatrick skin type. In addition, 41% of the transplant recipients had at least one actinic keratosis, a basal or squamous cell carcinoma, or a solar lentigo; 11% had at least one nevus spilus.
Moreover, “sun protection … and dermatology follow-up was poor” among the transplant recipients, said Dr. Sheu, of MassGeneral Hospital for Children, Boston. About 40% of the transplant recipients reported having a sunburn since their transplant, only 15% reported daily use of sunscreen, and 53% said they did not recall being told that sunburn could trigger graft-versus-host disease (GVHD).
About one-third of the patients had never seen a dermatologist; of those who had, two-thirds had only seen the dermatologist once, Dr. Sheu reported.
Late skin effects of HSCT are not as well described in children as they are in adults, she said. In adults, late skin effects include vitiligo, psoriasis, nonmelanoma skin cancers, and an increased nevi count.
The children in the study had undergone an HSCT between 1998 and 2013, at a median age of about 7 years (range was 1 month to 19 years). At the time of their skin exams, their mean age was 14 years, and they had been followed for a median of almost 4 years. Nevi were counted on the forearms, backs, legs, palms, and soles.
The median nevi count was 44 nevi, significantly more than the level seen in control subjects. Transplant recipients also had significantly more nevi in sun-exposed areas of the body, as well as on the palms and soles. Transplant recipients were more likely to have atypical nevi and to have nevi greater than 5 mm in diameter.
In addition to fair skin, factors associated with an increase in the overall nevi count included being older than age 10 at the time of the transplant and having total body irradiation, pretransplant chemotherapy, and myeloablative conditioning. Having had a sunburn since the transplant, reported by 40%, was also a risk factor.
Chronic GVHD and chronic GVHD of the skin were associated with the presence of atypical nevi; acute GVHD, the duration of immune suppression, and the use of topical steroids or calcineurin inhibitors were not associated with increased risk of atypical nevi.
She and her coinvestigators are currently analyzing the pathogenesis of these late effects in this population, and autoimmune skin conditions – vitiligo and alopecia – in 25% of the transplant recipients in the study.
In 2013, 1,100 children under aged 16 years in the United States underwent a bone marrow transplant, she noted.
Dr. Sheu had no disclosures.
AT AAD 16
Key clinical point: Children who have had a hematopoietic stem cell transplant need to have routine skin exams and be educated about sun protection needs.
Major finding: 41% of the transplant recipients had at least one actinic keratosis, a basal or squamous cell carcinoma, or a solar lentigo; 11% had at least one nevus spilus.
Data source: A single-center study of 85 posttransplant patients and 85 healthy controls who were matched by age, gender, and Fitzpatrick skin type.
Disclosures: The study was not sponsored and Dr. Sheu had no disclosures.
Ibrutinib bodes well for relapsed mantle-cell lymphoma
Progression-free survival was significantly better when patients with relapsed or refractory mantle-cell lymphoma were treated with oral ibrutinib than with intravenous temsirolimus, based on results from 280 patients in an international, randomized, open-label phase III trial.
Study subjects had undergone one or more previous rituximab-containing chemotherapy regimens to receive intravenous temsirolimus or oral ibrutinib at a daily dose of 560 mg.
Compared with temsirolimus, ibrutinib resulted in a 57% reduction in the risk of disease progression or death at a median follow-up of 20 months. Median progression-free survival – the trial’s primary endpoint – was 14.6 months for the ibrutinib group and 6.2 months for the temsirolimus group.
Ibrutinib was also better tolerated, with 68% of patients having grade 3 or higher treatment-emergent adverse events as compared to 87% of patients in the temsirolimus group, despite a median 4-fold longer treatment duration for the ibrutinib group than the temsirolimus group. Additionally, 6% of patients discontinued ibrutinib because of adverse events versus 26% in the temsirolimus group, reported Dr. Martin Dreyling of Klinikum der Universität in Munich, Germany, and his associates.
Based on results of the Functional Assessment of Cancer Therapy-Lymphoma (FACT-Lym) questionnaire, ibrutinib was associated with greater and more rapid improvements, and also with less worsening in lymphoma symptoms, as measured by the lymphoma subscale of the FACT-Lym (Lancet. 2016;387:770-78).
Ibrutinib, a first-in-class oral inhibitor of Bruton’s tyrosine kinase, is approved in the United States and the European Union at a dose of 560 mg per day for patients with mantle cell lymphoma who have received at least one previous line of therapy.
The mammalian target of rapamycin (mTOR) inhibitor temsirolimus is approved in the European Union for relapsed or refractory mantle-cell lymphoma, but does not have FDA approval for this indication.
The study, funded by Janssen, is ongoing. Future research, the investigators say, should examine ibrutinib-based combination approaches for patients with relapsed or refractory mantle-cell lymphoma and in front-line therapy.
Dr. Dreyling reported grants and personal fees from Janssen and Pfizer outside of the study. Several other authors reported grants from Janssen during the study and financial ties to the company.
The findings from this phase III trial clearly establish ibrutinib as a new standard for treatment of relapsed mantle-cell lymphoma. Within the next 2 years, many expect the agent will find its way into the frontline setting for treatment of mantle cell lymphoma in combination with standard chemotherapy, based on results of another already completed phase III trial (the SHINE trial).
Despite this remarkable progress, however, mantle-cell lymphoma remains incurable. Roughly 30%-40% of people with the disease will not respond to ibrutinib, and even among responders relapse seems inevitable.
Mantle-cell lymphoma has been a model for accelerated development of novel drugs. Ibrutinib was developed with tremendous speed, and the FDA’s approval of the agent in 2013 based on findings from a non-pivotal phase II trial was surprising to everyone other than the participating patients and physicians. Hopefully the resources mobilized to bring ibrutinib so far, so fast, will continue to be available to help us learn how best to use the drug.
Dr. Peter Martin is with the department of medicine at Weill Cornell Medical College in New York. His comments are excerpted from an editorial that accompanied the study in The Lancet. Dr. Martin reported that he is a consultant for Janssen and has received honoraria from the company for speaking.
The findings from this phase III trial clearly establish ibrutinib as a new standard for treatment of relapsed mantle-cell lymphoma. Within the next 2 years, many expect the agent will find its way into the frontline setting for treatment of mantle cell lymphoma in combination with standard chemotherapy, based on results of another already completed phase III trial (the SHINE trial).
Despite this remarkable progress, however, mantle-cell lymphoma remains incurable. Roughly 30%-40% of people with the disease will not respond to ibrutinib, and even among responders relapse seems inevitable.
Mantle-cell lymphoma has been a model for accelerated development of novel drugs. Ibrutinib was developed with tremendous speed, and the FDA’s approval of the agent in 2013 based on findings from a non-pivotal phase II trial was surprising to everyone other than the participating patients and physicians. Hopefully the resources mobilized to bring ibrutinib so far, so fast, will continue to be available to help us learn how best to use the drug.
Dr. Peter Martin is with the department of medicine at Weill Cornell Medical College in New York. His comments are excerpted from an editorial that accompanied the study in The Lancet. Dr. Martin reported that he is a consultant for Janssen and has received honoraria from the company for speaking.
The findings from this phase III trial clearly establish ibrutinib as a new standard for treatment of relapsed mantle-cell lymphoma. Within the next 2 years, many expect the agent will find its way into the frontline setting for treatment of mantle cell lymphoma in combination with standard chemotherapy, based on results of another already completed phase III trial (the SHINE trial).
Despite this remarkable progress, however, mantle-cell lymphoma remains incurable. Roughly 30%-40% of people with the disease will not respond to ibrutinib, and even among responders relapse seems inevitable.
