Journal of Clinical Outcomes Management

Irregular and especially long menstrual cycles, particularly in early and mid adulthood, are associated with an increased risk for cardiovascular disease. This finding is demonstrated in a new analysis of the Nurses’ Health Study II.

“To date, several studies have reported increased risks of cardiovascular risk factors or cardiovascular disease in connection with cycle disorders,” Yi-Xin Wang, MD, PhD, a research fellow in nutrition, and associates from the Harvard School of Public Health, Boston, wrote in an article published in JAMA Network Open.

Ute Seeland, MD, speaker of the Gender Medicine in Cardiology Working Group of the German Cardiology Society, said in an interview“We know that women who have indicated in their medical history that they have irregular menstrual cycles, invariably in connection with polycystic ovary syndrome (PCOS), more commonly develop diabetes and other metabolic disorders, as well as cardiovascular diseases.”
 

Cycle disorders’ role

However, the role that irregular or especially long cycles play at different points of a woman’s reproductive life span was unclear. Therefore, the research group investigated the associations in the Nurses’ Health Study II between cycle irregularity and cycle length in women of different age groups who later experienced cardiovascular events.

At the end of this study in 1989, the participants also provided information regarding the length and irregularity of their menstrual cycle from ages 14 to 17 years and again from ages 18 to 22 years. The information was updated in 1993 when the participants were aged 29-46 years. The data from 2019 to 2022 were analyzed.

“This kind of long-term cohort study is extremely rare and therefore something special,” said Dr. Seeland, who conducts research at the Institute for Social Medicine, Epidemiology, and Health Economics at the Charité – University Hospital Berlin.

The investigators used the following cycle classifications: very regular (no more than 3 or 4 days before or after the expected date), regular (within 5-7 days), usually irregular, always irregular, or no periods.

The cycle lengths were divided into the following categories: less than 21 days, 21-25 days, 26-31 days, 32-39 days, 40-50 days, more than 50 days, and too irregular to estimate the length.

The onset of cardiovascular diseases was determined using information from the participants and was confirmed by reviewing the medical files. Relevant to the study were lethal and nonlethal coronary heart diseases (such as myocardial infarction or coronary artery revascularization), as well as strokes.
 

Significant in adulthood

The data from 80,630 study participants were included in the analysis. At study inclusion, the average age of the participants was 37.7 years, and the average body mass index (BMI) was 25.1. “Since it was predominantly White nurses who took part in the study, the data are not transferable to other, more diverse populations,” said Dr. Seeland.

Over 24 years, 1,816 women (2.4%) had a cardiovascular event. “We observed an increased rate of cardiovascular events in women with an irregular cycle and longer cycle, both in early an in mid-adulthood,” wrote Dr. Wang and associates. “Similar trends were also observed for cycle disorders when younger, but this association was weaker than in adulthood.”

Compared with women with very regular cycles, women with irregular cycles or without periods who were aged 14-17 years, 18-22 years, or 29-49 years exhibited a 15%, 36%, and 40% higher risk of a cardiovascular event, respectively.

Similarly, women aged 18-22 years or 29-46 years with long cycles of 40 days or more had a 44% or 30% higher risk of cardiovascular disease, respectively, compared with women with cycle lengths of 26-31 days.

“The coronary heart diseases were decisive for the increase, and less so, the strokes,” wrote the researchers.
 

Classic risk factors?

Dr. Seeland praised the fact that the study authors tried to determine the role that classic cardiovascular risk factors played. “Compared with women with a regular cycle, women with an irregular cycle had a higher BMI, more frequently increased cholesterol levels, and an elevated blood pressure,” she said. Women with a long cycle displayed a similar pattern.

It can be assumed from this that over a woman’s life span, BMI affects the risk of cardiovascular disease. Therefore, Dr. Wang and coauthors adjusted the results on the basis of BMI, which varies over time.

Regarding other classic risk factors that may have played a role, “hypercholesterolemia, chronic high blood pressure, and type 2 diabetes were only responsible in 5.4%-13.5% of the associations,” wrote the researchers.

“Our results suggest that certain characteristics of the menstrual cycle across a woman’s reproductive lifespan may constitute additional risk markers for cardiovascular disease,” according to the authors.

The highest rates of cardiovascular disease were among women with permanently irregular or long cycles in early to mid adulthood, as well as women who had regular cycles when younger but had irregular cycles in mid adulthood. “This indicates that the change from one cycle phenotype to another could be a surrogate marker for metabolic changes, which in turn contribute to the formation of cardiovascular diseases,” wrote the authors.

The study was observational and so conclusions cannot be drawn regarding causal relationships. But Dr. Wang and associates indicate that the most common cause of an irregular menstrual cycle may be PCOS. “Roughly 90% of women with cycle disorders or oligomenorrhea have signs of PCOS. And it was shown that women with PCOS have an increased risk of cardiovascular disease.”

They concluded that “the associations observed between irregular and long cycles in early to mid-adulthood and cardiovascular diseases are likely attributable to underlying PCOS.”

For Dr. Seeland, however, this conclusion is “too monocausal. At no point in time did there seem to be any direct information regarding the frequency of PCOS during the data collection by the respondents.”

For now, we can only speculate about the mechanisms. “The association between a very irregular and long cycle and the increased risk of cardiovascular diseases has now only been described. More research should be done on the causes,” said Dr. Seeland.

This article was translated from the Medscape German edition. A version of this article first appeared on Medscape.com.

Irregular and especially long menstrual cycles, particularly in early and mid adulthood, are associated with an increased risk for cardiovascular disease. This finding is demonstrated in a new analysis of the Nurses’ Health Study II.

“To date, several studies have reported increased risks of cardiovascular risk factors or cardiovascular disease in connection with cycle disorders,” Yi-Xin Wang, MD, PhD, a research fellow in nutrition, and associates from the Harvard School of Public Health, Boston, wrote in an article published in JAMA Network Open.

Ute Seeland, MD, speaker of the Gender Medicine in Cardiology Working Group of the German Cardiology Society, said in an interview“We know that women who have indicated in their medical history that they have irregular menstrual cycles, invariably in connection with polycystic ovary syndrome (PCOS), more commonly develop diabetes and other metabolic disorders, as well as cardiovascular diseases.”
 

Cycle disorders’ role

However, the role that irregular or especially long cycles play at different points of a woman’s reproductive life span was unclear. Therefore, the research group investigated the associations in the Nurses’ Health Study II between cycle irregularity and cycle length in women of different age groups who later experienced cardiovascular events.

At the end of this study in 1989, the participants also provided information regarding the length and irregularity of their menstrual cycle from ages 14 to 17 years and again from ages 18 to 22 years. The information was updated in 1993 when the participants were aged 29-46 years. The data from 2019 to 2022 were analyzed.

“This kind of long-term cohort study is extremely rare and therefore something special,” said Dr. Seeland, who conducts research at the Institute for Social Medicine, Epidemiology, and Health Economics at the Charité – University Hospital Berlin.

The investigators used the following cycle classifications: very regular (no more than 3 or 4 days before or after the expected date), regular (within 5-7 days), usually irregular, always irregular, or no periods.

The cycle lengths were divided into the following categories: less than 21 days, 21-25 days, 26-31 days, 32-39 days, 40-50 days, more than 50 days, and too irregular to estimate the length.

The onset of cardiovascular diseases was determined using information from the participants and was confirmed by reviewing the medical files. Relevant to the study were lethal and nonlethal coronary heart diseases (such as myocardial infarction or coronary artery revascularization), as well as strokes.
 

Significant in adulthood

The data from 80,630 study participants were included in the analysis. At study inclusion, the average age of the participants was 37.7 years, and the average body mass index (BMI) was 25.1. “Since it was predominantly White nurses who took part in the study, the data are not transferable to other, more diverse populations,” said Dr. Seeland.

Over 24 years, 1,816 women (2.4%) had a cardiovascular event. “We observed an increased rate of cardiovascular events in women with an irregular cycle and longer cycle, both in early an in mid-adulthood,” wrote Dr. Wang and associates. “Similar trends were also observed for cycle disorders when younger, but this association was weaker than in adulthood.”

Compared with women with very regular cycles, women with irregular cycles or without periods who were aged 14-17 years, 18-22 years, or 29-49 years exhibited a 15%, 36%, and 40% higher risk of a cardiovascular event, respectively.

Similarly, women aged 18-22 years or 29-46 years with long cycles of 40 days or more had a 44% or 30% higher risk of cardiovascular disease, respectively, compared with women with cycle lengths of 26-31 days.

“The coronary heart diseases were decisive for the increase, and less so, the strokes,” wrote the researchers.
 

Classic risk factors?

Dr. Seeland praised the fact that the study authors tried to determine the role that classic cardiovascular risk factors played. “Compared with women with a regular cycle, women with an irregular cycle had a higher BMI, more frequently increased cholesterol levels, and an elevated blood pressure,” she said. Women with a long cycle displayed a similar pattern.

It can be assumed from this that over a woman’s life span, BMI affects the risk of cardiovascular disease. Therefore, Dr. Wang and coauthors adjusted the results on the basis of BMI, which varies over time.

Regarding other classic risk factors that may have played a role, “hypercholesterolemia, chronic high blood pressure, and type 2 diabetes were only responsible in 5.4%-13.5% of the associations,” wrote the researchers.

“Our results suggest that certain characteristics of the menstrual cycle across a woman’s reproductive lifespan may constitute additional risk markers for cardiovascular disease,” according to the authors.

The highest rates of cardiovascular disease were among women with permanently irregular or long cycles in early to mid adulthood, as well as women who had regular cycles when younger but had irregular cycles in mid adulthood. “This indicates that the change from one cycle phenotype to another could be a surrogate marker for metabolic changes, which in turn contribute to the formation of cardiovascular diseases,” wrote the authors.

The study was observational and so conclusions cannot be drawn regarding causal relationships. But Dr. Wang and associates indicate that the most common cause of an irregular menstrual cycle may be PCOS. “Roughly 90% of women with cycle disorders or oligomenorrhea have signs of PCOS. And it was shown that women with PCOS have an increased risk of cardiovascular disease.”

They concluded that “the associations observed between irregular and long cycles in early to mid-adulthood and cardiovascular diseases are likely attributable to underlying PCOS.”

For Dr. Seeland, however, this conclusion is “too monocausal. At no point in time did there seem to be any direct information regarding the frequency of PCOS during the data collection by the respondents.”

For now, we can only speculate about the mechanisms. “The association between a very irregular and long cycle and the increased risk of cardiovascular diseases has now only been described. More research should be done on the causes,” said Dr. Seeland.

This article was translated from the Medscape German edition. A version of this article first appeared on Medscape.com.

Irregular and especially long menstrual cycles, particularly in early and mid adulthood, are associated with an increased risk for cardiovascular disease. This finding is demonstrated in a new analysis of the Nurses’ Health Study II.

“To date, several studies have reported increased risks of cardiovascular risk factors or cardiovascular disease in connection with cycle disorders,” Yi-Xin Wang, MD, PhD, a research fellow in nutrition, and associates from the Harvard School of Public Health, Boston, wrote in an article published in JAMA Network Open.

Ute Seeland, MD, speaker of the Gender Medicine in Cardiology Working Group of the German Cardiology Society, said in an interview“We know that women who have indicated in their medical history that they have irregular menstrual cycles, invariably in connection with polycystic ovary syndrome (PCOS), more commonly develop diabetes and other metabolic disorders, as well as cardiovascular diseases.”
 

Cycle disorders’ role

However, the role that irregular or especially long cycles play at different points of a woman’s reproductive life span was unclear. Therefore, the research group investigated the associations in the Nurses’ Health Study II between cycle irregularity and cycle length in women of different age groups who later experienced cardiovascular events.

At the end of this study in 1989, the participants also provided information regarding the length and irregularity of their menstrual cycle from ages 14 to 17 years and again from ages 18 to 22 years. The information was updated in 1993 when the participants were aged 29-46 years. The data from 2019 to 2022 were analyzed.

“This kind of long-term cohort study is extremely rare and therefore something special,” said Dr. Seeland, who conducts research at the Institute for Social Medicine, Epidemiology, and Health Economics at the Charité – University Hospital Berlin.

The investigators used the following cycle classifications: very regular (no more than 3 or 4 days before or after the expected date), regular (within 5-7 days), usually irregular, always irregular, or no periods.

The cycle lengths were divided into the following categories: less than 21 days, 21-25 days, 26-31 days, 32-39 days, 40-50 days, more than 50 days, and too irregular to estimate the length.

The onset of cardiovascular diseases was determined using information from the participants and was confirmed by reviewing the medical files. Relevant to the study were lethal and nonlethal coronary heart diseases (such as myocardial infarction or coronary artery revascularization), as well as strokes.
 

Significant in adulthood

The data from 80,630 study participants were included in the analysis. At study inclusion, the average age of the participants was 37.7 years, and the average body mass index (BMI) was 25.1. “Since it was predominantly White nurses who took part in the study, the data are not transferable to other, more diverse populations,” said Dr. Seeland.

Over 24 years, 1,816 women (2.4%) had a cardiovascular event. “We observed an increased rate of cardiovascular events in women with an irregular cycle and longer cycle, both in early an in mid-adulthood,” wrote Dr. Wang and associates. “Similar trends were also observed for cycle disorders when younger, but this association was weaker than in adulthood.”

Compared with women with very regular cycles, women with irregular cycles or without periods who were aged 14-17 years, 18-22 years, or 29-49 years exhibited a 15%, 36%, and 40% higher risk of a cardiovascular event, respectively.

Similarly, women aged 18-22 years or 29-46 years with long cycles of 40 days or more had a 44% or 30% higher risk of cardiovascular disease, respectively, compared with women with cycle lengths of 26-31 days.

“The coronary heart diseases were decisive for the increase, and less so, the strokes,” wrote the researchers.
 

Classic risk factors?

Dr. Seeland praised the fact that the study authors tried to determine the role that classic cardiovascular risk factors played. “Compared with women with a regular cycle, women with an irregular cycle had a higher BMI, more frequently increased cholesterol levels, and an elevated blood pressure,” she said. Women with a long cycle displayed a similar pattern.

It can be assumed from this that over a woman’s life span, BMI affects the risk of cardiovascular disease. Therefore, Dr. Wang and coauthors adjusted the results on the basis of BMI, which varies over time.

Regarding other classic risk factors that may have played a role, “hypercholesterolemia, chronic high blood pressure, and type 2 diabetes were only responsible in 5.4%-13.5% of the associations,” wrote the researchers.