Mantle-cell lymphoma has been a model for accelerated development of novel drugs. Ibrutinib was developed with tremendous speed, and the FDA’s approval of the agent in 2013 based on findings from a non-pivotal phase II trial was surprising to everyone other than the participating patients and physicians. Hopefully the resources mobilized to bring ibrutinib so far, so fast, will continue to be available to help us learn how best to use the drug.
Dr. Peter Martin is with the department of medicine at Weill Cornell Medical College in New York. His comments are excerpted from an editorial that accompanied the study in The Lancet. Dr. Martin reported that he is a consultant for Janssen and has received honoraria from the company for speaking.
Progression-free survival was significantly better when patients with relapsed or refractory mantle-cell lymphoma were treated with oral ibrutinib than with intravenous temsirolimus, based on results from 280 patients in an international, randomized, open-label phase III trial.
Study subjects had undergone one or more previous rituximab-containing chemotherapy regimens to receive intravenous temsirolimus or oral ibrutinib at a daily dose of 560 mg.
Compared with temsirolimus, ibrutinib resulted in a 57% reduction in the risk of disease progression or death at a median follow-up of 20 months. Median progression-free survival – the trial’s primary endpoint – was 14.6 months for the ibrutinib group and 6.2 months for the temsirolimus group.
Ibrutinib was also better tolerated, with 68% of patients having grade 3 or higher treatment-emergent adverse events as compared to 87% of patients in the temsirolimus group, despite a median 4-fold longer treatment duration for the ibrutinib group than the temsirolimus group. Additionally, 6% of patients discontinued ibrutinib because of adverse events versus 26% in the temsirolimus group, reported Dr. Martin Dreyling of Klinikum der Universität in Munich, Germany, and his associates.
Based on results of the Functional Assessment of Cancer Therapy-Lymphoma (FACT-Lym) questionnaire, ibrutinib was associated with greater and more rapid improvements, and also with less worsening in lymphoma symptoms, as measured by the lymphoma subscale of the FACT-Lym (Lancet. 2016;387:770-78).
Ibrutinib, a first-in-class oral inhibitor of Bruton’s tyrosine kinase, is approved in the United States and the European Union at a dose of 560 mg per day for patients with mantle cell lymphoma who have received at least one previous line of therapy.
The mammalian target of rapamycin (mTOR) inhibitor temsirolimus is approved in the European Union for relapsed or refractory mantle-cell lymphoma, but does not have FDA approval for this indication.
The study, funded by Janssen, is ongoing. Future research, the investigators say, should examine ibrutinib-based combination approaches for patients with relapsed or refractory mantle-cell lymphoma and in front-line therapy.
Dr. Dreyling reported grants and personal fees from Janssen and Pfizer outside of the study. Several other authors reported grants from Janssen during the study and financial ties to the company.
Progression-free survival was significantly better when patients with relapsed or refractory mantle-cell lymphoma were treated with oral ibrutinib than with intravenous temsirolimus, based on results from 280 patients in an international, randomized, open-label phase III trial.
Study subjects had undergone one or more previous rituximab-containing chemotherapy regimens to receive intravenous temsirolimus or oral ibrutinib at a daily dose of 560 mg.
Compared with temsirolimus, ibrutinib resulted in a 57% reduction in the risk of disease progression or death at a median follow-up of 20 months. Median progression-free survival – the trial’s primary endpoint – was 14.6 months for the ibrutinib group and 6.2 months for the temsirolimus group.
Ibrutinib was also better tolerated, with 68% of patients having grade 3 or higher treatment-emergent adverse events as compared to 87% of patients in the temsirolimus group, despite a median 4-fold longer treatment duration for the ibrutinib group than the temsirolimus group. Additionally, 6% of patients discontinued ibrutinib because of adverse events versus 26% in the temsirolimus group, reported Dr. Martin Dreyling of Klinikum der Universität in Munich, Germany, and his associates.
Based on results of the Functional Assessment of Cancer Therapy-Lymphoma (FACT-Lym) questionnaire, ibrutinib was associated with greater and more rapid improvements, and also with less worsening in lymphoma symptoms, as measured by the lymphoma subscale of the FACT-Lym (Lancet. 2016;387:770-78).
Ibrutinib, a first-in-class oral inhibitor of Bruton’s tyrosine kinase, is approved in the United States and the European Union at a dose of 560 mg per day for patients with mantle cell lymphoma who have received at least one previous line of therapy.
The mammalian target of rapamycin (mTOR) inhibitor temsirolimus is approved in the European Union for relapsed or refractory mantle-cell lymphoma, but does not have FDA approval for this indication.
The study, funded by Janssen, is ongoing. Future research, the investigators say, should examine ibrutinib-based combination approaches for patients with relapsed or refractory mantle-cell lymphoma and in front-line therapy.
Dr. Dreyling reported grants and personal fees from Janssen and Pfizer outside of the study. Several other authors reported grants from Janssen during the study and financial ties to the company.
FROM THE LANCET
Key clinical point: Ibrutinib significantly improved progression-free survival, compared with temsirolimus in patients with relapsed or refractory mantle-cell lymphoma.
Major finding: Median progression-free survival was 14.6 months with ibrutinib and 6.2 months with temsirolimus.
Data source: A randomized open-label phase III trial (ongoing) that randomized 280 patients to each treatment group.
Disclosures: The study was funded by Janssen. Dr. Dreyling reported grants and personal fees from Janssen and Pfizer outside of the study, and other authors reported grants from Janssen during the study and financial ties to the company.
VIDEO: Genetic tests, clinical data sharpen pigmented lesion diagnosis
WAIKOLOA, HAWAII – While many pigmented lesions analyzed in the dermatopathology lab are easily classifiable as benign or malignant, a certain percentage of cases are “very challenging to all examiners” – and in those cases, newer testing methods such as immunostaining or genetic testing can provide useful information, according to Dr. Whitney High.
Morphologic analysis of pigmented lesions under the microscope to determine whether a lesion is benign or malignant has limitations, said Dr. High, director of dermatopathology at the University of Colorado at Denver, Aurora. “We don’t really actually know. We haven’t genetically queried the cells.”
In a video interview at the Hawaii Dermatology Seminar, Dr. High emphasized, however, that no test is 100% sensitive and 100% specific. In fact, such tests should be considered adjunctive – requiring “some type of physician oversight or guidance to decide what is a significant result, what is an insignificant result, what is a confounded result, [and] what is a discrepant result.”
Clinical information is also useful, Dr. High said, noting that when this information is not provided, “I don’t really have any feeling from the clinician as to whether the lesion is new, growing, changing, [or] doing anything suspicious.”
The Hawaii Dermatology Seminar is provided by Global Academy for Medical Education/Skin Disease Education Foundation. SDEF and this news organization are owned by the same parent company.
Dr. High had no disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
WAIKOLOA, HAWAII – While many pigmented lesions analyzed in the dermatopathology lab are easily classifiable as benign or malignant, a certain percentage of cases are “very challenging to all examiners” – and in those cases, newer testing methods such as immunostaining or genetic testing can provide useful information, according to Dr. Whitney High.
Morphologic analysis of pigmented lesions under the microscope to determine whether a lesion is benign or malignant has limitations, said Dr. High, director of dermatopathology at the University of Colorado at Denver, Aurora. “We don’t really actually know. We haven’t genetically queried the cells.”
In a video interview at the Hawaii Dermatology Seminar, Dr. High emphasized, however, that no test is 100% sensitive and 100% specific. In fact, such tests should be considered adjunctive – requiring “some type of physician oversight or guidance to decide what is a significant result, what is an insignificant result, what is a confounded result, [and] what is a discrepant result.”