“Our results suggest that certain characteristics of the menstrual cycle across a woman’s reproductive lifespan may constitute additional risk markers for cardiovascular disease,” according to the authors.

The highest rates of cardiovascular disease were among women with permanently irregular or long cycles in early to mid adulthood, as well as women who had regular cycles when younger but had irregular cycles in mid adulthood. “This indicates that the change from one cycle phenotype to another could be a surrogate marker for metabolic changes, which in turn contribute to the formation of cardiovascular diseases,” wrote the authors.

The study was observational and so conclusions cannot be drawn regarding causal relationships. But Dr. Wang and associates indicate that the most common cause of an irregular menstrual cycle may be PCOS. “Roughly 90% of women with cycle disorders or oligomenorrhea have signs of PCOS. And it was shown that women with PCOS have an increased risk of cardiovascular disease.”

They concluded that “the associations observed between irregular and long cycles in early to mid-adulthood and cardiovascular diseases are likely attributable to underlying PCOS.”

For Dr. Seeland, however, this conclusion is “too monocausal. At no point in time did there seem to be any direct information regarding the frequency of PCOS during the data collection by the respondents.”

For now, we can only speculate about the mechanisms. “The association between a very irregular and long cycle and the increased risk of cardiovascular diseases has now only been described. More research should be done on the causes,” said Dr. Seeland.

This article was translated from the Medscape German edition. A version of this article first appeared on Medscape.com.

In this current age of mass misinformation and disinformation on the Internet, a tongue-in-cheek study that evaluated beliefs and attitudes toward cancer among conspiracy theorists and people who oppose vaccinations has received some harsh criticism.

The study, entitled, “Everything Causes Cancer? Beliefs and Attitudes Towards Cancer Prevention Among Anti-Vaxxers, Flat Earthers, and Reptilian Conspiracists: Online Cross Sectional Survey,” was published in the Christmas 2022 issue of The British Medical Journal (BMJ).

The authors explain that they set out to evaluate “the patterns of beliefs about cancer among people who believed in conspiracies, rejected the COVID-19 vaccine, or preferred alternative medicine.”

They sought such people on social media and online chat platforms and asked them questions about real and mythical causes of cancer.

Almost half of survey participants agreed with the statement, “It seems like everything causes cancer.”

Overall, among all participants, awareness of the actual causes of cancer was greater than awareness of the mythical causes of cancer, the authors report. However, awareness of the actual causes of cancer was lower among the unvaccinated and members of conspiracy groups than among their counterparts.

The authors are concerned that their findings suggest “a direct connection between digital misinformation and consequent potential erroneous health decisions, which may represent a further preventable fraction of cancer.”
 

Backlash and criticism

The study “highlights the difficulty society encounters in distinguishing the actual causes of cancer from mythical causes,” The BMJ commented on Twitter.

However, both the study and the journal received some backlash.

This is a “horrible article seeking to smear people with concerns about COVID vaccines,” commented Clare Craig, a British consultant pathologist who specializes in cancer diagnostics.

The study and its methodology were also harshly criticized on Twitter by Normal Fenton, professor of risk information management at the Queen Mary University of London.

The senior author of the study, Laura Costas, a medical epidemiologist with the Catalan Institute of Oncology, Barcelona, told this news organization that the naysayers on social media, many of whom focused their comments on the COVID-19 vaccine, prove the purpose of the study – that misinformation spreads widely on the internet.

“Most comments focused on spreading COVID-19 myths, which were not the direct subject of the study, and questioned the motivations of BMJ authors and the scientific community, assuming they had a common malevolent hidden agenda,” Ms. Costas said.

“They stated the need of having critical thinking, a trait in common with the scientific method, but dogmatically dismissed any information that comes from official sources,” she added.

Ms. Costas commented that “society encounters difficulty in differentiating actual from mythical causes of cancer owing to mass information. We therefore planned this study with a certain satire, which is in line with the essence of The BMJ Christmas issue.”

The BMJ has a long history of publishing a lighthearted Christmas edition full of original, satirical, and nontraditional studies. Previous years have seen studies that explored potential harms from holly and ivy, survival time of chocolates on hospital wards, and the question, “Were James Bond’s drinks shaken because of alcohol induced tremor?”
 

Study details

Ms. Costas and colleagues sought participants for their survey from online forums that included 4chan and Reddit, which are known for their controversial content posted by anonymous users. Data were also collected from ForoCoches and HispaChan, well-known Spanish online forums. These online sites were intentionally chosen because researchers thought “conspiracy beliefs would be more prevalent,” according to Ms. Costas.

Across the multiple forums, there were 1,494 participants. Of these, 209 participants were unvaccinated against COVID-19, 112 preferred alternatives rather than conventional medicine, and 62 reported that they believed the earth was flat or believed that humanoids take reptilian forms to manipulate human societies.

The team then sought to assess beliefs about actual and mythical (nonestablished) causes of cancer by presenting the participants with the closed risk factor questions on two validated scales – the Cancer Awareness Measure (CAM) and CAM–Mythical Causes Scale (CAM-MYCS).

Responses to both were recorded on a five-point scale; answers ranged from “strongly disagree” to “strongly agree.”

The CAM assesses cancer risk perceptions of 11 established risk factors for cancer: smoking actively or passively, consuming alcohol, low levels of physical activity, consuming red or processed meat, getting sunburnt as a child, family history of cancer, human papillomavirus infection, being overweight, age greater than or equal to 70 years, and low vegetable and fruit consumption.

The CAM-MYCS measure includes 12 questions on risk perceptions of mythical causes of cancer – nonestablished causes that are commonly believed to cause cancer but for which there is no supporting scientific evidence, the authors explain. These items include drinking from plastic bottles; eating food containing artificial sweeteners or additives and genetically modified food; using microwave ovens, aerosol containers, mobile phones, and cleaning products; living near power lines; feeling stressed; experiencing physical trauma; and being exposed to electromagnetic frequencies/non-ionizing radiation, such as wi-fi networks, radio, and television.

The most endorsed mythical causes of cancer were eating food containing additives (63.9%) or sweeteners (50.7%), feeling stressed (59.7%), and eating genetically modified foods (38.4%).

A version of this article first appeared on Medscape.com.

In this current age of mass misinformation and disinformation on the Internet, a tongue-in-cheek study that evaluated beliefs and attitudes toward cancer among conspiracy theorists and people who oppose vaccinations has received some harsh criticism.

The study, entitled, “Everything Causes Cancer? Beliefs and Attitudes Towards Cancer Prevention Among Anti-Vaxxers, Flat Earthers, and Reptilian Conspiracists: Online Cross Sectional Survey,” was published in the Christmas 2022 issue of The British Medical Journal (BMJ).

The authors explain that they set out to evaluate “the patterns of beliefs about cancer among people who believed in conspiracies, rejected the COVID-19 vaccine, or preferred alternative medicine.”

They sought such people on social media and online chat platforms and asked them questions about real and mythical causes of cancer.

Almost half of survey participants agreed with the statement, “It seems like everything causes cancer.”

Overall, among all participants, awareness of the actual causes of cancer was greater than awareness of the mythical causes of cancer, the authors report. However, awareness of the actual causes of cancer was lower among the unvaccinated and members of conspiracy groups than among their counterparts.

The authors are concerned that their findings suggest “a direct connection between digital misinformation and consequent potential erroneous health decisions, which may represent a further preventable fraction of cancer.”
 

Backlash and criticism

The study “highlights the difficulty society encounters in distinguishing the actual causes of cancer from mythical causes,” The BMJ commented on Twitter.

However, both the study and the journal received some backlash.

This is a “horrible article seeking to smear people with concerns about COVID vaccines,” commented Clare Craig, a British consultant pathologist who specializes in cancer diagnostics.

The study and its methodology were also harshly criticized on Twitter by Normal Fenton, professor of risk information management at the Queen Mary University of London.

The senior author of the study, Laura Costas, a medical epidemiologist with the Catalan Institute of Oncology, Barcelona, told this news organization that the naysayers on social media, many of whom focused their comments on the COVID-19 vaccine, prove the purpose of the study – that misinformation spreads widely on the internet.

“Most comments focused on spreading COVID-19 myths, which were not the direct subject of the study, and questioned the motivations of BMJ authors and the scientific community, assuming they had a common malevolent hidden agenda,” Ms. Costas said.

“They stated the need of having critical thinking, a trait in common with the scientific method, but dogmatically dismissed any information that comes from official sources,” she added.

Ms. Costas commented that “society encounters difficulty in differentiating actual from mythical causes of cancer owing to mass information. We therefore planned this study with a certain satire, which is in line with the essence of The BMJ Christmas issue.”

The BMJ has a long history of publishing a lighthearted Christmas edition full of original, satirical, and nontraditional studies. Previous years have seen studies that explored potential harms from holly and ivy, survival time of chocolates on hospital wards, and the question, “Were James Bond’s drinks shaken because of alcohol induced tremor?”
 

Study details

Ms. Costas and colleagues sought participants for their survey from online forums that included 4chan and Reddit, which are known for their controversial content posted by anonymous users. Data were also collected from ForoCoches and HispaChan, well-known Spanish online forums. These online sites were intentionally chosen because researchers thought “conspiracy beliefs would be more prevalent,” according to Ms. Costas.

Across the multiple forums, there were 1,494 participants. Of these, 209 participants were unvaccinated against COVID-19, 112 preferred alternatives rather than conventional medicine, and 62 reported that they believed the earth was flat or believed that humanoids take reptilian forms to manipulate human societies.

The team then sought to assess beliefs about actual and mythical (nonestablished) causes of cancer by presenting the participants with the closed risk factor questions on two validated scales – the Cancer Awareness Measure (CAM) and CAM–Mythical Causes Scale (CAM-MYCS).

Responses to both were recorded on a five-point scale; answers ranged from “strongly disagree” to “strongly agree.”

The CAM assesses cancer risk perceptions of 11 established risk factors for cancer: smoking actively or passively, consuming alcohol, low levels of physical activity, consuming red or processed meat, getting sunburnt as a child, family history of cancer, human papillomavirus infection, being overweight, age greater than or equal to 70 years, and low vegetable and fruit consumption.

The CAM-MYCS measure includes 12 questions on risk perceptions of mythical causes of cancer – nonestablished causes that are commonly believed to cause cancer but for which there is no supporting scientific evidence, the authors explain. These items include drinking from plastic bottles; eating food containing artificial sweeteners or additives and genetically modified food; using microwave ovens, aerosol containers, mobile phones, and cleaning products; living near power lines; feeling stressed; experiencing physical trauma; and being exposed to electromagnetic frequencies/non-ionizing radiation, such as wi-fi networks, radio, and television.

The most endorsed mythical causes of cancer were eating food containing additives (63.9%) or sweeteners (50.7%), feeling stressed (59.7%), and eating genetically modified foods (38.4%).

A version of this article first appeared on Medscape.com.

In this current age of mass misinformation and disinformation on the Internet, a tongue-in-cheek study that evaluated beliefs and attitudes toward cancer among conspiracy theorists and people who oppose vaccinations has received some harsh criticism.

The study, entitled, “Everything Causes Cancer? Beliefs and Attitudes Towards Cancer Prevention Among Anti-Vaxxers, Flat Earthers, and Reptilian Conspiracists: Online Cross Sectional Survey,” was published in the Christmas 2022 issue of The British Medical Journal (BMJ).

The authors explain that they set out to evaluate “the patterns of beliefs about cancer among people who believed in conspiracies, rejected the COVID-19 vaccine, or preferred alternative medicine.”

They sought such people on social media and online chat platforms and asked them questions about real and mythical causes of cancer.

Almost half of survey participants agreed with the statement, “It seems like everything causes cancer.”

Overall, among all participants, awareness of the actual causes of cancer was greater than awareness of the mythical causes of cancer, the authors report. However, awareness of the actual causes of cancer was lower among the unvaccinated and members of conspiracy groups than among their counterparts.

The authors are concerned that their findings suggest “a direct connection between digital misinformation and consequent potential erroneous health decisions, which may represent a further preventable fraction of cancer.”
 

Backlash and criticism

The study “highlights the difficulty society encounters in distinguishing the actual causes of cancer from mythical causes,” The BMJ commented on Twitter.

However, both the study and the journal received some backlash.

This is a “horrible article seeking to smear people with concerns about COVID vaccines,” commented Clare Craig, a British consultant pathologist who specializes in cancer diagnostics.

The study and its methodology were also harshly criticized on Twitter by Normal Fenton, professor of risk information management at the Queen Mary University of London.

The senior author of the study, Laura Costas, a medical epidemiologist with the Catalan Institute of Oncology, Barcelona, told this news organization that the naysayers on social media, many of whom focused their comments on the COVID-19 vaccine, prove the purpose of the study – that misinformation spreads widely on the internet.

“Most comments focused on spreading COVID-19 myths, which were not the direct subject of the study, and questioned the motivations of BMJ authors and the scientific community, assuming they had a common malevolent hidden agenda,” Ms. Costas said.

“They stated the need of having critical thinking, a trait in common with the scientific method, but dogmatically dismissed any information that comes from official sources,” she added.

Ms. Costas commented that “society encounters difficulty in differentiating actual from mythical causes of cancer owing to mass information. We therefore planned this study with a certain satire, which is in line with the essence of The BMJ Christmas issue.”

The BMJ has a long history of publishing a lighthearted Christmas edition full of original, satirical, and nontraditional studies. Previous years have seen studies that explored potential harms from holly and ivy, survival time of chocolates on hospital wards, and the question, “Were James Bond’s drinks shaken because of alcohol induced tremor?”
 

Study details

Ms. Costas and colleagues sought participants for their survey from online forums that included 4chan and Reddit, which are known for their controversial content posted by anonymous users. Data were also collected from ForoCoches and HispaChan, well-known Spanish online forums. These online sites were intentionally chosen because researchers thought “conspiracy beliefs would be more prevalent,” according to Ms. Costas.

Across the multiple forums, there were 1,494 participants. Of these, 209 participants were unvaccinated against COVID-19, 112 preferred alternatives rather than conventional medicine, and 62 reported that they believed the earth was flat or believed that humanoids take reptilian forms to manipulate human societies.

The team then sought to assess beliefs about actual and mythical (nonestablished) causes of cancer by presenting the participants with the closed risk factor questions on two validated scales – the Cancer Awareness Measure (CAM) and CAM–Mythical Causes Scale (CAM-MYCS).