Clinical information is also useful, Dr. High said, noting that when this information is not provided, “I don’t really have any feeling from the clinician as to whether the lesion is new, growing, changing, [or] doing anything suspicious.”
The Hawaii Dermatology Seminar is provided by Global Academy for Medical Education/Skin Disease Education Foundation. SDEF and this news organization are owned by the same parent company.
Dr. High had no disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
WAIKOLOA, HAWAII – While many pigmented lesions analyzed in the dermatopathology lab are easily classifiable as benign or malignant, a certain percentage of cases are “very challenging to all examiners” – and in those cases, newer testing methods such as immunostaining or genetic testing can provide useful information, according to Dr. Whitney High.
Morphologic analysis of pigmented lesions under the microscope to determine whether a lesion is benign or malignant has limitations, said Dr. High, director of dermatopathology at the University of Colorado at Denver, Aurora. “We don’t really actually know. We haven’t genetically queried the cells.”
In a video interview at the Hawaii Dermatology Seminar, Dr. High emphasized, however, that no test is 100% sensitive and 100% specific. In fact, such tests should be considered adjunctive – requiring “some type of physician oversight or guidance to decide what is a significant result, what is an insignificant result, what is a confounded result, [and] what is a discrepant result.”
Clinical information is also useful, Dr. High said, noting that when this information is not provided, “I don’t really have any feeling from the clinician as to whether the lesion is new, growing, changing, [or] doing anything suspicious.”
The Hawaii Dermatology Seminar is provided by Global Academy for Medical Education/Skin Disease Education Foundation. SDEF and this news organization are owned by the same parent company.
Dr. High had no disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT SDEF HAWAII DERMATOLOGY SEMINAR
VIDEO: New microscopy tools improve melanoma detection
WAIKOLOA, HAWAII – Armed with dermoscopy and reflective confocal microscopy, dermatologists have been “pushing the envelope and becoming better and better at detecting melanoma and limiting the number of benign lesions being removed,” said Dr. Ashfaq A. Marghoob.
Dermoscopy – now used by about 75% of dermatologists in the United States – has lowered the benign-to-malignant ratio to about 5:1, Dr. Marghoob explained. That’s five benign nevi removed for every one melanoma found.
In an interview at the Hawaii Dermatology Seminar, Dr. Marghoob of Memorial Sloan Kettering Cancer Center, New York, discussed the impact that new technologies such as reflectance confocal microscopy are having on finding melanomas and differentiating them from benign nevi.
The Hawaii Dermatology Seminar is provided by the Global Academy for Medical Education/Skin Disease Education Foundation. The SDEF and this news organization are owned by the same parent company.
Dr. Marghoob had no disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
WAIKOLOA, HAWAII – Armed with dermoscopy and reflective confocal microscopy, dermatologists have been “pushing the envelope and becoming better and better at detecting melanoma and limiting the number of benign lesions being removed,” said Dr. Ashfaq A. Marghoob.
Dermoscopy – now used by about 75% of dermatologists in the United States – has lowered the benign-to-malignant ratio to about 5:1, Dr. Marghoob explained. That’s five benign nevi removed for every one melanoma found.
In an interview at the Hawaii Dermatology Seminar, Dr. Marghoob of Memorial Sloan Kettering Cancer Center, New York, discussed the impact that new technologies such as reflectance confocal microscopy are having on finding melanomas and differentiating them from benign nevi.
The Hawaii Dermatology Seminar is provided by the Global Academy for Medical Education/Skin Disease Education Foundation. The SDEF and this news organization are owned by the same parent company.
Dr. Marghoob had no disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
WAIKOLOA, HAWAII – Armed with dermoscopy and reflective confocal microscopy, dermatologists have been “pushing the envelope and becoming better and better at detecting melanoma and limiting the number of benign lesions being removed,” said Dr. Ashfaq A. Marghoob.
Dermoscopy – now used by about 75% of dermatologists in the United States – has lowered the benign-to-malignant ratio to about 5:1, Dr. Marghoob explained. That’s five benign nevi removed for every one melanoma found.
In an interview at the Hawaii Dermatology Seminar, Dr. Marghoob of Memorial Sloan Kettering Cancer Center, New York, discussed the impact that new technologies such as reflectance confocal microscopy are having on finding melanomas and differentiating them from benign nevi.
The Hawaii Dermatology Seminar is provided by the Global Academy for Medical Education/Skin Disease Education Foundation. The SDEF and this news organization are owned by the same parent company.
Dr. Marghoob had no disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT SDEF HAWAII DERMATOLOGY SEMINAR
Second targeted combination regime approved for metastatic melanoma
Click on the PDF icon at the top of this introduction to read the full article.
Click on the PDF icon at the top of this introduction to read the full article.
Click on the PDF icon at the top of this introduction to read the full article.
Product News: 02 2016
Cosentyx
Novartis Pharmaceuticals Corporation announces US Food and Drug Administration approval of 2 new indications for Cosentyx (secukinumab): to treat patients with active ankylosing spondylitis and active psoriatic arthritis. Cosentyx is a human monoclonal antibody that selectively binds to IL-17A and inhibits its interaction with the IL-17 receptor. Research suggests that IL-17A may play an important role in driving the body’s immune response in psoriasis, psoriatic arthritis, and ankylosing spondylitis. Cosentyx was approved in January 2015 for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy. For more information, visit www.cosentyx.com.
Emverm
Impax Laboratories, Inc, receives US Food and Drug Administration approval for the supplemental new drug application of Emverm (mebendazole) 100-mg chewable tablets for the treatment of pinworm and certain worm infections. Emverm is indicated for treatment of pinworm, whipworm, common roundworm, common hookworm, and American hookworm in single or mixed infections. Emverm is expected to become available early in the second quarter of 2016. For more information, visit www.impaxlabs.com.
Keytruda
Merck & Co, Inc, announces US Food and Drug Administration approval of an expanded indication for Keytruda (pembrolizumab) that includes the first-line treatment of patients with unresectable or metastatic melanoma. Keytruda is indicated in the United States at a dose of 2 mg/kg administered as an intravenous infusion over 30 minutes every 3 weeks. Keytruda is an anti–programmed death receptor-1 therapy that works by increasing the ability of the body’s immune system to help detect and fight tumor cells. For more information, visit www.keytruda.com.
Opdivo + Yervoy Regimen
The US Food and Drug Administration has granted accelerated approval of nivolumab (Opdivo) in combination with ipilimumab (Yervoy) for the treatment of patients with BRAF V600 wild-type unresectable or metastatic melanoma. An international, multicenter, double-blind, randomized, active-controlled trial in patients who were previously untreated for unresectable or metastatic BRAF V600 wild-type melanoma demonstrated an increase in the objective response rate, prolonged response durations, and improvement in progression-free survival. When used in combination with ipilimumab, the recommended dose and schedule is nivolumab 1 mg/kg administered as an intravenous infusion over 60 minutes, followed by ipilimumab on the same day every 3 weeks for 4 doses. The recommended subsequent dose of nivolumab, as a single agent, is 3 mg/kg as an intravenous infusion over 60 minutes every 2 weeks until disease progression or unacceptable toxicity. For more information, visit www.opdivoyervoyhcp.com.
TriAcnéal Day Mattifying Lotion and Night Smoothing Lotion
Pierre Fabre Dermo-Cosmetique USA introduces 2 TriAcnéal lotions in the Avène line for the treatment and prevention of acne. TriAcnéal Day Mattifying Lotion provides hydrating and mattifying care. It is gentle enough for daily use and can be used alone or in combination with topical acne prescriptions. A trio of ingredients target acne: PCC enzyme (consisting of papain, sodium alginate, caprylyl glycol, and hexanediol) for exfoliation to counteract the formation of new comedones, Diolényl (consisting of caprylyl glycol linseedate and potassium sorbate)to treat existing blemishes and prevent new lesions, and glyceryl laurate to reduce oil production. TriAcnéal Night Smoothing Lotion works to reduce the appearance of acne scars and provides moisturization and redness-reduction benefits. The nighttime formula contains PCC enzyme and Diolényl as well as retinaldehyde to diminish visible signs of aging. For more information, visit www.aveneusa.com.
If you would like your product included in Product News, please e-mail a press release to the Editorial Office at cutis@frontlinemedcom.com.
Cosentyx
Novartis Pharmaceuticals Corporation announces US Food and Drug Administration approval of 2 new indications for Cosentyx (secukinumab): to treat patients with active ankylosing spondylitis and active psoriatic arthritis. Cosentyx is a human monoclonal antibody that selectively binds to IL-17A and inhibits its interaction with the IL-17 receptor. Research suggests that IL-17A may play an important role in driving the body’s immune response in psoriasis, psoriatic arthritis, and ankylosing spondylitis. Cosentyx was approved in January 2015 for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy. For more information, visit www.cosentyx.com.
Emverm
Impax Laboratories, Inc, receives US Food and Drug Administration approval for the supplemental new drug application of Emverm (mebendazole) 100-mg chewable tablets for the treatment of pinworm and certain worm infections. Emverm is indicated for treatment of pinworm, whipworm, common roundworm, common hookworm, and American hookworm in single or mixed infections. Emverm is expected to become available early in the second quarter of 2016. For more information, visit www.impaxlabs.com.
Keytruda
Merck & Co, Inc, announces US Food and Drug Administration approval of an expanded indication for Keytruda (pembrolizumab) that includes the first-line treatment of patients with unresectable or metastatic melanoma. Keytruda is indicated in the United States at a dose of 2 mg/kg administered as an intravenous infusion over 30 minutes every 3 weeks. Keytruda is an anti–programmed death receptor-1 therapy that works by increasing the ability of the body’s immune system to help detect and fight tumor cells. For more information, visit www.keytruda.com.
Opdivo + Yervoy Regimen
The US Food and Drug Administration has granted accelerated approval of nivolumab (Opdivo) in combination with ipilimumab (Yervoy) for the treatment of patients with BRAF V600 wild-type unresectable or metastatic melanoma. An international, multicenter, double-blind, randomized, active-controlled trial in patients who were previously untreated for unresectable or metastatic BRAF V600 wild-type melanoma demonstrated an increase in the objective response rate, prolonged response durations, and improvement in progression-free survival. When used in combination with ipilimumab, the recommended dose and schedule is nivolumab 1 mg/kg administered as an intravenous infusion over 60 minutes, followed by ipilimumab on the same day every 3 weeks for 4 doses. The recommended subsequent dose of nivolumab, as a single agent, is 3 mg/kg as an intravenous infusion over 60 minutes every 2 weeks until disease progression or unacceptable toxicity. For more information, visit www.opdivoyervoyhcp.com.
TriAcnéal Day Mattifying Lotion and Night Smoothing Lotion
Pierre Fabre Dermo-Cosmetique USA introduces 2 TriAcnéal lotions in the Avène line for the treatment and prevention of acne. TriAcnéal Day Mattifying Lotion provides hydrating and mattifying care. It is gentle enough for daily use and can be used alone or in combination with topical acne prescriptions. A trio of ingredients target acne: PCC enzyme (consisting of papain, sodium alginate, caprylyl glycol, and hexanediol) for exfoliation to counteract the formation of new comedones, Diolényl (consisting of caprylyl glycol linseedate and potassium sorbate)to treat existing blemishes and prevent new lesions, and glyceryl laurate to reduce oil production. TriAcnéal Night Smoothing Lotion works to reduce the appearance of acne scars and provides moisturization and redness-reduction benefits. The nighttime formula contains PCC enzyme and Diolényl as well as retinaldehyde to diminish visible signs of aging. For more information, visit www.aveneusa.com.
If you would like your product included in Product News, please e-mail a press release to the Editorial Office at cutis@frontlinemedcom.com.
Cosentyx
Novartis Pharmaceuticals Corporation announces US Food and Drug Administration approval of 2 new indications for Cosentyx (secukinumab): to treat patients with active ankylosing spondylitis and active psoriatic arthritis. Cosentyx is a human monoclonal antibody that selectively binds to IL-17A and inhibits its interaction with the IL-17 receptor. Research suggests that IL-17A may play an important role in driving the body’s immune response in psoriasis, psoriatic arthritis, and ankylosing spondylitis. Cosentyx was approved in January 2015 for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy. For more information, visit www.cosentyx.com.
Emverm
Impax Laboratories, Inc, receives US Food and Drug Administration approval for the supplemental new drug application of Emverm (mebendazole) 100-mg chewable tablets for the treatment of pinworm and certain worm infections. Emverm is indicated for treatment of pinworm, whipworm, common roundworm, common hookworm, and American hookworm in single or mixed infections. Emverm is expected to become available early in the second quarter of 2016. For more information, visit www.impaxlabs.com.
Keytruda
Merck & Co, Inc, announces US Food and Drug Administration approval of an expanded indication for Keytruda (pembrolizumab) that includes the first-line treatment of patients with unresectable or metastatic melanoma. Keytruda is indicated in the United States at a dose of 2 mg/kg administered as an intravenous infusion over 30 minutes every 3 weeks. Keytruda is an anti–programmed death receptor-1 therapy that works by increasing the ability of the body’s immune system to help detect and fight tumor cells. For more information, visit www.keytruda.com.
Opdivo + Yervoy Regimen
The US Food and Drug Administration has granted accelerated approval of nivolumab (Opdivo) in combination with ipilimumab (Yervoy) for the treatment of patients with BRAF V600 wild-type unresectable or metastatic melanoma. An international, multicenter, double-blind, randomized, active-controlled trial in patients who were previously untreated for unresectable or metastatic BRAF V600 wild-type melanoma demonstrated an increase in the objective response rate, prolonged response durations, and improvement in progression-free survival. When used in combination with ipilimumab, the recommended dose and schedule is nivolumab 1 mg/kg administered as an intravenous infusion over 60 minutes, followed by ipilimumab on the same day every 3 weeks for 4 doses. The recommended subsequent dose of nivolumab, as a single agent, is 3 mg/kg as an intravenous infusion over 60 minutes every 2 weeks until disease progression or unacceptable toxicity. For more information, visit www.opdivoyervoyhcp.com.
TriAcnéal Day Mattifying Lotion and Night Smoothing Lotion
Pierre Fabre Dermo-Cosmetique USA introduces 2 TriAcnéal lotions in the Avène line for the treatment and prevention of acne. TriAcnéal Day Mattifying Lotion provides hydrating and mattifying care. It is gentle enough for daily use and can be used alone or in combination with topical acne prescriptions. A trio of ingredients target acne: PCC enzyme (consisting of papain, sodium alginate, caprylyl glycol, and hexanediol) for exfoliation to counteract the formation of new comedones, Diolényl (consisting of caprylyl glycol linseedate and potassium sorbate)to treat existing blemishes and prevent new lesions, and glyceryl laurate to reduce oil production. TriAcnéal Night Smoothing Lotion works to reduce the appearance of acne scars and provides moisturization and redness-reduction benefits. The nighttime formula contains PCC enzyme and Diolényl as well as retinaldehyde to diminish visible signs of aging. For more information, visit www.aveneusa.com.