Responses to both were recorded on a five-point scale; answers ranged from “strongly disagree” to “strongly agree.”

The CAM assesses cancer risk perceptions of 11 established risk factors for cancer: smoking actively or passively, consuming alcohol, low levels of physical activity, consuming red or processed meat, getting sunburnt as a child, family history of cancer, human papillomavirus infection, being overweight, age greater than or equal to 70 years, and low vegetable and fruit consumption.

The CAM-MYCS measure includes 12 questions on risk perceptions of mythical causes of cancer – nonestablished causes that are commonly believed to cause cancer but for which there is no supporting scientific evidence, the authors explain. These items include drinking from plastic bottles; eating food containing artificial sweeteners or additives and genetically modified food; using microwave ovens, aerosol containers, mobile phones, and cleaning products; living near power lines; feeling stressed; experiencing physical trauma; and being exposed to electromagnetic frequencies/non-ionizing radiation, such as wi-fi networks, radio, and television.

The most endorsed mythical causes of cancer were eating food containing additives (63.9%) or sweeteners (50.7%), feeling stressed (59.7%), and eating genetically modified foods (38.4%).

A version of this article first appeared on Medscape.com.

A new hereditary test can determine whether a cancer-disposing gene was inherited from a patient’s father or mother without the need for parental DNA, potentially improving disease screening and management.

“The presence of parental imprints in regions of the genome has been known for a long time,” study author Peter Lansdorp, MD, PhD, of the BC Cancer Research Centre in Vancouver, said in an interview. In addition, the ability of a specific sequencing technology (Strand-seq) to generate a set of DNA variants that tend to be inherited together from a single parent has been documented in several studies.

“That these two pieces can be put together to assign alleles in a patient to one of the parents without studying the DNA of the parents is a major advance,” said Dr. Lansdorp.

Principal author Steven J.M. Jones, PhD, associate director of bioinformatics at BC Cancer Research Centre, explained, “for directing cascade genetic testing, the test could be used almost immediately, even as a research test. It just guides which side of the family to focus familial genetic testing efforts on and is internally validated by the patient’s variant and later confirmed by clinical testing in the family.”

Directing cascade genetic testing to one side of the family over the other could speed time to diagnosis of more carriers and allow for more efficient use of genetic counseling resources, Dr. Jones added, especially when parents are deceased or unavailable.

The study was published online in Cell Genomics.
 

Low error rate

Determining a parent of origin for hereditary variants “is essential to evaluate disease risk when a pathogenic variant has PofO effects, that is, when a patient’s risk of disease depends on from which parent it is inherited,” the authors wrote. An example is hereditary paraganglioma-pheochromocytoma syndrome as a result of pathogenic variants in SDHD or SDHAF2 genes. Individuals with the variants are at high risk of developing certain cancers, but only if a defective gene is inherited from their father. If inherited from their mother, there is no increased risk.

The new method relies on a technique called “phased DNA methylation” at maternally and paternally imprinted gene loci, as well as chromosome length phasing of DNA sequences.

The team used five human genome “trios” – two parents and the proband (the first person in a family to receive genetic testing or counseling for a suspected hereditary risk) – to pilot the approach. They showed that the method can correctly identify the PofO with an average mismatch error rate of 0.31% for single nucleotide variants and 1.89% for insertions or deletions (indels).

“We will need to validate this technology for different genes in real-world samples from individuals of diverse backgrounds,” said Dr. Jones. The first step is to validate the technology in scenarios with immediate clinical utility, like with SDHD, where lifelong medical management is affected by knowledge of whether the variant was inherited from the mother or father.

“We would also like to quickly validate this for common hereditary cancer genes, like BRCA1, BRCA2, and Lynch syndrome–associated genes, where prediction of PofO may improve low rates of genetic testing in family members by providing more accurate estimates of their risk to carry the familial variant.”

Challenges to moving the test to the clinic, Dr. Jones said, include scaling up the technology, demonstrating clinical and economic utility, compared with existing testing approaches, “and familiarizing clinicians with a new type of test that will routinely give this added dimension of information.”
 

‘Tremendously promising technology’

Pathologist Stephen Yip, MD, PhD, of the Vancouver Coastal Health Research Institute, who was not involved in the study but disclosed that he collaborates with the authors on other grant-funded projects, said in a comment that “this is a tremendously promising technology that has immediate practical implications in the investigation of PofO of a pathogenic locus, particularly when genetic material is available only from the proband.”

However, “rigorous validation against the current gold standard of short-reading, next-generation sequencing of trios is needed prior to clinical deployment,” he said. “This will take time and effort. However, the promise of this technology is worth the effort.

“Also, there is the possibility of uncovering novel genetics during testing, which could present an ethical dilemma,” he noted. “A robust consenting and ethical framework and early involvement of an ethicist would be helpful.”

Research in Dr. Lansdorp’s laboratory is funded by the Terry Fox Research Institute, the Canadian Institutes of Health Research, the Canadian Foundation for Innovation, and the government of British Columbia. Dr. Lansdorp, Dr. Jones, and Dr. Yip reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A new hereditary test can determine whether a cancer-disposing gene was inherited from a patient’s father or mother without the need for parental DNA, potentially improving disease screening and management.

“The presence of parental imprints in regions of the genome has been known for a long time,” study author Peter Lansdorp, MD, PhD, of the BC Cancer Research Centre in Vancouver, said in an interview. In addition, the ability of a specific sequencing technology (Strand-seq) to generate a set of DNA variants that tend to be inherited together from a single parent has been documented in several studies.

“That these two pieces can be put together to assign alleles in a patient to one of the parents without studying the DNA of the parents is a major advance,” said Dr. Lansdorp.

Principal author Steven J.M. Jones, PhD, associate director of bioinformatics at BC Cancer Research Centre, explained, “for directing cascade genetic testing, the test could be used almost immediately, even as a research test. It just guides which side of the family to focus familial genetic testing efforts on and is internally validated by the patient’s variant and later confirmed by clinical testing in the family.”

Directing cascade genetic testing to one side of the family over the other could speed time to diagnosis of more carriers and allow for more efficient use of genetic counseling resources, Dr. Jones added, especially when parents are deceased or unavailable.

The study was published online in Cell Genomics.
 

Low error rate

Determining a parent of origin for hereditary variants “is essential to evaluate disease risk when a pathogenic variant has PofO effects, that is, when a patient’s risk of disease depends on from which parent it is inherited,” the authors wrote. An example is hereditary paraganglioma-pheochromocytoma syndrome as a result of pathogenic variants in SDHD or SDHAF2 genes. Individuals with the variants are at high risk of developing certain cancers, but only if a defective gene is inherited from their father. If inherited from their mother, there is no increased risk.

The new method relies on a technique called “phased DNA methylation” at maternally and paternally imprinted gene loci, as well as chromosome length phasing of DNA sequences.

The team used five human genome “trios” – two parents and the proband (the first person in a family to receive genetic testing or counseling for a suspected hereditary risk) – to pilot the approach. They showed that the method can correctly identify the PofO with an average mismatch error rate of 0.31% for single nucleotide variants and 1.89% for insertions or deletions (indels).

“We will need to validate this technology for different genes in real-world samples from individuals of diverse backgrounds,” said Dr. Jones. The first step is to validate the technology in scenarios with immediate clinical utility, like with SDHD, where lifelong medical management is affected by knowledge of whether the variant was inherited from the mother or father.

“We would also like to quickly validate this for common hereditary cancer genes, like BRCA1, BRCA2, and Lynch syndrome–associated genes, where prediction of PofO may improve low rates of genetic testing in family members by providing more accurate estimates of their risk to carry the familial variant.”

Challenges to moving the test to the clinic, Dr. Jones said, include scaling up the technology, demonstrating clinical and economic utility, compared with existing testing approaches, “and familiarizing clinicians with a new type of test that will routinely give this added dimension of information.”
 

‘Tremendously promising technology’

Pathologist Stephen Yip, MD, PhD, of the Vancouver Coastal Health Research Institute, who was not involved in the study but disclosed that he collaborates with the authors on other grant-funded projects, said in a comment that “this is a tremendously promising technology that has immediate practical implications in the investigation of PofO of a pathogenic locus, particularly when genetic material is available only from the proband.”

However, “rigorous validation against the current gold standard of short-reading, next-generation sequencing of trios is needed prior to clinical deployment,” he said. “This will take time and effort. However, the promise of this technology is worth the effort.

“Also, there is the possibility of uncovering novel genetics during testing, which could present an ethical dilemma,” he noted. “A robust consenting and ethical framework and early involvement of an ethicist would be helpful.”

Research in Dr. Lansdorp’s laboratory is funded by the Terry Fox Research Institute, the Canadian Institutes of Health Research, the Canadian Foundation for Innovation, and the government of British Columbia. Dr. Lansdorp, Dr. Jones, and Dr. Yip reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A new hereditary test can determine whether a cancer-disposing gene was inherited from a patient’s father or mother without the need for parental DNA, potentially improving disease screening and management.

“The presence of parental imprints in regions of the genome has been known for a long time,” study author Peter Lansdorp, MD, PhD, of the BC Cancer Research Centre in Vancouver, said in an interview. In addition, the ability of a specific sequencing technology (Strand-seq) to generate a set of DNA variants that tend to be inherited together from a single parent has been documented in several studies.

“That these two pieces can be put together to assign alleles in a patient to one of the parents without studying the DNA of the parents is a major advance,” said Dr. Lansdorp.

Principal author Steven J.M. Jones, PhD, associate director of bioinformatics at BC Cancer Research Centre, explained, “for directing cascade genetic testing, the test could be used almost immediately, even as a research test. It just guides which side of the family to focus familial genetic testing efforts on and is internally validated by the patient’s variant and later confirmed by clinical testing in the family.”

Directing cascade genetic testing to one side of the family over the other could speed time to diagnosis of more carriers and allow for more efficient use of genetic counseling resources, Dr. Jones added, especially when parents are deceased or unavailable.

The study was published online in Cell Genomics.
 

Low error rate

Determining a parent of origin for hereditary variants “is essential to evaluate disease risk when a pathogenic variant has PofO effects, that is, when a patient’s risk of disease depends on from which parent it is inherited,” the authors wrote. An example is hereditary paraganglioma-pheochromocytoma syndrome as a result of pathogenic variants in SDHD or SDHAF2 genes. Individuals with the variants are at high risk of developing certain cancers, but only if a defective gene is inherited from their father. If inherited from their mother, there is no increased risk.

The new method relies on a technique called “phased DNA methylation” at maternally and paternally imprinted gene loci, as well as chromosome length phasing of DNA sequences.

The team used five human genome “trios” – two parents and the proband (the first person in a family to receive genetic testing or counseling for a suspected hereditary risk) – to pilot the approach. They showed that the method can correctly identify the PofO with an average mismatch error rate of 0.31% for single nucleotide variants and 1.89% for insertions or deletions (indels).

“We will need to validate this technology for different genes in real-world samples from individuals of diverse backgrounds,” said Dr. Jones. The first step is to validate the technology in scenarios with immediate clinical utility, like with SDHD, where lifelong medical management is affected by knowledge of whether the variant was inherited from the mother or father.

“We would also like to quickly validate this for common hereditary cancer genes, like BRCA1, BRCA2, and Lynch syndrome–associated genes, where prediction of PofO may improve low rates of genetic testing in family members by providing more accurate estimates of their risk to carry the familial variant.”

Challenges to moving the test to the clinic, Dr. Jones said, include scaling up the technology, demonstrating clinical and economic utility, compared with existing testing approaches, “and familiarizing clinicians with a new type of test that will routinely give this added dimension of information.”
 

‘Tremendously promising technology’

Pathologist Stephen Yip, MD, PhD, of the Vancouver Coastal Health Research Institute, who was not involved in the study but disclosed that he collaborates with the authors on other grant-funded projects, said in a comment that “this is a tremendously promising technology that has immediate practical implications in the investigation of PofO of a pathogenic locus, particularly when genetic material is available only from the proband.”

However, “rigorous validation against the current gold standard of short-reading, next-generation sequencing of trios is needed prior to clinical deployment,” he said. “This will take time and effort. However, the promise of this technology is worth the effort.

“Also, there is the possibility of uncovering novel genetics during testing, which could present an ethical dilemma,” he noted. “A robust consenting and ethical framework and early involvement of an ethicist would be helpful.”

Research in Dr. Lansdorp’s laboratory is funded by the Terry Fox Research Institute, the Canadian Institutes of Health Research, the Canadian Foundation for Innovation, and the government of British Columbia. Dr. Lansdorp, Dr. Jones, and Dr. Yip reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

It was 2 p.m. on a sunny and humid day, 1 hour before my 8-hour shift was over in the emergency department at the community hospital that I was rotating through. It was part of my fourth-year emergency medicine (EM) clerkship. Not that I would have noticed the weather, save for the few seconds the sliding door to the ED would open periodically, as if on its own cadence, with the sounds of stomping boots and a rolling gurney making its way through.

We were busy. At this particular hospital, I was told, EM volume is already up 35% this year compared with the previous year, and bed holds had been hitting new highs each week.

One more hour until my shift is over and a poor soul will take over my computer, seat, and the chaos.

I took a glance at the electronic health record again, seeing whether there was anything I could do to discharge any of the patients to relieve some of the strain. Knee pain, toe pain, headache/migraine, shoulder pain, elevated blood pressure. Although it’s true that any of these listed complaints could have emergent etiologies, the truth was that all of these patients were here owing to exacerbations of chronic issues. And yet most, if not all, of these patients had been here for nearly 8 hours, some even longer, waiting for treatment and exacerbating an already busy ED.

“I don’t understand. Couldn’t these patients have sought care outpatient with their PCP [primary care physician]? It would have been a lot cheaper and faster.” I asked. A seasoned ED physician, bald, graying, and whom I had just met today and hadn’t spoken to much until this very moment, turned to me and said: “We have become the dumping ground for primary care complaints.”

‘Go to the ED’

“PCPs are already too busy,” the physician continued. “It’s just easier to say: ‘Go to the ED. They’ll take care of it.’ ”

He continued: “In my 30 years of practicing, emergency medicine has changed so much. When I first started in the 1980s, I was only seeing emergencies, and it was fun. Now, 80% of my patients are primary care complaints. These days, I am more of a primary care physician than an emergency physician.”

Hmmm, I thought. Was this physician burned out and jaded? Quite possibly. Was this change the physician experienced throughout his career more likely attributed to a capitalist-run, profit-driven health care system and its cohort of underinsured and noninsured citizens? Certainly. I’m only a fourth-year medical student, so my view of the situation is no doubt limited.

But something he said definitely rang my bell: I’m more of a primary care physician than an emergency physician. That is an argument I can consider. Whether it is caused by poorly designed reimbursement schedules or the state of America’s profit-driven health care system, there is no doubt that these days, emergency physicians are in fact seeing a lot of primary care complaints, which effectively makes these physicians double as PCPs on a daily basis.

I let this thought ruminate on my drive home, along with how there’s a such a huge demand for PCPs, resulting in it taking up to 3 months to get an appointment with one. That’s crazy, and I understand the need to come to the ED where you’ll (hopefully) be seen the same day.

I also ruminated on how emergency physicians have the highest rate of burnout among all the specialties, with no career recourse afterward. Either you’re part of the hospital machine complex, or you’re out. Practicing EM for nearly 30 years is apparently a rarity these days. Most emergency physicians last 5 years, 10 years tops, and then are so burned out that they retire to pursue a life outside of medicine (real estate seems to be popular). But this is a shame.

Emergency docs exiting medicine

Emergency physicians have seen a ton of wildly different pathologies and have treated a variety of different conditions, including conditions usually reserved for primary care. To let knowledgeable, experienced emergency physicians just exit medicine, with no recourse to further contribute to this country’s health system outside of the hospital machine, is a travesty in its own right.

I ruminated further on the 2021 American College of Emergency Physicians 2021 report on the EM physician workforce, which stated that there is projected to be an oversupply of emergency physicians by 2030, leaving thousands of them out of work. No doubt that report has left an impact on the volume of residency applications into EM in 2021. No one wants to go through residency and be unemployed at the end of it.

And finally, I ruminated on the sheer volume of patients visiting EDs across the country. Patient volumes are up, wait times in general are up, wait times in the ED are up, and bed holds to get admitted are hitting highs across the country each week. The deluge of patients visiting the ED is not getting better, and it’s only likely to get worse as the population ages.

It’s time to offer emergency physicians a path to outpatient primary care.

Now before I get hung for this suggestion (“I went into EM precisely not to do outpatient care!”), hear me out: Such a path should be offered via a 1-year accelerated fellowship and will allow emergency physicians to practice outpatient primary care medicine independently. And although working in urgent care centers is already an option, the opportunity to own and operate their own primary care practice should also exist.

In my humble opinion, by offering such a path, the following objectives could be accomplished:

Alleviate the pressure on primary care medicine in the United States. It’s no secret that the United States needs more primary care physicians. Allowing emergency physicians who got burnt out by hospital life an alternative way to serve their community and country via outpatient primary care would greatly alleviate the pressure on the need for PCPs today.

Provide an alternative career path for emergency physicians. We would be doing a disservice if we don’t offer emergency physicians a way to revive their burnout and utilize their skill set in a post-ED life. Outpatient primary care is the perfect way to do this, and it’s a win-win-win on several fronts: We need more outpatient physicians, they need an opportunity to flex their knowledge in an alternative setting.

Solve the “ACEP” problem. The ACEP report scared medical students away from applying to residency in EM. Who wants to go through 3 years of residency only to be unemployed at the end of it? By offering a path to outpatient primary care, we can offer an important and viable path for those emergency physicians who would be unemployed to continue to practice medicine and serve the community, thereby alleviating concern about an oversupply.

For better or for worse, because of the state of health care today, ED physicians have been exposed to a myriad of primary care concerns, all of which have prepared them for a career as an outpatient PCP. By offering such a path, we can provide more flexibility for an emergency physician’s career, help alleviate the primary care shortage affecting the United States, and serve our community and country in new and helpful ways.

Dr. Gogna is a fourth-year medical student at Philadelphia College of Osteopathic Medicine Georgia, Suwanee. He reported no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

It was 2 p.m. on a sunny and humid day, 1 hour before my 8-hour shift was over in the emergency department at the community hospital that I was rotating through. It was part of my fourth-year emergency medicine (EM) clerkship. Not that I would have noticed the weather, save for the few seconds the sliding door to the ED would open periodically, as if on its own cadence, with the sounds of stomping boots and a rolling gurney making its way through.

We were busy. At this particular hospital, I was told, EM volume is already up 35% this year compared with the previous year, and bed holds had been hitting new highs each week.

One more hour until my shift is over and a poor soul will take over my computer, seat, and the chaos.

I took a glance at the electronic health record again, seeing whether there was anything I could do to discharge any of the patients to relieve some of the strain. Knee pain, toe pain, headache/migraine, shoulder pain, elevated blood pressure. Although it’s true that any of these listed complaints could have emergent etiologies, the truth was that all of these patients were here owing to exacerbations of chronic issues. And yet most, if not all, of these patients had been here for nearly 8 hours, some even longer, waiting for treatment and exacerbating an already busy ED.

“I don’t understand. Couldn’t these patients have sought care outpatient with their PCP [primary care physician]? It would have been a lot cheaper and faster.” I asked. A seasoned ED physician, bald, graying, and whom I had just met today and hadn’t spoken to much until this very moment, turned to me and said: “We have become the dumping ground for primary care complaints.”

‘Go to the ED’

“PCPs are already too busy,” the physician continued. “It’s just easier to say: ‘Go to the ED. They’ll take care of it.’ ”

He continued: “In my 30 years of practicing, emergency medicine has changed so much. When I first started in the 1980s, I was only seeing emergencies, and it was fun. Now, 80% of my patients are primary care complaints. These days, I am more of a primary care physician than an emergency physician.”

Hmmm, I thought. Was this physician burned out and jaded? Quite possibly. Was this change the physician experienced throughout his career more likely attributed to a capitalist-run, profit-driven health care system and its cohort of underinsured and noninsured citizens? Certainly. I’m only a fourth-year medical student, so my view of the situation is no doubt limited.

But something he said definitely rang my bell: I’m more of a primary care physician than an emergency physician. That is an argument I can consider. Whether it is caused by poorly designed reimbursement schedules or the state of America’s profit-driven health care system, there is no doubt that these days, emergency physicians are in fact seeing a lot of primary care complaints, which effectively makes these physicians double as PCPs on a daily basis.

I let this thought ruminate on my drive home, along with how there’s a such a huge demand for PCPs, resulting in it taking up to 3 months to get an appointment with one. That’s crazy, and I understand the need to come to the ED where you’ll (hopefully) be seen the same day.

I also ruminated on how emergency physicians have the highest rate of burnout among all the specialties, with no career recourse afterward. Either you’re part of the hospital machine complex, or you’re out. Practicing EM for nearly 30 years is apparently a rarity these days. Most emergency physicians last 5 years, 10 years tops, and then are so burned out that they retire to pursue a life outside of medicine (real estate seems to be popular). But this is a shame.

Emergency docs exiting medicine

Emergency physicians have seen a ton of wildly different pathologies and have treated a variety of different conditions, including conditions usually reserved for primary care. To let knowledgeable, experienced emergency physicians just exit medicine, with no recourse to further contribute to this country’s health system outside of the hospital machine, is a travesty in its own right.

I ruminated further on the 2021 American College of Emergency Physicians 2021 report on the EM physician workforce, which stated that there is projected to be an oversupply of emergency physicians by 2030, leaving thousands of them out of work. No doubt that report has left an impact on the volume of residency applications into EM in 2021. No one wants to go through residency and be unemployed at the end of it.

And finally, I ruminated on the sheer volume of patients visiting EDs across the country. Patient volumes are up, wait times in general are up, wait times in the ED are up, and bed holds to get admitted are hitting highs across the country each week. The deluge of patients visiting the ED is not getting better, and it’s only likely to get worse as the population ages.

It’s time to offer emergency physicians a path to outpatient primary care.

Now before I get hung for this suggestion (“I went into EM precisely not to do outpatient care!”), hear me out: Such a path should be offered via a 1-year accelerated fellowship and will allow emergency physicians to practice outpatient primary care medicine independently. And although working in urgent care centers is already an option, the opportunity to own and operate their own primary care practice should also exist.

In my humble opinion, by offering such a path, the following objectives could be accomplished:

Alleviate the pressure on primary care medicine in the United States. It’s no secret that the United States needs more primary care physicians. Allowing emergency physicians who got burnt out by hospital life an alternative way to serve their community and country via outpatient primary care would greatly alleviate the pressure on the need for PCPs today.

Provide an alternative career path for emergency physicians. We would be doing a disservice if we don’t offer emergency physicians a way to revive their burnout and utilize their skill set in a post-ED life. Outpatient primary care is the perfect way to do this, and it’s a win-win-win on several fronts: We need more outpatient physicians, they need an opportunity to flex their knowledge in an alternative setting.

Solve the “ACEP” problem. The ACEP report scared medical students away from applying to residency in EM. Who wants to go through 3 years of residency only to be unemployed at the end of it? By offering a path to outpatient primary care, we can offer an important and viable path for those emergency physicians who would be unemployed to continue to practice medicine and serve the community, thereby alleviating concern about an oversupply.

For better or for worse, because of the state of health care today, ED physicians have been exposed to a myriad of primary care concerns, all of which have prepared them for a career as an outpatient PCP. By offering such a path, we can provide more flexibility for an emergency physician’s career, help alleviate the primary care shortage affecting the United States, and serve our community and country in new and helpful ways.

Dr. Gogna is a fourth-year medical student at Philadelphia College of Osteopathic Medicine Georgia, Suwanee. He reported no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

It was 2 p.m. on a sunny and humid day, 1 hour before my 8-hour shift was over in the emergency department at the community hospital that I was rotating through. It was part of my fourth-year emergency medicine (EM) clerkship. Not that I would have noticed the weather, save for the few seconds the sliding door to the ED would open periodically, as if on its own cadence, with the sounds of stomping boots and a rolling gurney making its way through.

We were busy. At this particular hospital, I was told, EM volume is already up 35% this year compared with the previous year, and bed holds had been hitting new highs each week.

One more hour until my shift is over and a poor soul will take over my computer, seat, and the chaos.

I took a glance at the electronic health record again, seeing whether there was anything I could do to discharge any of the patients to relieve some of the strain. Knee pain, toe pain, headache/migraine, shoulder pain, elevated blood pressure. Although it’s true that any of these listed complaints could have emergent etiologies, the truth was that all of these patients were here owing to exacerbations of chronic issues. And yet most, if not all, of these patients had been here for nearly 8 hours, some even longer, waiting for treatment and exacerbating an already busy ED.

“I don’t understand. Couldn’t these patients have sought care outpatient with their PCP [primary care physician]? It would have been a lot cheaper and faster.” I asked. A seasoned ED physician, bald, graying, and whom I had just met today and hadn’t spoken to much until this very moment, turned to me and said: “We have become the dumping ground for primary care complaints.”

‘Go to the ED’

“PCPs are already too busy,” the physician continued. “It’s just easier to say: ‘Go to the ED. They’ll take care of it.’ ”

He continued: “In my 30 years of practicing, emergency medicine has changed so much. When I first started in the 1980s, I was only seeing emergencies, and it was fun. Now, 80% of my patients are primary care complaints. These days, I am more of a primary care physician than an emergency physician.”

Hmmm, I thought. Was this physician burned out and jaded? Quite possibly. Was this change the physician experienced throughout his career more likely attributed to a capitalist-run, profit-driven health care system and its cohort of underinsured and noninsured citizens? Certainly. I’m only a fourth-year medical student, so my view of the situation is no doubt limited.

But something he said definitely rang my bell: I’m more of a primary care physician than an emergency physician. That is an argument I can consider. Whether it is caused by poorly designed reimbursement schedules or the state of America’s profit-driven health care system, there is no doubt that these days, emergency physicians are in fact seeing a lot of primary care complaints, which effectively makes these physicians double as PCPs on a daily basis.

I let this thought ruminate on my drive home, along with how there’s a such a huge demand for PCPs, resulting in it taking up to 3 months to get an appointment with one. That’s crazy, and I understand the need to come to the ED where you’ll (hopefully) be seen the same day.

I also ruminated on how emergency physicians have the highest rate of burnout among all the specialties, with no career recourse afterward. Either you’re part of the hospital machine complex, or you’re out. Practicing EM for nearly 30 years is apparently a rarity these days. Most emergency physicians last 5 years, 10 years tops, and then are so burned out that they retire to pursue a life outside of medicine (real estate seems to be popular). But this is a shame.

Emergency docs exiting medicine

Emergency physicians have seen a ton of wildly different pathologies and have treated a variety of different conditions, including conditions usually reserved for primary care. To let knowledgeable, experienced emergency physicians just exit medicine, with no recourse to further contribute to this country’s health system outside of the hospital machine, is a travesty in its own right.

I ruminated further on the 2021 American College of Emergency Physicians 2021 report on the EM physician workforce, which stated that there is projected to be an oversupply of emergency physicians by 2030, leaving thousands of them out of work. No doubt that report has left an impact on the volume of residency applications into EM in 2021. No one wants to go through residency and be unemployed at the end of it.

And finally, I ruminated on the sheer volume of patients visiting EDs across the country. Patient volumes are up, wait times in general are up, wait times in the ED are up, and bed holds to get admitted are hitting highs across the country each week. The deluge of patients visiting the ED is not getting better, and it’s only likely to get worse as the population ages.

It’s time to offer emergency physicians a path to outpatient primary care.

Now before I get hung for this suggestion (“I went into EM precisely not to do outpatient care!”), hear me out: Such a path should be offered via a 1-year accelerated fellowship and will allow emergency physicians to practice outpatient primary care medicine independently. And although working in urgent care centers is already an option, the opportunity to own and operate their own primary care practice should also exist.

In my humble opinion, by offering such a path, the following objectives could be accomplished:

Alleviate the pressure on primary care medicine in the United States. It’s no secret that the United States needs more primary care physicians. Allowing emergency physicians who got burnt out by hospital life an alternative way to serve their community and country via outpatient primary care would greatly alleviate the pressure on the need for PCPs today.

Provide an alternative career path for emergency physicians. We would be doing a disservice if we don’t offer emergency physicians a way to revive their burnout and utilize their skill set in a post-ED life. Outpatient primary care is the perfect way to do this, and it’s a win-win-win on several fronts: We need more outpatient physicians, they need an opportunity to flex their knowledge in an alternative setting.