If you would like your product included in Product News, please e-mail a press release to the Editorial Office at cutis@frontlinemedcom.com.
VIDEO: What’s new on atopic dermatitis drugs and cancer concerns?
WAIKOLOA, HAWAII – Topical calcineurin inhibitors’ boxed warnings give many patients and physicians pause over cancer concerns – but a new database analysis may put some minds at ease about the drugs’ use for atopic dermatitis.
“Pimecrolimus and tacrolimus are given topically, not internally – very little absorption occurs. So, it was hoped that ... we wouldn’t see cancer increases in these patients,” explained Dr. Joseph F. Fowler Jr., clinical professor of dermatology at the University of Louisville (Ky.). “And in fact, that’s exactly what was shown in this large study.”
In an interview at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation, Dr. Fowler discussed the data from new research examining cancer incidence and calcineurin inhibitor use.
SDEF and this news organization are owned by the same parent company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
WAIKOLOA, HAWAII – Topical calcineurin inhibitors’ boxed warnings give many patients and physicians pause over cancer concerns – but a new database analysis may put some minds at ease about the drugs’ use for atopic dermatitis.
“Pimecrolimus and tacrolimus are given topically, not internally – very little absorption occurs. So, it was hoped that ... we wouldn’t see cancer increases in these patients,” explained Dr. Joseph F. Fowler Jr., clinical professor of dermatology at the University of Louisville (Ky.). “And in fact, that’s exactly what was shown in this large study.”
In an interview at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation, Dr. Fowler discussed the data from new research examining cancer incidence and calcineurin inhibitor use.
SDEF and this news organization are owned by the same parent company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
WAIKOLOA, HAWAII – Topical calcineurin inhibitors’ boxed warnings give many patients and physicians pause over cancer concerns – but a new database analysis may put some minds at ease about the drugs’ use for atopic dermatitis.
“Pimecrolimus and tacrolimus are given topically, not internally – very little absorption occurs. So, it was hoped that ... we wouldn’t see cancer increases in these patients,” explained Dr. Joseph F. Fowler Jr., clinical professor of dermatology at the University of Louisville (Ky.). “And in fact, that’s exactly what was shown in this large study.”
In an interview at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation, Dr. Fowler discussed the data from new research examining cancer incidence and calcineurin inhibitor use.
SDEF and this news organization are owned by the same parent company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT SDEF HAWAII DERMATOLOGY SEMINAR
When the Doctor Is Not a Doctor
It is now common for patients to arrive in a physician office and never see the physician. Instead, patients are seen by so-called physician extenders. As our population ages, the need for medical care continues to grow beyond the capacity of the 900,000 US physicians that provide required services, particularly in the first level (primary care). The response to the physician shortage has entailed a variety of strategies. There has been a major immigration of foreign physicians, particularly from India; US medical schools have been encouraged to increase enrollment; and new medical schools have been inaugurated. Physicians have been pushed to adopt electronic medical records to permit increased throughput of patients in office practices. These multiple approaches have had an effect, though sometimes the results are undesirable. For example, complicated computer programs often detract from the physician-patient relationship.
One of the early solutions offered to deal with the doctor shortage in primary care was the concept of physician extenders (PEs), also called mid-level practitioners, who are professionals trained to take on a number of the simpler tasks performed by physicians. There are 2 basic classes of PEs: nurse practitioners and physician assistants. Nurse practitioners are originally trained to perform nursing but then undertake a course of study including scientific courses and clinical exposure to various parts of medicine. Physician assistants receive similar training. The duration of training for PEs usually is 18 to 24 months, whereas physicians attend medical school for 4 years. Unlike physicians, mid-level practitioners do not enter physician postgraduate residency training programs, which last many years.
The original concept was that PEs would work side by side with physicians who would supervise the care provided by the PEs. This team concept was designed to free physicians from the more mundane aspects of medical care and allow them to focus on the more challenging diagnostic and therapeutic issues presented by individual patients. In an era in which the burden of documentation has become increasingly onerous, the assistance of paraprofessionals can spare physicians the entry of redundant details in electronic databases that do not contribute to patient welfare.
However, research suggests that the concept of mid-level providers undertaking first-level care side by side with physicians has diverged from the original goal. An article by Coldiron and Ratnarathorn (JAMA Dermatol. 2014;150:1153-1159) studied Medicare billing data. The authors discovered that a variety of activities, many with higher reimbursement than primary care, were billed directly by PEs without apparent physician involvement, including a large number of complex invasive procedures, more than half in dermatology. Their article focused on dermatologic procedures, such as the destruction of skin cancers and advanced surgical repairs, but they listed many other procedures that are typically in the domain of highly trained physicians, including radiologic interpretations such as mammography and joint injections such as spinal injections. The data they presented were substantiated by publications in the medical literature suggesting that mid-level providers at certain hospitals even perform heart catheterizations and gastrointestinal endoscopies.
There have been no apologies for the unsupervised conduct of physician activities by nonphysicians. On the contrary, many PEs claim to be as well trained and proficient as medical doctors. Coldiron and Ratnarathorn argued otherwise. They pointed out that physicians receive an average of 10,000 hours of training compared to 2000 hours for mid-level practitioners, and they raised concerns about misdiagnoses, complications, and unnecessary procedures performed by PEs without supervision. In an editorial, Jalian and Avram (JAMA Dermatol. 2014;150:1149-1151) pointed out that a disproportionate number of cases of lawsuits for laser-induced injuries are related to performance by nonphysicians.
The pressures to allow nonphysicians to practice medicine independently are increasing. There is a shortage of physicians, especially in states such as Massachusetts that have substantial governmental limitation of physician reimbursement. In Massachusetts, regulations encourage mid-level practitioners to practice without physician supervision and even call themselves “doctors.” Furthermore, hospitals have faced residency funding cuts by Medicare and have had regulatory limitation of work hours by medical doctors in residency training. As a result, many institutions have turned to PEs to perform procedures that are typically performed by medical doctors.
Perhaps the greatest pressure favoring use of nonphysicians is financial. Mid-level practitioners receive lower salaries, typically 45% less, than medical doctors. In an era in which lowering costs has supplanted the goal of offering the best medical care possible, the attraction of replacement of a physician by a professional with less training becomes irresistible. It also is of concern that many physicians ignore the requirement to supervise the work of mid-level practitioners to maximize profit. Physicians often hire a mid-level provider rather than finding another physician to partner in their practice. Patients referred to a dermatologist often are seen by a PE and never even see the physician.
The concept of PEs working in a team with physicians remains an excellent approach to remedying the shortage of medical doctors, but we need to return to the original plan. Physician extenders should perform primary care rather than complex and lucrative subspecialties. There must be adequate supervision and definitely participation by physicians in rendering care.
All of the authors in the articles cited argue for greater regulation of unsupervised PEs to prevent performance of procedures where they lack expertise. Although the regulatory approach is sensible, it is more important to ensure that patients choose who gives them their medical care. They should not be obligated to see mid-level practitioners if they want to see a medical doctor. Above all, patients must be informed of the qualifications of those who provide their medical care. They should not be blindsided when they arrive for an appointment with their physician and find themselves shunted to a PE. We must not allow financial considerations to override the integrity of the medical care process.
What do you think is the optimal and safest role for PEs in a dermatology practice?
We want to know your views! Tell us what you think.
It is now common for patients to arrive in a physician office and never see the physician. Instead, patients are seen by so-called physician extenders. As our population ages, the need for medical care continues to grow beyond the capacity of the 900,000 US physicians that provide required services, particularly in the first level (primary care). The response to the physician shortage has entailed a variety of strategies. There has been a major immigration of foreign physicians, particularly from India; US medical schools have been encouraged to increase enrollment; and new medical schools have been inaugurated. Physicians have been pushed to adopt electronic medical records to permit increased throughput of patients in office practices. These multiple approaches have had an effect, though sometimes the results are undesirable. For example, complicated computer programs often detract from the physician-patient relationship.
One of the early solutions offered to deal with the doctor shortage in primary care was the concept of physician extenders (PEs), also called mid-level practitioners, who are professionals trained to take on a number of the simpler tasks performed by physicians. There are 2 basic classes of PEs: nurse practitioners and physician assistants. Nurse practitioners are originally trained to perform nursing but then undertake a course of study including scientific courses and clinical exposure to various parts of medicine. Physician assistants receive similar training. The duration of training for PEs usually is 18 to 24 months, whereas physicians attend medical school for 4 years. Unlike physicians, mid-level practitioners do not enter physician postgraduate residency training programs, which last many years.
The original concept was that PEs would work side by side with physicians who would supervise the care provided by the PEs. This team concept was designed to free physicians from the more mundane aspects of medical care and allow them to focus on the more challenging diagnostic and therapeutic issues presented by individual patients. In an era in which the burden of documentation has become increasingly onerous, the assistance of paraprofessionals can spare physicians the entry of redundant details in electronic databases that do not contribute to patient welfare.
However, research suggests that the concept of mid-level providers undertaking first-level care side by side with physicians has diverged from the original goal. An article by Coldiron and Ratnarathorn (JAMA Dermatol. 2014;150:1153-1159) studied Medicare billing data. The authors discovered that a variety of activities, many with higher reimbursement than primary care, were billed directly by PEs without apparent physician involvement, including a large number of complex invasive procedures, more than half in dermatology. Their article focused on dermatologic procedures, such as the destruction of skin cancers and advanced surgical repairs, but they listed many other procedures that are typically in the domain of highly trained physicians, including radiologic interpretations such as mammography and joint injections such as spinal injections. The data they presented were substantiated by publications in the medical literature suggesting that mid-level providers at certain hospitals even perform heart catheterizations and gastrointestinal endoscopies.
There have been no apologies for the unsupervised conduct of physician activities by nonphysicians. On the contrary, many PEs claim to be as well trained and proficient as medical doctors. Coldiron and Ratnarathorn argued otherwise. They pointed out that physicians receive an average of 10,000 hours of training compared to 2000 hours for mid-level practitioners, and they raised concerns about misdiagnoses, complications, and unnecessary procedures performed by PEs without supervision. In an editorial, Jalian and Avram (JAMA Dermatol. 2014;150:1149-1151) pointed out that a disproportionate number of cases of lawsuits for laser-induced injuries are related to performance by nonphysicians.
The pressures to allow nonphysicians to practice medicine independently are increasing. There is a shortage of physicians, especially in states such as Massachusetts that have substantial governmental limitation of physician reimbursement. In Massachusetts, regulations encourage mid-level practitioners to practice without physician supervision and even call themselves “doctors.” Furthermore, hospitals have faced residency funding cuts by Medicare and have had regulatory limitation of work hours by medical doctors in residency training. As a result, many institutions have turned to PEs to perform procedures that are typically performed by medical doctors.
Perhaps the greatest pressure favoring use of nonphysicians is financial. Mid-level practitioners receive lower salaries, typically 45% less, than medical doctors. In an era in which lowering costs has supplanted the goal of offering the best medical care possible, the attraction of replacement of a physician by a professional with less training becomes irresistible. It also is of concern that many physicians ignore the requirement to supervise the work of mid-level practitioners to maximize profit. Physicians often hire a mid-level provider rather than finding another physician to partner in their practice. Patients referred to a dermatologist often are seen by a PE and never even see the physician.
The concept of PEs working in a team with physicians remains an excellent approach to remedying the shortage of medical doctors, but we need to return to the original plan. Physician extenders should perform primary care rather than complex and lucrative subspecialties. There must be adequate supervision and definitely participation by physicians in rendering care.
All of the authors in the articles cited argue for greater regulation of unsupervised PEs to prevent performance of procedures where they lack expertise. Although the regulatory approach is sensible, it is more important to ensure that patients choose who gives them their medical care. They should not be obligated to see mid-level practitioners if they want to see a medical doctor. Above all, patients must be informed of the qualifications of those who provide their medical care. They should not be blindsided when they arrive for an appointment with their physician and find themselves shunted to a PE. We must not allow financial considerations to override the integrity of the medical care process.
What do you think is the optimal and safest role for PEs in a dermatology practice?
We want to know your views! Tell us what you think.
It is now common for patients to arrive in a physician office and never see the physician. Instead, patients are seen by so-called physician extenders. As our population ages, the need for medical care continues to grow beyond the capacity of the 900,000 US physicians that provide required services, particularly in the first level (primary care). The response to the physician shortage has entailed a variety of strategies. There has been a major immigration of foreign physicians, particularly from India; US medical schools have been encouraged to increase enrollment; and new medical schools have been inaugurated. Physicians have been pushed to adopt electronic medical records to permit increased throughput of patients in office practices. These multiple approaches have had an effect, though sometimes the results are undesirable. For example, complicated computer programs often detract from the physician-patient relationship.
One of the early solutions offered to deal with the doctor shortage in primary care was the concept of physician extenders (PEs), also called mid-level practitioners, who are professionals trained to take on a number of the simpler tasks performed by physicians. There are 2 basic classes of PEs: nurse practitioners and physician assistants. Nurse practitioners are originally trained to perform nursing but then undertake a course of study including scientific courses and clinical exposure to various parts of medicine. Physician assistants receive similar training. The duration of training for PEs usually is 18 to 24 months, whereas physicians attend medical school for 4 years. Unlike physicians, mid-level practitioners do not enter physician postgraduate residency training programs, which last many years.
The original concept was that PEs would work side by side with physicians who would supervise the care provided by the PEs. This team concept was designed to free physicians from the more mundane aspects of medical care and allow them to focus on the more challenging diagnostic and therapeutic issues presented by individual patients. In an era in which the burden of documentation has become increasingly onerous, the assistance of paraprofessionals can spare physicians the entry of redundant details in electronic databases that do not contribute to patient welfare.
However, research suggests that the concept of mid-level providers undertaking first-level care side by side with physicians has diverged from the original goal. An article by Coldiron and Ratnarathorn (JAMA Dermatol. 2014;150:1153-1159) studied Medicare billing data. The authors discovered that a variety of activities, many with higher reimbursement than primary care, were billed directly by PEs without apparent physician involvement, including a large number of complex invasive procedures, more than half in dermatology. Their article focused on dermatologic procedures, such as the destruction of skin cancers and advanced surgical repairs, but they listed many other procedures that are typically in the domain of highly trained physicians, including radiologic interpretations such as mammography and joint injections such as spinal injections. The data they presented were substantiated by publications in the medical literature suggesting that mid-level providers at certain hospitals even perform heart catheterizations and gastrointestinal endoscopies.