Solve the “ACEP” problem. The ACEP report scared medical students away from applying to residency in EM. Who wants to go through 3 years of residency only to be unemployed at the end of it? By offering a path to outpatient primary care, we can offer an important and viable path for those emergency physicians who would be unemployed to continue to practice medicine and serve the community, thereby alleviating concern about an oversupply.

For better or for worse, because of the state of health care today, ED physicians have been exposed to a myriad of primary care concerns, all of which have prepared them for a career as an outpatient PCP. By offering such a path, we can provide more flexibility for an emergency physician’s career, help alleviate the primary care shortage affecting the United States, and serve our community and country in new and helpful ways.

Dr. Gogna is a fourth-year medical student at Philadelphia College of Osteopathic Medicine Georgia, Suwanee. He reported no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

Nursing oversight groups in the United States and Canada are holding the line on testing standards as more would-be nurses fail entry exams. As a result, pressure is growing to make tests easier to pass given widespread nursing shortages, and some critics wonder whether the exams accurately assess students’ true abilities.

When it comes to training more nurses to keep up with growing demand, the U.S. organization that oversees the main licensing exams for nurses decided earlier this month not to change the passing standards for entry-level tests. Meanwhile, nursing test examiners have seen a drop in passing rates for nurses taking the standard licensing exam since the pandemic began.

A similar scenario also is unfolding in Quebec, where the agency overseeing nurse licensing exams announced last month it is holding the line on its passing rates despite an outcry from nurses after more than half of those taking the exam in September failed. Quebec’s commissioner for professional admissions is investigating dozens of complaints from nurses about the failure rate. Nurses who failed the test can sign up to retake it in March.

Joseph Oujeil, DESS, DEF, has been teaching in Canada for 4 years, now at two Quebec nursing schools. “This is surprising and very shocking to our students as well as nurses from outside Quebec who were [completing] an integration program to adjust their practice to Quebec guidelines,” Mr. Oujeil told this news organization. Students from outside the province failed the licensing exam at a higher rate than their Quebec-native peers, he explained.

Quebec’s professional Order of Nurses of Quebec (OIIQ) responded to the nurses’ outcry in a press release last month, saying that the pandemic may be partly to blame for the lower passing rate because it made it more difficult to access internships, labs, and face-to-face teaching. Some students weren’t able to demonstrate their ability to practice during the exam as in previous years, OIIQ reported.

Mr. Oujeil agreed. “I’m sure the pandemic has an impact on the situation as well as some students did less training in hospitals” because of restrictions caused by the pandemic, he said. But students also told Mr. Oujeil some questions seemed ambiguous.

OIIQ stated in its release that it doesn’t want to lower the standard. The goal is to protect the public “by and with nurses,” to “ensure the competence and integrity of nurses in Quebec,” and “promote quality nursing practice,” the release noted.

Similarly in the United States, the National Council of State Boards of Nursing (NCSBN) announced Dec. 8 that it would uphold the current passing standards for its entry-level NCLEX tests for registered nurses and practical nurses. NCSBN analyzes the passing standard every 3 years “to keep the test plan and passing standard current,” a press release explains.

NCLEX pass rates have dropped from about 73% for all candidates and 88% for first-time U.S.-educated candidates to 69% and 82% respectively in 2021, the last full year for which results are available, NCSBN spokesperson Dawn Kappel told this news organization.

Over the past 3 years, including during the pandemic, the board decided “that the current passing standard is appropriate as a measure of safe and effective entry-level nurse practice,” after reviewing national nurse surveys and the findings of panels of nurses representing NCSBN’s geographic areas in the United States and Canada, board president Jay Douglas, MSM, RN, CSAC, said in a press release.

Still, NCSBN is not blind to the larger issues facing nursing, Ms. Kappel told this news organization. “There is a huge nursing shortage in the U.S. and Canada. We want as many nurses in the workforce as possible, but we want to ensure safe practice,” she said.

“Everyone has access to the same test, regardless of which state, province, or country they take it in,” she said. Some international students may not perform as well as U.S.-educated students because of their command of English and the nursing education standards in their home countries, Ms. Kappel added.

“Obviously COVID and the challenge of education in general” affected the results, she said.

Mr. Oujeil, the nursing school professor, said he is frustrated by the test results because the majority of students who failed maintained good grades and passed all of their trainings. Yet they scored just below the passing rate of 55%. He said students are proposing the passing rate be lowered to 50%. The current test doesn’t reflect what students are learning in the classroom or during clinical trainings, Mr. Oujeil added. “I don’t know of any students who scored more than 60%.”

He said he understands that the mission of the OIIQ is protecting the population, but he doesn’t believe lowering the passing rate to 50% will put the population at risk – and it will help offset the staffing shortage.

“I’m especially frustrated by those who were doing integration programs – mothers and fathers with children with family lives and financial responsibilities. Many of them are good, hard workers and were shocked they should have to pass the exam another time.”

Since 2018, the pass rate on the first attempt at the Quebec test has generally been between 71% and 96%, compared with 51.4% during the exam in September, according to the OIIQ press release. Meanwhile, graduates from 30 of the 55 schools and universities in Quebec teaching nurses performed above the average on the recent professional exam, OIIQ reported.

The professional licensing organization pointed out that nursing candidates have three attempts to pass their exam. “In order to better prepare for their next attempt, all those who failed received an individual response detailing the difficulties encountered. The OIIQ offers all the tools necessary to pass the exam; a detailed guide and preparatory workshops are available online.

“In the run up to the next exams, we will continue to support students by working with educational institutions to provide the optimal conditions for passing the exam. This exam is usually successful and we are convinced that the return to face-to-face teaching, as well as support for students, will be factors of success,” OIIQ President Luc Mathieu said in a press release.

Nursing candidates “who have not passed the exam will be put to work in the network, with the possibility of practicing under the supervision of a nurse. ... In addition, we will contact health establishments in order to support them in their supervision activities” of the candidates, he said.

A version of this article first appeared on Medscape.com.

Nursing oversight groups in the United States and Canada are holding the line on testing standards as more would-be nurses fail entry exams. As a result, pressure is growing to make tests easier to pass given widespread nursing shortages, and some critics wonder whether the exams accurately assess students’ true abilities.

When it comes to training more nurses to keep up with growing demand, the U.S. organization that oversees the main licensing exams for nurses decided earlier this month not to change the passing standards for entry-level tests. Meanwhile, nursing test examiners have seen a drop in passing rates for nurses taking the standard licensing exam since the pandemic began.

A similar scenario also is unfolding in Quebec, where the agency overseeing nurse licensing exams announced last month it is holding the line on its passing rates despite an outcry from nurses after more than half of those taking the exam in September failed. Quebec’s commissioner for professional admissions is investigating dozens of complaints from nurses about the failure rate. Nurses who failed the test can sign up to retake it in March.

Joseph Oujeil, DESS, DEF, has been teaching in Canada for 4 years, now at two Quebec nursing schools. “This is surprising and very shocking to our students as well as nurses from outside Quebec who were [completing] an integration program to adjust their practice to Quebec guidelines,” Mr. Oujeil told this news organization. Students from outside the province failed the licensing exam at a higher rate than their Quebec-native peers, he explained.

Quebec’s professional Order of Nurses of Quebec (OIIQ) responded to the nurses’ outcry in a press release last month, saying that the pandemic may be partly to blame for the lower passing rate because it made it more difficult to access internships, labs, and face-to-face teaching. Some students weren’t able to demonstrate their ability to practice during the exam as in previous years, OIIQ reported.

Mr. Oujeil agreed. “I’m sure the pandemic has an impact on the situation as well as some students did less training in hospitals” because of restrictions caused by the pandemic, he said. But students also told Mr. Oujeil some questions seemed ambiguous.

OIIQ stated in its release that it doesn’t want to lower the standard. The goal is to protect the public “by and with nurses,” to “ensure the competence and integrity of nurses in Quebec,” and “promote quality nursing practice,” the release noted.

Similarly in the United States, the National Council of State Boards of Nursing (NCSBN) announced Dec. 8 that it would uphold the current passing standards for its entry-level NCLEX tests for registered nurses and practical nurses. NCSBN analyzes the passing standard every 3 years “to keep the test plan and passing standard current,” a press release explains.

NCLEX pass rates have dropped from about 73% for all candidates and 88% for first-time U.S.-educated candidates to 69% and 82% respectively in 2021, the last full year for which results are available, NCSBN spokesperson Dawn Kappel told this news organization.

Over the past 3 years, including during the pandemic, the board decided “that the current passing standard is appropriate as a measure of safe and effective entry-level nurse practice,” after reviewing national nurse surveys and the findings of panels of nurses representing NCSBN’s geographic areas in the United States and Canada, board president Jay Douglas, MSM, RN, CSAC, said in a press release.

Still, NCSBN is not blind to the larger issues facing nursing, Ms. Kappel told this news organization. “There is a huge nursing shortage in the U.S. and Canada. We want as many nurses in the workforce as possible, but we want to ensure safe practice,” she said.

“Everyone has access to the same test, regardless of which state, province, or country they take it in,” she said. Some international students may not perform as well as U.S.-educated students because of their command of English and the nursing education standards in their home countries, Ms. Kappel added.

“Obviously COVID and the challenge of education in general” affected the results, she said.

Mr. Oujeil, the nursing school professor, said he is frustrated by the test results because the majority of students who failed maintained good grades and passed all of their trainings. Yet they scored just below the passing rate of 55%. He said students are proposing the passing rate be lowered to 50%. The current test doesn’t reflect what students are learning in the classroom or during clinical trainings, Mr. Oujeil added. “I don’t know of any students who scored more than 60%.”

He said he understands that the mission of the OIIQ is protecting the population, but he doesn’t believe lowering the passing rate to 50% will put the population at risk – and it will help offset the staffing shortage.

“I’m especially frustrated by those who were doing integration programs – mothers and fathers with children with family lives and financial responsibilities. Many of them are good, hard workers and were shocked they should have to pass the exam another time.”

Since 2018, the pass rate on the first attempt at the Quebec test has generally been between 71% and 96%, compared with 51.4% during the exam in September, according to the OIIQ press release. Meanwhile, graduates from 30 of the 55 schools and universities in Quebec teaching nurses performed above the average on the recent professional exam, OIIQ reported.

The professional licensing organization pointed out that nursing candidates have three attempts to pass their exam. “In order to better prepare for their next attempt, all those who failed received an individual response detailing the difficulties encountered. The OIIQ offers all the tools necessary to pass the exam; a detailed guide and preparatory workshops are available online.

“In the run up to the next exams, we will continue to support students by working with educational institutions to provide the optimal conditions for passing the exam. This exam is usually successful and we are convinced that the return to face-to-face teaching, as well as support for students, will be factors of success,” OIIQ President Luc Mathieu said in a press release.

Nursing candidates “who have not passed the exam will be put to work in the network, with the possibility of practicing under the supervision of a nurse. ... In addition, we will contact health establishments in order to support them in their supervision activities” of the candidates, he said.

A version of this article first appeared on Medscape.com.

Nursing oversight groups in the United States and Canada are holding the line on testing standards as more would-be nurses fail entry exams. As a result, pressure is growing to make tests easier to pass given widespread nursing shortages, and some critics wonder whether the exams accurately assess students’ true abilities.

When it comes to training more nurses to keep up with growing demand, the U.S. organization that oversees the main licensing exams for nurses decided earlier this month not to change the passing standards for entry-level tests. Meanwhile, nursing test examiners have seen a drop in passing rates for nurses taking the standard licensing exam since the pandemic began.

A similar scenario also is unfolding in Quebec, where the agency overseeing nurse licensing exams announced last month it is holding the line on its passing rates despite an outcry from nurses after more than half of those taking the exam in September failed. Quebec’s commissioner for professional admissions is investigating dozens of complaints from nurses about the failure rate. Nurses who failed the test can sign up to retake it in March.

Joseph Oujeil, DESS, DEF, has been teaching in Canada for 4 years, now at two Quebec nursing schools. “This is surprising and very shocking to our students as well as nurses from outside Quebec who were [completing] an integration program to adjust their practice to Quebec guidelines,” Mr. Oujeil told this news organization. Students from outside the province failed the licensing exam at a higher rate than their Quebec-native peers, he explained.

Quebec’s professional Order of Nurses of Quebec (OIIQ) responded to the nurses’ outcry in a press release last month, saying that the pandemic may be partly to blame for the lower passing rate because it made it more difficult to access internships, labs, and face-to-face teaching. Some students weren’t able to demonstrate their ability to practice during the exam as in previous years, OIIQ reported.

Mr. Oujeil agreed. “I’m sure the pandemic has an impact on the situation as well as some students did less training in hospitals” because of restrictions caused by the pandemic, he said. But students also told Mr. Oujeil some questions seemed ambiguous.

OIIQ stated in its release that it doesn’t want to lower the standard. The goal is to protect the public “by and with nurses,” to “ensure the competence and integrity of nurses in Quebec,” and “promote quality nursing practice,” the release noted.

Similarly in the United States, the National Council of State Boards of Nursing (NCSBN) announced Dec. 8 that it would uphold the current passing standards for its entry-level NCLEX tests for registered nurses and practical nurses. NCSBN analyzes the passing standard every 3 years “to keep the test plan and passing standard current,” a press release explains.

NCLEX pass rates have dropped from about 73% for all candidates and 88% for first-time U.S.-educated candidates to 69% and 82% respectively in 2021, the last full year for which results are available, NCSBN spokesperson Dawn Kappel told this news organization.

Over the past 3 years, including during the pandemic, the board decided “that the current passing standard is appropriate as a measure of safe and effective entry-level nurse practice,” after reviewing national nurse surveys and the findings of panels of nurses representing NCSBN’s geographic areas in the United States and Canada, board president Jay Douglas, MSM, RN, CSAC, said in a press release.

Still, NCSBN is not blind to the larger issues facing nursing, Ms. Kappel told this news organization. “There is a huge nursing shortage in the U.S. and Canada. We want as many nurses in the workforce as possible, but we want to ensure safe practice,” she said.

“Everyone has access to the same test, regardless of which state, province, or country they take it in,” she said. Some international students may not perform as well as U.S.-educated students because of their command of English and the nursing education standards in their home countries, Ms. Kappel added.

“Obviously COVID and the challenge of education in general” affected the results, she said.

Mr. Oujeil, the nursing school professor, said he is frustrated by the test results because the majority of students who failed maintained good grades and passed all of their trainings. Yet they scored just below the passing rate of 55%. He said students are proposing the passing rate be lowered to 50%. The current test doesn’t reflect what students are learning in the classroom or during clinical trainings, Mr. Oujeil added. “I don’t know of any students who scored more than 60%.”

He said he understands that the mission of the OIIQ is protecting the population, but he doesn’t believe lowering the passing rate to 50% will put the population at risk – and it will help offset the staffing shortage.

“I’m especially frustrated by those who were doing integration programs – mothers and fathers with children with family lives and financial responsibilities. Many of them are good, hard workers and were shocked they should have to pass the exam another time.”

Since 2018, the pass rate on the first attempt at the Quebec test has generally been between 71% and 96%, compared with 51.4% during the exam in September, according to the OIIQ press release. Meanwhile, graduates from 30 of the 55 schools and universities in Quebec teaching nurses performed above the average on the recent professional exam, OIIQ reported.

The professional licensing organization pointed out that nursing candidates have three attempts to pass their exam. “In order to better prepare for their next attempt, all those who failed received an individual response detailing the difficulties encountered. The OIIQ offers all the tools necessary to pass the exam; a detailed guide and preparatory workshops are available online.

“In the run up to the next exams, we will continue to support students by working with educational institutions to provide the optimal conditions for passing the exam. This exam is usually successful and we are convinced that the return to face-to-face teaching, as well as support for students, will be factors of success,” OIIQ President Luc Mathieu said in a press release.

Nursing candidates “who have not passed the exam will be put to work in the network, with the possibility of practicing under the supervision of a nurse. ... In addition, we will contact health establishments in order to support them in their supervision activities” of the candidates, he said.

A version of this article first appeared on Medscape.com.

A new analysis finds that vonoprazan triple therapy (Voquezna) is the most cost-effective first-line regimen to eradicate Helicobacter pylori infection in the United States.

Rifabutin triple therapy (Talicia) is the second most cost-effective strategy for H. pylori eradication, followed in order of decreasing cost-effectiveness by vonoprazan dual therapy, bismuth quadruple therapy, and clarithromycin triple therapy.

The analysis is believed to be the first to report on the cost-effectiveness of vonoprazan- and rifabutin-based regimens as first-line treatments for H. pylori infection from the perspective of U.S. health care payers.

The findings “strongly” suggest that vonoprazan triple therapy would provide the greatest net health benefit and monetary benefit for U.S. payers, reported Ismaeel Yunusa, PharmD, PhD, of the University of South Carolina College of Pharmacy in Columbia, and colleagues.

The study was published online in the American Journal of Gastroenterology.

It’s estimated that more than 114 million people in the United States have H. pylori infection. Clinical practice guidelines recommend H. pylori eradication in all patients with a positive test of active infection.

Using a Markov model, Dr. Yunusa and colleagues estimated the cost-effectiveness of five prepackaged or co-formulated H. pylori eradication regimens: clarithromycin triple therapy, bismuth quadruple therapy, vonoprazan dual therapy, vonoprazan triple therapy, and rifabutin triple therapy.

The model estimated the expected costs in 2022 U.S. dollars, expected quality-adjusted life years (QALYs), incremental cost-effectiveness ratio (ICERs), and expected net monetary benefit over 20 years.

Among their key findings and conclusions:

• Bismuth quadruple therapy had the highest expected cost ($1,439) and rifabutin triple regimen had the lowest expected cost ($1,048).
• Because rifabutin triple therapy was predicted to cost less and was more effective than clarithromycin triple therapy, bismuth quadruple therapy, and vonoprazan dual therapy, it dominated all treatment strategies – except for vonoprazan triple therapy.
• Compared with rifabutin triple therapy, vonoprazan triple therapy had a higher expected cost ($1,172 vs. $1,048) and expected QALY (14.262 vs. 14.256), yielding an ICER of $22,573 per QALY. 
• Vonoprazan triple therapy had the highest expected net monetary benefit and was the most cost-effective at willingness to pay thresholds between $50,000 and $150,000 per QALY, followed by rifabutin triple therapy.
• Vonoprazan triple therapy would result on average in an incremental net benefit of $1,655 per patient than clarithromycin triple therapy.
• Because the rifabutin-based regimen was more cost-effective than all but vonoprazan triple therapy, it has a potential role as an alternative first-line treatment.
• Rifabutin triple therapy and vonoprazan dual therapy would need to be considerably discounted (by 15%-43% and by 44%-85%, respectively), to be cost-effective at commonly used cost-effectiveness thresholds.
• Vonoprazan dual therapy demonstrated limited value relative to other available options; thus, its widespread adoption as a first-line strategy seems unlikely.
• Based on the results, it would be hard to justify the use of bismuth quadruple therapy or clarithromycin triple therapy since they provide the lowest net monetary benefit and have lower eradication rates.

The investigators noted that their analysis considered only direct costs of therapy, not other costs such as appointments, travel, and time away from work.

They also assumed medical costs, including endoscopy and H. pylori testing, would not change regardless of treatment regimen. Therefore, total health care costs may be underestimated.

The study did not receive any funding. The authors have declared no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A new analysis finds that vonoprazan triple therapy (Voquezna) is the most cost-effective first-line regimen to eradicate Helicobacter pylori infection in the United States.

Rifabutin triple therapy (Talicia) is the second most cost-effective strategy for H. pylori eradication, followed in order of decreasing cost-effectiveness by vonoprazan dual therapy, bismuth quadruple therapy, and clarithromycin triple therapy.

The analysis is believed to be the first to report on the cost-effectiveness of vonoprazan- and rifabutin-based regimens as first-line treatments for H. pylori infection from the perspective of U.S. health care payers.

The findings “strongly” suggest that vonoprazan triple therapy would provide the greatest net health benefit and monetary benefit for U.S. payers, reported Ismaeel Yunusa, PharmD, PhD, of the University of South Carolina College of Pharmacy in Columbia, and colleagues.

The study was published online in the American Journal of Gastroenterology.

It’s estimated that more than 114 million people in the United States have H. pylori infection. Clinical practice guidelines recommend H. pylori eradication in all patients with a positive test of active infection.

Using a Markov model, Dr. Yunusa and colleagues estimated the cost-effectiveness of five prepackaged or co-formulated H. pylori eradication regimens: clarithromycin triple therapy, bismuth quadruple therapy, vonoprazan dual therapy, vonoprazan triple therapy, and rifabutin triple therapy.

The model estimated the expected costs in 2022 U.S. dollars, expected quality-adjusted life years (QALYs), incremental cost-effectiveness ratio (ICERs), and expected net monetary benefit over 20 years.

Among their key findings and conclusions:

• Bismuth quadruple therapy had the highest expected cost ($1,439) and rifabutin triple regimen had the lowest expected cost ($1,048).
• Because rifabutin triple therapy was predicted to cost less and was more effective than clarithromycin triple therapy, bismuth quadruple therapy, and vonoprazan dual therapy, it dominated all treatment strategies – except for vonoprazan triple therapy.
• Compared with rifabutin triple therapy, vonoprazan triple therapy had a higher expected cost ($1,172 vs. $1,048) and expected QALY (14.262 vs. 14.256), yielding an ICER of $22,573 per QALY. 
• Vonoprazan triple therapy had the highest expected net monetary benefit and was the most cost-effective at willingness to pay thresholds between $50,000 and $150,000 per QALY, followed by rifabutin triple therapy.
• Vonoprazan triple therapy would result on average in an incremental net benefit of $1,655 per patient than clarithromycin triple therapy.
• Because the rifabutin-based regimen was more cost-effective than all but vonoprazan triple therapy, it has a potential role as an alternative first-line treatment.
• Rifabutin triple therapy and vonoprazan dual therapy would need to be considerably discounted (by 15%-43% and by 44%-85%, respectively), to be cost-effective at commonly used cost-effectiveness thresholds.
• Vonoprazan dual therapy demonstrated limited value relative to other available options; thus, its widespread adoption as a first-line strategy seems unlikely.
• Based on the results, it would be hard to justify the use of bismuth quadruple therapy or clarithromycin triple therapy since they provide the lowest net monetary benefit and have lower eradication rates.

The investigators noted that their analysis considered only direct costs of therapy, not other costs such as appointments, travel, and time away from work.

They also assumed medical costs, including endoscopy and H. pylori testing, would not change regardless of treatment regimen. Therefore, total health care costs may be underestimated.

The study did not receive any funding. The authors have declared no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A new analysis finds that vonoprazan triple therapy (Voquezna) is the most cost-effective first-line regimen to eradicate Helicobacter pylori infection in the United States.

Rifabutin triple therapy (Talicia) is the second most cost-effective strategy for H. pylori eradication, followed in order of decreasing cost-effectiveness by vonoprazan dual therapy, bismuth quadruple therapy, and clarithromycin triple therapy.

The analysis is believed to be the first to report on the cost-effectiveness of vonoprazan- and rifabutin-based regimens as first-line treatments for H. pylori infection from the perspective of U.S. health care payers.

The findings “strongly” suggest that vonoprazan triple therapy would provide the greatest net health benefit and monetary benefit for U.S. payers, reported Ismaeel Yunusa, PharmD, PhD, of the University of South Carolina College of Pharmacy in Columbia, and colleagues.

The study was published online in the American Journal of Gastroenterology.

It’s estimated that more than 114 million people in the United States have H. pylori infection. Clinical practice guidelines recommend H. pylori eradication in all patients with a positive test of active infection.

Using a Markov model, Dr. Yunusa and colleagues estimated the cost-effectiveness of five prepackaged or co-formulated H. pylori eradication regimens: clarithromycin triple therapy, bismuth quadruple therapy, vonoprazan dual therapy, vonoprazan triple therapy, and rifabutin triple therapy.

The model estimated the expected costs in 2022 U.S. dollars, expected quality-adjusted life years (QALYs), incremental cost-effectiveness ratio (ICERs), and expected net monetary benefit over 20 years.

Among their key findings and conclusions:

• Bismuth quadruple therapy had the highest expected cost ($1,439) and rifabutin triple regimen had the lowest expected cost ($1,048).
• Because rifabutin triple therapy was predicted to cost less and was more effective than clarithromycin triple therapy, bismuth quadruple therapy, and vonoprazan dual therapy, it dominated all treatment strategies – except for vonoprazan triple therapy.
• Compared with rifabutin triple therapy, vonoprazan triple therapy had a higher expected cost ($1,172 vs. $1,048) and expected QALY (14.262 vs. 14.256), yielding an ICER of $22,573 per QALY. 
• Vonoprazan triple therapy had the highest expected net monetary benefit and was the most cost-effective at willingness to pay thresholds between $50,000 and $150,000 per QALY, followed by rifabutin triple therapy.
• Vonoprazan triple therapy would result on average in an incremental net benefit of $1,655 per patient than clarithromycin triple therapy.
• Because the rifabutin-based regimen was more cost-effective than all but vonoprazan triple therapy, it has a potential role as an alternative first-line treatment.
• Rifabutin triple therapy and vonoprazan dual therapy would need to be considerably discounted (by 15%-43% and by 44%-85%, respectively), to be cost-effective at commonly used cost-effectiveness thresholds.
• Vonoprazan dual therapy demonstrated limited value relative to other available options; thus, its widespread adoption as a first-line strategy seems unlikely.
• Based on the results, it would be hard to justify the use of bismuth quadruple therapy or clarithromycin triple therapy since they provide the lowest net monetary benefit and have lower eradication rates.

The investigators noted that their analysis considered only direct costs of therapy, not other costs such as appointments, travel, and time away from work.

They also assumed medical costs, including endoscopy and H. pylori testing, would not change regardless of treatment regimen. Therefore, total health care costs may be underestimated.

The study did not receive any funding. The authors have declared no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Congress averted bigger reductions in Medicare’s future payments for clinicians in its massive, year-end spending bill, but physicians will still see a 2% cut in a key payment variable in 2023.

The bill also authorizes new policies regarding accelerated drug approvals and substance use disorder treatment.

The House voted 225-201 to clear a wide-ranging legislative package, known as an omnibus, for President Joe Biden’s signature. The Senate voted 68-29 to approve the measure.

Clinicians had been facing as much as 8.5% in cuts to certain factors that set their Medicare payment. The American Medical Association credited an advocacy campaign it joined with more than 150 organizations with fending off the much-feared reimbursement cuts. The 2% trim for 2023 will decline to 1.25% for 2024.

These reductions will hit as many clinicians face the toll on rising costs for running their practices, as Congress has not included inflation-based payment adjustments in Medicare’s physician payment rule, the AMA said.

“Congress must immediately begin the work of long-overdue Medicare physician payment reform that will lead to the program stability that beneficiaries and physicians need,” AMA President Jack Resneck, MD, said in a statement.

While the omnibus bill blocks 6.5% of Medicare payment cuts originally slated to take effect in 2023, it still puts “untenable strain” on primary care clinicians, said Tochi Iroku-Malize, MD, MPH, president of the American Academy of Family Physicians, in a statement.

“However, we’re pleased to see several provisions that will improve access to care, including bolstering mental health services, extending telehealth, and expanding Medicaid and CHIP coverage,” Dr. Iroku-Malize added.
 

New health care policies in omnibus

Lawmakers adopted many health care policy changes in the omnibus package, which contained 12 overdue spending bills for fiscal year 2023. (Much of the federal government has been funded through stop-gap measures since this budget year began on Oct. 1.) The final measure runs to more than 4,100 pages in PDF form.

House Energy and Commerce Chairman Frank Pallone Jr. (D-NJ) said the health care provisions will:

• Expand patient access to opioid addiction treatment by making it easier for clinicians to dispense buprenorphine for opioid use disorder maintenance or detoxification treatment
• Require health care providers to complete a training requirement on identifying and treating patients with substance use disorders
• Guarantee 12 months of continuous Medicaid coverage for 40 million children
• Provide 2 years of additional Children’s Health Insurance Program (CHIP) funding
• Permanently extend the option for states to offer 12 months of Medicaid coverage to new mothers
• Continue Medicare’s expanded access to telehealth by extending COVID-19 telehealth flexibilities through Dec. 31, 2024.

FDA’s accelerated approval

The omnibus also will shorten the period of uncertainty patients and clinicians face with medicines cleared under the accelerated approval pathway.

The Food and Drug Administration uses accelerated approvals to give conditional clearances to medicines for fatal and serious conditions based on limited evidence signaling a potential benefit. Companies are expected to continue research needed to prove whether promising signals, such as stemming tumor growth, benefits patients.

Concerns have mounted when companies delay confirmatory trials or try to maintain accelerated approvals for drugs that fail those trials.