There have been no apologies for the unsupervised conduct of physician activities by nonphysicians. On the contrary, many PEs claim to be as well trained and proficient as medical doctors. Coldiron and Ratnarathorn argued otherwise. They pointed out that physicians receive an average of 10,000 hours of training compared to 2000 hours for mid-level practitioners, and they raised concerns about misdiagnoses, complications, and unnecessary procedures performed by PEs without supervision. In an editorial, Jalian and Avram (JAMA Dermatol. 2014;150:1149-1151) pointed out that a disproportionate number of cases of lawsuits for laser-induced injuries are related to performance by nonphysicians.
The pressures to allow nonphysicians to practice medicine independently are increasing. There is a shortage of physicians, especially in states such as Massachusetts that have substantial governmental limitation of physician reimbursement. In Massachusetts, regulations encourage mid-level practitioners to practice without physician supervision and even call themselves “doctors.” Furthermore, hospitals have faced residency funding cuts by Medicare and have had regulatory limitation of work hours by medical doctors in residency training. As a result, many institutions have turned to PEs to perform procedures that are typically performed by medical doctors.
Perhaps the greatest pressure favoring use of nonphysicians is financial. Mid-level practitioners receive lower salaries, typically 45% less, than medical doctors. In an era in which lowering costs has supplanted the goal of offering the best medical care possible, the attraction of replacement of a physician by a professional with less training becomes irresistible. It also is of concern that many physicians ignore the requirement to supervise the work of mid-level practitioners to maximize profit. Physicians often hire a mid-level provider rather than finding another physician to partner in their practice. Patients referred to a dermatologist often are seen by a PE and never even see the physician.
The concept of PEs working in a team with physicians remains an excellent approach to remedying the shortage of medical doctors, but we need to return to the original plan. Physician extenders should perform primary care rather than complex and lucrative subspecialties. There must be adequate supervision and definitely participation by physicians in rendering care.
All of the authors in the articles cited argue for greater regulation of unsupervised PEs to prevent performance of procedures where they lack expertise. Although the regulatory approach is sensible, it is more important to ensure that patients choose who gives them their medical care. They should not be obligated to see mid-level practitioners if they want to see a medical doctor. Above all, patients must be informed of the qualifications of those who provide their medical care. They should not be blindsided when they arrive for an appointment with their physician and find themselves shunted to a PE. We must not allow financial considerations to override the integrity of the medical care process.
What do you think is the optimal and safest role for PEs in a dermatology practice?
We want to know your views! Tell us what you think.
New tanning dependence screening tool ‘promising’
The validity of a new screening tool used to identify people who are addicted to indoor tanning has been confirmed in a recent study.
In background information to their study, the researchers, led by Jerod L. Stapleton of the Rutgers Cancer Institute of New Jersey, said tools for assessing tanning addiction had been developed by adapting existing substance addiction screening tools. However, concerns had been raised about their validity, with some research suggesting assessment results did not correspond to actual tanning behaviors.
The Behavioral Addiction Indoor Tanning Screener (BAITS) screening tool was first described in the DSM-5. The tool was designed to capture the experience of diminished control and urges to use indoor tanning, the research team explained in a short communication published in Acta Dermato-Venereologica (2015 [doi: 10.2340/00015555-2290]).
The aim of the current study was to validate BAITS classification criteria by comparing it with the Structured Interview for Tanning Abuse and Dependence (SITAD) clinical assessment as well as indoor tanning use 6 months later.
Of the 164 participants, 81% did not agree with any BAITS items, 10% agreed with one, and 9% agreed with two or more. Those who agreed with two or more BAITS items were highly likely to be diagnosed as tanning dependent on the SITAD (73%), compared with those with one response (25%) or zero responses (1%) (P less than .001).
Participants who agreed with two or more BAITS items also reported an indoor tanning frequency at 6 months more than two and a half times higher than that of those agreeing with one item, and more than four and a half times higher than that of participants who endorsed no items.
“The BAITS represents a promising screening tool for symptoms of tanning addiction with preliminary evidence of validity,“ the research team wrote.
The BAITS could be used to identify patients in need of counseling to avoid indoor tanning, they suggested. “Although there is a lack of behavioral interventions targeted to individuals who are addicted to tanning, even brief counseling by clinicians regarding addictive behaviors, like smoking, can lead to measurable reductions in use.”
No conflicts of interest were declared. The study was funded by a grant from the National Cancer Institute.
The validity of a new screening tool used to identify people who are addicted to indoor tanning has been confirmed in a recent study.
In background information to their study, the researchers, led by Jerod L. Stapleton of the Rutgers Cancer Institute of New Jersey, said tools for assessing tanning addiction had been developed by adapting existing substance addiction screening tools. However, concerns had been raised about their validity, with some research suggesting assessment results did not correspond to actual tanning behaviors.
The Behavioral Addiction Indoor Tanning Screener (BAITS) screening tool was first described in the DSM-5. The tool was designed to capture the experience of diminished control and urges to use indoor tanning, the research team explained in a short communication published in Acta Dermato-Venereologica (2015 [doi: 10.2340/00015555-2290]).
The aim of the current study was to validate BAITS classification criteria by comparing it with the Structured Interview for Tanning Abuse and Dependence (SITAD) clinical assessment as well as indoor tanning use 6 months later.
Of the 164 participants, 81% did not agree with any BAITS items, 10% agreed with one, and 9% agreed with two or more. Those who agreed with two or more BAITS items were highly likely to be diagnosed as tanning dependent on the SITAD (73%), compared with those with one response (25%) or zero responses (1%) (P less than .001).
Participants who agreed with two or more BAITS items also reported an indoor tanning frequency at 6 months more than two and a half times higher than that of those agreeing with one item, and more than four and a half times higher than that of participants who endorsed no items.
“The BAITS represents a promising screening tool for symptoms of tanning addiction with preliminary evidence of validity,“ the research team wrote.
The BAITS could be used to identify patients in need of counseling to avoid indoor tanning, they suggested. “Although there is a lack of behavioral interventions targeted to individuals who are addicted to tanning, even brief counseling by clinicians regarding addictive behaviors, like smoking, can lead to measurable reductions in use.”
No conflicts of interest were declared. The study was funded by a grant from the National Cancer Institute.
The validity of a new screening tool used to identify people who are addicted to indoor tanning has been confirmed in a recent study.
In background information to their study, the researchers, led by Jerod L. Stapleton of the Rutgers Cancer Institute of New Jersey, said tools for assessing tanning addiction had been developed by adapting existing substance addiction screening tools. However, concerns had been raised about their validity, with some research suggesting assessment results did not correspond to actual tanning behaviors.
The Behavioral Addiction Indoor Tanning Screener (BAITS) screening tool was first described in the DSM-5. The tool was designed to capture the experience of diminished control and urges to use indoor tanning, the research team explained in a short communication published in Acta Dermato-Venereologica (2015 [doi: 10.2340/00015555-2290]).
The aim of the current study was to validate BAITS classification criteria by comparing it with the Structured Interview for Tanning Abuse and Dependence (SITAD) clinical assessment as well as indoor tanning use 6 months later.
Of the 164 participants, 81% did not agree with any BAITS items, 10% agreed with one, and 9% agreed with two or more. Those who agreed with two or more BAITS items were highly likely to be diagnosed as tanning dependent on the SITAD (73%), compared with those with one response (25%) or zero responses (1%) (P less than .001).
Participants who agreed with two or more BAITS items also reported an indoor tanning frequency at 6 months more than two and a half times higher than that of those agreeing with one item, and more than four and a half times higher than that of participants who endorsed no items.
“The BAITS represents a promising screening tool for symptoms of tanning addiction with preliminary evidence of validity,“ the research team wrote.
The BAITS could be used to identify patients in need of counseling to avoid indoor tanning, they suggested. “Although there is a lack of behavioral interventions targeted to individuals who are addicted to tanning, even brief counseling by clinicians regarding addictive behaviors, like smoking, can lead to measurable reductions in use.”