Mr. Pallone said the omnibus contains provisions that:

• Require the FDA to specify conditions for required post-approval studies
• Authorize the FDA to require post-approval studies to be underway at the time of approval or within a specified time period following approval.
• Clarify and streamline current FDA authority to withdraw approvals when sponsors fail to conduct studies with due diligence.

Reshma Ramachandran, MD, MPP, MHS, who serves as the chair of the Doctors for America’s FDA Task Force, told this news organization that she was pleased to see these provisions pass. She had been disappointed they were not included earlier this year in the latest Prescription Drug User Fee Act reauthorization.

The provisions in the omnibus make “clear what steps the FDA can take to remove an unproven drug off the market should manufacturers fail to complete these studies or demonstrate meaningful clinical benefit,” Dr. Ramachandran wrote in an email.

Dr. Ramachandran said she hopes lawmakers build on these steps in the future. She suggested Congress add a mandate to require drug labels to clearly state when the FDA is still waiting for evidence needed to confirm benefits of medicines cleared by accelerated approval.

“Nevertheless, Congress in including and, hopefully, passing these reforms has made it clear that drug companies need to provide meaningful evidence that their accelerated approval drugs work in patients and FDA can take action to protect patients should this not occur,” Dr. Ramachandran wrote.

A version of this article first appeared on Medscape.com.

Congress averted bigger reductions in Medicare’s future payments for clinicians in its massive, year-end spending bill, but physicians will still see a 2% cut in a key payment variable in 2023.

The bill also authorizes new policies regarding accelerated drug approvals and substance use disorder treatment.

The House voted 225-201 to clear a wide-ranging legislative package, known as an omnibus, for President Joe Biden’s signature. The Senate voted 68-29 to approve the measure.

Clinicians had been facing as much as 8.5% in cuts to certain factors that set their Medicare payment. The American Medical Association credited an advocacy campaign it joined with more than 150 organizations with fending off the much-feared reimbursement cuts. The 2% trim for 2023 will decline to 1.25% for 2024.

These reductions will hit as many clinicians face the toll on rising costs for running their practices, as Congress has not included inflation-based payment adjustments in Medicare’s physician payment rule, the AMA said.

“Congress must immediately begin the work of long-overdue Medicare physician payment reform that will lead to the program stability that beneficiaries and physicians need,” AMA President Jack Resneck, MD, said in a statement.

While the omnibus bill blocks 6.5% of Medicare payment cuts originally slated to take effect in 2023, it still puts “untenable strain” on primary care clinicians, said Tochi Iroku-Malize, MD, MPH, president of the American Academy of Family Physicians, in a statement.

“However, we’re pleased to see several provisions that will improve access to care, including bolstering mental health services, extending telehealth, and expanding Medicaid and CHIP coverage,” Dr. Iroku-Malize added.
 

New health care policies in omnibus

Lawmakers adopted many health care policy changes in the omnibus package, which contained 12 overdue spending bills for fiscal year 2023. (Much of the federal government has been funded through stop-gap measures since this budget year began on Oct. 1.) The final measure runs to more than 4,100 pages in PDF form.

House Energy and Commerce Chairman Frank Pallone Jr. (D-NJ) said the health care provisions will:

• Expand patient access to opioid addiction treatment by making it easier for clinicians to dispense buprenorphine for opioid use disorder maintenance or detoxification treatment
• Require health care providers to complete a training requirement on identifying and treating patients with substance use disorders
• Guarantee 12 months of continuous Medicaid coverage for 40 million children
• Provide 2 years of additional Children’s Health Insurance Program (CHIP) funding
• Permanently extend the option for states to offer 12 months of Medicaid coverage to new mothers
• Continue Medicare’s expanded access to telehealth by extending COVID-19 telehealth flexibilities through Dec. 31, 2024.

FDA’s accelerated approval

The omnibus also will shorten the period of uncertainty patients and clinicians face with medicines cleared under the accelerated approval pathway.

The Food and Drug Administration uses accelerated approvals to give conditional clearances to medicines for fatal and serious conditions based on limited evidence signaling a potential benefit. Companies are expected to continue research needed to prove whether promising signals, such as stemming tumor growth, benefits patients.

Concerns have mounted when companies delay confirmatory trials or try to maintain accelerated approvals for drugs that fail those trials.

Mr. Pallone said the omnibus contains provisions that:

• Require the FDA to specify conditions for required post-approval studies
• Authorize the FDA to require post-approval studies to be underway at the time of approval or within a specified time period following approval.
• Clarify and streamline current FDA authority to withdraw approvals when sponsors fail to conduct studies with due diligence.

Reshma Ramachandran, MD, MPP, MHS, who serves as the chair of the Doctors for America’s FDA Task Force, told this news organization that she was pleased to see these provisions pass. She had been disappointed they were not included earlier this year in the latest Prescription Drug User Fee Act reauthorization.

The provisions in the omnibus make “clear what steps the FDA can take to remove an unproven drug off the market should manufacturers fail to complete these studies or demonstrate meaningful clinical benefit,” Dr. Ramachandran wrote in an email.

Dr. Ramachandran said she hopes lawmakers build on these steps in the future. She suggested Congress add a mandate to require drug labels to clearly state when the FDA is still waiting for evidence needed to confirm benefits of medicines cleared by accelerated approval.

“Nevertheless, Congress in including and, hopefully, passing these reforms has made it clear that drug companies need to provide meaningful evidence that their accelerated approval drugs work in patients and FDA can take action to protect patients should this not occur,” Dr. Ramachandran wrote.

A version of this article first appeared on Medscape.com.

Congress averted bigger reductions in Medicare’s future payments for clinicians in its massive, year-end spending bill, but physicians will still see a 2% cut in a key payment variable in 2023.

The bill also authorizes new policies regarding accelerated drug approvals and substance use disorder treatment.

The House voted 225-201 to clear a wide-ranging legislative package, known as an omnibus, for President Joe Biden’s signature. The Senate voted 68-29 to approve the measure.

Clinicians had been facing as much as 8.5% in cuts to certain factors that set their Medicare payment. The American Medical Association credited an advocacy campaign it joined with more than 150 organizations with fending off the much-feared reimbursement cuts. The 2% trim for 2023 will decline to 1.25% for 2024.

These reductions will hit as many clinicians face the toll on rising costs for running their practices, as Congress has not included inflation-based payment adjustments in Medicare’s physician payment rule, the AMA said.

“Congress must immediately begin the work of long-overdue Medicare physician payment reform that will lead to the program stability that beneficiaries and physicians need,” AMA President Jack Resneck, MD, said in a statement.

While the omnibus bill blocks 6.5% of Medicare payment cuts originally slated to take effect in 2023, it still puts “untenable strain” on primary care clinicians, said Tochi Iroku-Malize, MD, MPH, president of the American Academy of Family Physicians, in a statement.

“However, we’re pleased to see several provisions that will improve access to care, including bolstering mental health services, extending telehealth, and expanding Medicaid and CHIP coverage,” Dr. Iroku-Malize added.
 

New health care policies in omnibus

Lawmakers adopted many health care policy changes in the omnibus package, which contained 12 overdue spending bills for fiscal year 2023. (Much of the federal government has been funded through stop-gap measures since this budget year began on Oct. 1.) The final measure runs to more than 4,100 pages in PDF form.

House Energy and Commerce Chairman Frank Pallone Jr. (D-NJ) said the health care provisions will:

• Expand patient access to opioid addiction treatment by making it easier for clinicians to dispense buprenorphine for opioid use disorder maintenance or detoxification treatment
• Require health care providers to complete a training requirement on identifying and treating patients with substance use disorders
• Guarantee 12 months of continuous Medicaid coverage for 40 million children
• Provide 2 years of additional Children’s Health Insurance Program (CHIP) funding
• Permanently extend the option for states to offer 12 months of Medicaid coverage to new mothers
• Continue Medicare’s expanded access to telehealth by extending COVID-19 telehealth flexibilities through Dec. 31, 2024.

FDA’s accelerated approval

The omnibus also will shorten the period of uncertainty patients and clinicians face with medicines cleared under the accelerated approval pathway.

The Food and Drug Administration uses accelerated approvals to give conditional clearances to medicines for fatal and serious conditions based on limited evidence signaling a potential benefit. Companies are expected to continue research needed to prove whether promising signals, such as stemming tumor growth, benefits patients.

Concerns have mounted when companies delay confirmatory trials or try to maintain accelerated approvals for drugs that fail those trials.

Mr. Pallone said the omnibus contains provisions that:

• Require the FDA to specify conditions for required post-approval studies
• Authorize the FDA to require post-approval studies to be underway at the time of approval or within a specified time period following approval.
• Clarify and streamline current FDA authority to withdraw approvals when sponsors fail to conduct studies with due diligence.

Reshma Ramachandran, MD, MPP, MHS, who serves as the chair of the Doctors for America’s FDA Task Force, told this news organization that she was pleased to see these provisions pass. She had been disappointed they were not included earlier this year in the latest Prescription Drug User Fee Act reauthorization.

The provisions in the omnibus make “clear what steps the FDA can take to remove an unproven drug off the market should manufacturers fail to complete these studies or demonstrate meaningful clinical benefit,” Dr. Ramachandran wrote in an email.

Dr. Ramachandran said she hopes lawmakers build on these steps in the future. She suggested Congress add a mandate to require drug labels to clearly state when the FDA is still waiting for evidence needed to confirm benefits of medicines cleared by accelerated approval.

“Nevertheless, Congress in including and, hopefully, passing these reforms has made it clear that drug companies need to provide meaningful evidence that their accelerated approval drugs work in patients and FDA can take action to protect patients should this not occur,” Dr. Ramachandran wrote.

A version of this article first appeared on Medscape.com.

People who follow a vegetarian lifestyle have around twice as many depressive episodes as those who eat meat, according to the Brazilian Longitudinal Study of Adult Health.

What to know

The high incidence of depression among vegetarians is not caused by nutrition but possibly by several factors, including the vegetarian social experience; depression itself may increase the likelihood of becoming vegetarian, or both vegetarianism and depression may be associated with guilt through factors involving the meat industry.

Adopting a vegetarian diet might affect one’s relationship with others and involvement in social activities and may sometimes be associated with teasing or other forms of social ostracism.

It is possible that being depressed and dwelling on negative thoughts cause people to be more likely to become vegetarian rather than the other way around.

Videos depicting violence and cruelty in the meat industry may affect depressed people, causing them to dwell on the images, feel guilty for their part in creating the demand for meat, and become vegetarian.

Survey data were collected in Brazil, a country famous for its meat-heavy diet, and while there has been a sharp increase in vegetarianism, vegetarians still account for less than 0.5%.

This is a summary of the article, “Association Between Meatless Diet and Depressive Episodes: A Cross-sectional Analysis of Baseline Data From the Longitudinal Study of Adult Health (ELSA-Brasil),” published in the Journal of Affective Disorders. The full article can be found at sciencedirect.com.

A version of this article first appeared on Medscape.com.

People who follow a vegetarian lifestyle have around twice as many depressive episodes as those who eat meat, according to the Brazilian Longitudinal Study of Adult Health.

What to know

The high incidence of depression among vegetarians is not caused by nutrition but possibly by several factors, including the vegetarian social experience; depression itself may increase the likelihood of becoming vegetarian, or both vegetarianism and depression may be associated with guilt through factors involving the meat industry.

Adopting a vegetarian diet might affect one’s relationship with others and involvement in social activities and may sometimes be associated with teasing or other forms of social ostracism.

It is possible that being depressed and dwelling on negative thoughts cause people to be more likely to become vegetarian rather than the other way around.

Videos depicting violence and cruelty in the meat industry may affect depressed people, causing them to dwell on the images, feel guilty for their part in creating the demand for meat, and become vegetarian.

Survey data were collected in Brazil, a country famous for its meat-heavy diet, and while there has been a sharp increase in vegetarianism, vegetarians still account for less than 0.5%.

This is a summary of the article, “Association Between Meatless Diet and Depressive Episodes: A Cross-sectional Analysis of Baseline Data From the Longitudinal Study of Adult Health (ELSA-Brasil),” published in the Journal of Affective Disorders. The full article can be found at sciencedirect.com.

A version of this article first appeared on Medscape.com.

People who follow a vegetarian lifestyle have around twice as many depressive episodes as those who eat meat, according to the Brazilian Longitudinal Study of Adult Health.

What to know

The high incidence of depression among vegetarians is not caused by nutrition but possibly by several factors, including the vegetarian social experience; depression itself may increase the likelihood of becoming vegetarian, or both vegetarianism and depression may be associated with guilt through factors involving the meat industry.

Adopting a vegetarian diet might affect one’s relationship with others and involvement in social activities and may sometimes be associated with teasing or other forms of social ostracism.

It is possible that being depressed and dwelling on negative thoughts cause people to be more likely to become vegetarian rather than the other way around.

Videos depicting violence and cruelty in the meat industry may affect depressed people, causing them to dwell on the images, feel guilty for their part in creating the demand for meat, and become vegetarian.

Survey data were collected in Brazil, a country famous for its meat-heavy diet, and while there has been a sharp increase in vegetarianism, vegetarians still account for less than 0.5%.

This is a summary of the article, “Association Between Meatless Diet and Depressive Episodes: A Cross-sectional Analysis of Baseline Data From the Longitudinal Study of Adult Health (ELSA-Brasil),” published in the Journal of Affective Disorders. The full article can be found at sciencedirect.com.

A version of this article first appeared on Medscape.com.

Clinicians in the United States are reporting more cases of invasive group A streptococcal infection (iGAS) in children, according to an alert from the Centers for Disease Control and Prevention. These infections are rare but can be deadly, and they can affect adults as well as children.

Health care providers should consider this bacterial infection as a possible cause of severe illness in children and adults, including those with recent or co-occurring viral respiratory infections, the agency advised in a Dec. 22 alert.

In some cases, iGAS manifests as persistent or worsening symptoms after a patient with a known viral infection initially starts to show signs of improvement, according to the agency.

In November, the CDC was notified about a possible increase in cases of pediatric iGAS at a hospital in Colorado. Since then, two surveillance systems – the Infectious Diseases Society of America’s Emerging Infections Network and the CDC’s Active Bacterial Core Surveillance System – have detected potential increases in pediatric iGAS cases in other states.

The uptick has coincided with “increased circulation of respiratory syncytial virus (RSV), influenza viruses, SARS-CoV-2, and other respiratory viruses,” the advisory stated. “While the overall number of cases has remained relatively low and iGAS infections remain rare in children, [the] CDC is investigating these reports.”
 