No conflicts of interest were declared. The study was funded by a grant from the National Cancer Institute.
FROM ACTA DERMATO-VENEREOLOGICA
Key clinical point: A new screening tool for symptoms of tanning addiction has shown preliminary evidence of validity.
Major finding: Participants who agreed with two or more BAITS items were highly likely to be diagnosed as tanning dependent on the SITAD (73%), compared with those with one response (25%) or zero responses (1%).
Data source: An online survey that included the BAITS screening tool sent to a random sample of 700 students, and a follow-up survey at 6 months. Overall, 164 participants were included in the study.
Disclosures: No conflicts of interest were declared. The study was funded by a grant from the National Cancer Institute.
Average person with atopic dermatitis has no increased risk of actinic keratosis or nonmelanoma skin cancer
People with atopic dermatitis do not appear to be at greater risk for actinic keratosis or basal cell and squamous cell cancer, according to a recent population-based, cross-sectional study.
“This is the first study to examine the association between atopic dermatitis and actinic keratosis [AK]. Our findings suggest that within a population-based sample, atopic dermatitis patients do not have more AKs than the rest of the population. Patients with atopic dermatitis were not found to have more AKs or keratotic cancers [basal or squamous cell cancers]. Moreover, individuals with atopic dermatitis seem to be less likely to develop multiple AKs,” said Dr. Enes Hajdarbegovic and his associates of the Erasmus Medical Centre, Rotterdam, the Netherlands.
The study is part of an ongoing, prospective, Dutch population-based cohort study that follows people in a district of Rotterdam since 1990. There are now 14,926 participants in the database. The current study included 4,375 participants who had undergone full body skin examinations; 56% of patients were female, and the mean age was 68 years (Br J Dermatol. 2016 Jan 29. doi: 10.1111/bjd.14423).
Twenty-four percent had 1 or more AKs; 57% had 1-3 of these lesions; 23% had 4-9, and 20% had more than 10. The mean age of participants with AK was significantly higher, compared with those without AK (73 years vs. 66 years; P less than .01).
Of the 4,375 participants screened, 6.3% met the diagnostic criteria for atopic dermatitis. A lower proportion of those with atopic dermatitis had AK: 16% vs. 24%, respectively (P = .002). In a multinomial model, atopic dermatitis patients were 78% less likely to have 10 or more AKs than were those without atopic dermatitis. No effect of atopic dermatitis was found on basal cell cancer (adjusted odds ratio, 0.71) and squamous cell cancer (adjusted OR, 1.54).
The authors explained that it is already known that patients with severe atopic dermatitis exposed to ultraviolet light and immunosuppressants are at increased risk of keratinocyte malignancies. This study shows that a community-dwelling person with moderate atopic dermatitis does not develop more AKs or keratinocyte cancers.
The investigators said they had no relevant financial disclosures.
People with atopic dermatitis do not appear to be at greater risk for actinic keratosis or basal cell and squamous cell cancer, according to a recent population-based, cross-sectional study.
“This is the first study to examine the association between atopic dermatitis and actinic keratosis [AK]. Our findings suggest that within a population-based sample, atopic dermatitis patients do not have more AKs than the rest of the population. Patients with atopic dermatitis were not found to have more AKs or keratotic cancers [basal or squamous cell cancers]. Moreover, individuals with atopic dermatitis seem to be less likely to develop multiple AKs,” said Dr. Enes Hajdarbegovic and his associates of the Erasmus Medical Centre, Rotterdam, the Netherlands.
The study is part of an ongoing, prospective, Dutch population-based cohort study that follows people in a district of Rotterdam since 1990. There are now 14,926 participants in the database. The current study included 4,375 participants who had undergone full body skin examinations; 56% of patients were female, and the mean age was 68 years (Br J Dermatol. 2016 Jan 29. doi: 10.1111/bjd.14423).
Twenty-four percent had 1 or more AKs; 57% had 1-3 of these lesions; 23% had 4-9, and 20% had more than 10. The mean age of participants with AK was significantly higher, compared with those without AK (73 years vs. 66 years; P less than .01).
Of the 4,375 participants screened, 6.3% met the diagnostic criteria for atopic dermatitis. A lower proportion of those with atopic dermatitis had AK: 16% vs. 24%, respectively (P = .002). In a multinomial model, atopic dermatitis patients were 78% less likely to have 10 or more AKs than were those without atopic dermatitis. No effect of atopic dermatitis was found on basal cell cancer (adjusted odds ratio, 0.71) and squamous cell cancer (adjusted OR, 1.54).
The authors explained that it is already known that patients with severe atopic dermatitis exposed to ultraviolet light and immunosuppressants are at increased risk of keratinocyte malignancies. This study shows that a community-dwelling person with moderate atopic dermatitis does not develop more AKs or keratinocyte cancers.
The investigators said they had no relevant financial disclosures.
People with atopic dermatitis do not appear to be at greater risk for actinic keratosis or basal cell and squamous cell cancer, according to a recent population-based, cross-sectional study.
“This is the first study to examine the association between atopic dermatitis and actinic keratosis [AK]. Our findings suggest that within a population-based sample, atopic dermatitis patients do not have more AKs than the rest of the population. Patients with atopic dermatitis were not found to have more AKs or keratotic cancers [basal or squamous cell cancers]. Moreover, individuals with atopic dermatitis seem to be less likely to develop multiple AKs,” said Dr. Enes Hajdarbegovic and his associates of the Erasmus Medical Centre, Rotterdam, the Netherlands.
The study is part of an ongoing, prospective, Dutch population-based cohort study that follows people in a district of Rotterdam since 1990. There are now 14,926 participants in the database. The current study included 4,375 participants who had undergone full body skin examinations; 56% of patients were female, and the mean age was 68 years (Br J Dermatol. 2016 Jan 29. doi: 10.1111/bjd.14423).
Twenty-four percent had 1 or more AKs; 57% had 1-3 of these lesions; 23% had 4-9, and 20% had more than 10. The mean age of participants with AK was significantly higher, compared with those without AK (73 years vs. 66 years; P less than .01).
Of the 4,375 participants screened, 6.3% met the diagnostic criteria for atopic dermatitis. A lower proportion of those with atopic dermatitis had AK: 16% vs. 24%, respectively (P = .002). In a multinomial model, atopic dermatitis patients were 78% less likely to have 10 or more AKs than were those without atopic dermatitis. No effect of atopic dermatitis was found on basal cell cancer (adjusted odds ratio, 0.71) and squamous cell cancer (adjusted OR, 1.54).
The authors explained that it is already known that patients with severe atopic dermatitis exposed to ultraviolet light and immunosuppressants are at increased risk of keratinocyte malignancies. This study shows that a community-dwelling person with moderate atopic dermatitis does not develop more AKs or keratinocyte cancers.
The investigators said they had no relevant financial disclosures.
FROM THE BRITISH JOURNAL OF DERMATOLOGY
Key clinical point: People with atopic dermatitis do not appear to be at greater risk for actinic keratosis or basal cell and squamous cell cancer.
Major finding: In a multinomial model, atopic dermatitis patients were 78% less likely to have 10 or more actinic keratoses than were those without atopic dermatitis. No effect of atopic dermatitis was found on basal cell cancer (adjusted OR, 0.71) and squamous cell cancer (adjusted OR, 1.54).
Data source: A prospective, Dutch population-based cohort study of 4,375 participants who had undergone full body skin examinations.
Disclosures: The investigators said they had no relevant financial disclosures.