Not just strep throat

Group A Streptococcus bacteria can cause strep throat and infections in skin and soft tissue. The pathogens also can lead to uncommon but severe diseases, such as sepsis, streptococcal toxic shock syndrome, and necrotizing fasciitis, according to the CDC. The severe illnesses “are associated with high mortality rates and require immediate treatment, including appropriate antibiotic therapy,” the agency said.

Groups at higher risk for iGAS include people aged 65 years or older, American Indian and Alaska Native populations, residents of long-term care facilities, those with wounds or skin disease, people who inject drugs, and people experiencing homelessness.

People with medical conditions such as diabetes, cancer, immunosuppression, and chronic kidney, heart, or respiratory disease also are at increased risk.

Invasive strep A infections initially decreased during the COVID-19 pandemic amid measures to reduce the spread of disease, such as masking and social distancing. But since September, monthly cases have exceeded those in 2020 and 2021. “It is too early to determine whether this rise is beyond what would be expected for pre-COVID” seasonal patterns, the CDC said.
 

Recommendations

Because iGAS can occur after the flu or chickenpox, health care providers should offer influenza and varicella vaccinations to all eligible people who are not up to date with their vaccines.

In addition, clinicians should educate patients about symptoms of iGAS that require urgent medical attention, including necrotizing fasciitis, cellulitis, and toxic shock syndrome.

They also should obtain cultures for suspected cases of iGAS as clinically indicated, follow guidelines for the diagnosis and treatment of strep throat, and be aware of alternative ways to treat strep throat in children amid a shortage of amoxicillin suspension.

Researchers have reported more cases of iGAS in the United Kingdom this year, as well. According to the UK Health Security Agency, 74 deaths, including 16 children, in England have been attributed to iGAS since September.

“We know that this is concerning for parents, but I want to stress that while we are seeing an increase in cases in children, this remains very uncommon,” UKHSA Deputy Director Colin Brown said in a news release. “There are lots of winter bugs circulating that can make your child feel unwell that mostly aren’t cause for alarm. However, make sure you talk to a health professional if your child is getting worse after a bout of scarlet fever, a sore throat, or respiratory infection.”

A fever that doesn’t resolve, dehydration, extreme tiredness, and difficulty breathing are signs to watch out for, Dr. Brown said.

A version of this article first appeared on Medscape.com.

Clinicians in the United States are reporting more cases of invasive group A streptococcal infection (iGAS) in children, according to an alert from the Centers for Disease Control and Prevention. These infections are rare but can be deadly, and they can affect adults as well as children.

Health care providers should consider this bacterial infection as a possible cause of severe illness in children and adults, including those with recent or co-occurring viral respiratory infections, the agency advised in a Dec. 22 alert.

In some cases, iGAS manifests as persistent or worsening symptoms after a patient with a known viral infection initially starts to show signs of improvement, according to the agency.

In November, the CDC was notified about a possible increase in cases of pediatric iGAS at a hospital in Colorado. Since then, two surveillance systems – the Infectious Diseases Society of America’s Emerging Infections Network and the CDC’s Active Bacterial Core Surveillance System – have detected potential increases in pediatric iGAS cases in other states.

The uptick has coincided with “increased circulation of respiratory syncytial virus (RSV), influenza viruses, SARS-CoV-2, and other respiratory viruses,” the advisory stated. “While the overall number of cases has remained relatively low and iGAS infections remain rare in children, [the] CDC is investigating these reports.”
 

Not just strep throat

Group A Streptococcus bacteria can cause strep throat and infections in skin and soft tissue. The pathogens also can lead to uncommon but severe diseases, such as sepsis, streptococcal toxic shock syndrome, and necrotizing fasciitis, according to the CDC. The severe illnesses “are associated with high mortality rates and require immediate treatment, including appropriate antibiotic therapy,” the agency said.

Groups at higher risk for iGAS include people aged 65 years or older, American Indian and Alaska Native populations, residents of long-term care facilities, those with wounds or skin disease, people who inject drugs, and people experiencing homelessness.

People with medical conditions such as diabetes, cancer, immunosuppression, and chronic kidney, heart, or respiratory disease also are at increased risk.

Invasive strep A infections initially decreased during the COVID-19 pandemic amid measures to reduce the spread of disease, such as masking and social distancing. But since September, monthly cases have exceeded those in 2020 and 2021. “It is too early to determine whether this rise is beyond what would be expected for pre-COVID” seasonal patterns, the CDC said.
 

Recommendations

Because iGAS can occur after the flu or chickenpox, health care providers should offer influenza and varicella vaccinations to all eligible people who are not up to date with their vaccines.

In addition, clinicians should educate patients about symptoms of iGAS that require urgent medical attention, including necrotizing fasciitis, cellulitis, and toxic shock syndrome.

They also should obtain cultures for suspected cases of iGAS as clinically indicated, follow guidelines for the diagnosis and treatment of strep throat, and be aware of alternative ways to treat strep throat in children amid a shortage of amoxicillin suspension.

Researchers have reported more cases of iGAS in the United Kingdom this year, as well. According to the UK Health Security Agency, 74 deaths, including 16 children, in England have been attributed to iGAS since September.

“We know that this is concerning for parents, but I want to stress that while we are seeing an increase in cases in children, this remains very uncommon,” UKHSA Deputy Director Colin Brown said in a news release. “There are lots of winter bugs circulating that can make your child feel unwell that mostly aren’t cause for alarm. However, make sure you talk to a health professional if your child is getting worse after a bout of scarlet fever, a sore throat, or respiratory infection.”

A fever that doesn’t resolve, dehydration, extreme tiredness, and difficulty breathing are signs to watch out for, Dr. Brown said.

A version of this article first appeared on Medscape.com.

Clinicians in the United States are reporting more cases of invasive group A streptococcal infection (iGAS) in children, according to an alert from the Centers for Disease Control and Prevention. These infections are rare but can be deadly, and they can affect adults as well as children.

Health care providers should consider this bacterial infection as a possible cause of severe illness in children and adults, including those with recent or co-occurring viral respiratory infections, the agency advised in a Dec. 22 alert.

In some cases, iGAS manifests as persistent or worsening symptoms after a patient with a known viral infection initially starts to show signs of improvement, according to the agency.

In November, the CDC was notified about a possible increase in cases of pediatric iGAS at a hospital in Colorado. Since then, two surveillance systems – the Infectious Diseases Society of America’s Emerging Infections Network and the CDC’s Active Bacterial Core Surveillance System – have detected potential increases in pediatric iGAS cases in other states.

The uptick has coincided with “increased circulation of respiratory syncytial virus (RSV), influenza viruses, SARS-CoV-2, and other respiratory viruses,” the advisory stated. “While the overall number of cases has remained relatively low and iGAS infections remain rare in children, [the] CDC is investigating these reports.”
 

Not just strep throat

Group A Streptococcus bacteria can cause strep throat and infections in skin and soft tissue. The pathogens also can lead to uncommon but severe diseases, such as sepsis, streptococcal toxic shock syndrome, and necrotizing fasciitis, according to the CDC. The severe illnesses “are associated with high mortality rates and require immediate treatment, including appropriate antibiotic therapy,” the agency said.

Groups at higher risk for iGAS include people aged 65 years or older, American Indian and Alaska Native populations, residents of long-term care facilities, those with wounds or skin disease, people who inject drugs, and people experiencing homelessness.

People with medical conditions such as diabetes, cancer, immunosuppression, and chronic kidney, heart, or respiratory disease also are at increased risk.

Invasive strep A infections initially decreased during the COVID-19 pandemic amid measures to reduce the spread of disease, such as masking and social distancing. But since September, monthly cases have exceeded those in 2020 and 2021. “It is too early to determine whether this rise is beyond what would be expected for pre-COVID” seasonal patterns, the CDC said.
 

Recommendations

Because iGAS can occur after the flu or chickenpox, health care providers should offer influenza and varicella vaccinations to all eligible people who are not up to date with their vaccines.

In addition, clinicians should educate patients about symptoms of iGAS that require urgent medical attention, including necrotizing fasciitis, cellulitis, and toxic shock syndrome.

They also should obtain cultures for suspected cases of iGAS as clinically indicated, follow guidelines for the diagnosis and treatment of strep throat, and be aware of alternative ways to treat strep throat in children amid a shortage of amoxicillin suspension.

Researchers have reported more cases of iGAS in the United Kingdom this year, as well. According to the UK Health Security Agency, 74 deaths, including 16 children, in England have been attributed to iGAS since September.

“We know that this is concerning for parents, but I want to stress that while we are seeing an increase in cases in children, this remains very uncommon,” UKHSA Deputy Director Colin Brown said in a news release. “There are lots of winter bugs circulating that can make your child feel unwell that mostly aren’t cause for alarm. However, make sure you talk to a health professional if your child is getting worse after a bout of scarlet fever, a sore throat, or respiratory infection.”

A fever that doesn’t resolve, dehydration, extreme tiredness, and difficulty breathing are signs to watch out for, Dr. Brown said.

A version of this article first appeared on Medscape.com.

Breast cancer treatments have made great strides in recent years with significant reductions in overall mortality. However, the incidence of breast cancer has increased just slightly in recent years after a dip in the early 2000s.

“The good news is that mortality is decreasing, but it still remains high. We still have a long way to go to tackle this problem of breast cancer incidence as well as the number of deaths,” said Angela DeMichele, MD, co-leader of the breast cancer research program at the University of Pennsylvania’s Abramson Cancer Center. She participated in a session on obstacles in breast cancer treatment held in December at the San Antonio Breast Cancer Symposium. She joined other oncologists in outlining key challenges that need to be addressed to improve breast cancer diagnosis and treatment.

They highlighted six obstacles: The need for more prevention/early detection strategies; the underutilization of artificial intelligence; underuse of precision oncology such as targeted therapies; the need for innovation in clinical trials; a widening gap in cancer disparities; and the need to align incentives and funding for research collaboration, training, and retention.

Since 2012, the Food and Drug Administration has approved 20 new therapeutics to treat breast cancer. Nadia Harbeck, MD, PhD, director of the breast center at LMU University Hospital, Munich, said that the development of new therapies has in a way become a victim of its own success. Therapies and survival have improved, making it harder to compare novel therapies to the standard of care and prove a benefit. Treatment guidelines are changing so quickly that clinical trials are sometimes obsolete by the time they are published because of changes to the standard of care. That places a need on more real-world evidence that can be designed to be useful in the clinic, and AI can help here. “We need to convince regulators to act upon cleverly planned real world evidence analysis. You can randomize them, you can use registries, and you should also be able to change labels because of [new] data,” Dr. Harbeck said.

There are many risk factors that drive breast cancer, and it is very heterogeneous, said Christine Ambrosone, PhD, chair of the department of cancer prevention and control at Roswell Park Comprehensive Cancer Center, Buffalo, N.Y. She called for identifying patients who are at risk for a poor prognosis, such as patients with hormone receptor–negative breast cancer, high-grade, and triple-negative breast cancer. Otherwise there is a risk of overtreatment of low-risk tumors, which could potentially be identified with new tools in precision oncology such as liquid biopsy tests, also known as multicancer early detection tests. These tests can detect cancers long before they become symptomatic. The first such test was launched this year and many more are in clinical trials.

Regina Barzilay, PhD, professor and expert in the use of artificial intelligence in health at the Massachusetts Institute of Technology, pointed out that machine learning is used in many fields, but hardly at all in breast cancer. It could be applied to data on biomarkers and other factors collected from retrospective analyses and clinical trials. She added that machine learning is often applied to biochemistry and single cell analysis of other tumor types, but rarely in breast cancer. “It is severely underutilized,” Dr. Barzilay said. One challenge is that researchers are not necessarily familiar with the techniques of machine learning and AI. Another issue is that breast cancer data are not easy to share and may not be readily available to AI researchers. “An investment in interchangeable data is crucially important,” she said.

Artificial intelligence could assist in identifying and modeling factors that contribute to cancer risk by teasing apart complicated relationships, such as the association between pregnancy, breastfeeding, and breast cancer risk. Pregnancy reduces the risk of hormone receptor–positive disease, but increases the risk of hormone receptor–negative disease.

Another key challenge is the underuse of “omics” technologies, which measure large scale patterns in biological characteristics such as gene variation or protein expression. That has roots in the history of breast cancer being considered as a separate entity from other solid tumors such as lung or pancreatic cancer. Fabrice André, MD, PhD, an oncologist with Gustave Roussy Cancer Center, France, emphasized that breast cancer shouldn’t be considered an entity when it’s metastatic. Instead, tumors should be defined by molecular characteristics they share. He anticipates a personalized medicine future where academic and industry groups collaborate to create an individualized therapy for patients based on genetic factors.
 

Access to therapies for all patients

Novel and effective therapies can make a difference only if patients have access to them, and a key obstacle to improving breast cancer care is racism and inequities in health care. “We have to acknowledge that there is racism in medicine. I think once we acknowledge that, then we can look at things in our practices that we need to change. We can think very broadly and look at things that perhaps disadvantage one population over another,” said Lori Pierce, MD, a radiation oncologist with the University of Michigan, Ann Arbor.

Dr. Pierce also emphasized the need to recruit more underrepresented groups to participate in clinical trials. For example, of six breast cancer clinical trials – for margetuximab (Margenza), sacituzumab govitecan (Trodelvy), tucatinib (Tukysa), trastuzumab deruxtecan (Enhertu), alpelisib (Piqray), and talazoparib (Talzenna), only a small percentage included Black, Asian, and Hispanic women. For trastuzumab deruxtecan, which is widely recognized as a best-in-class HER2-targeting antibody drug conjugate, 51% were White, 42% Asian, 6% Hispanic, and 3% Black. For sacituzumab govitecan, a blockbuster drug for triple-negative breast cancer (TNBC), an aggressive subtype of breast cancer that disproportionately affects Black women, only 7% of women enrolled in clinical trials were Black. In clinical trials for margetuximab, approved to treat HER2-positive breast cancer, 80% of participants were White, 5% Black, 6% Asian, and 9% Hispanic.

There is a perception that minorities may be unwilling to participate in clinical trials, but that’s not true, according to Patty Spears, a research manager of the Patient Advocates for Research Council at the University of North Carolina. “We know that there are data that clearly show that patients will go on clinical trials at the same rate, whether they’re Black, White, Asian, or whatever. You have to be able to have them in your system and ask them to go on trial,” she said.

Another panelist told a personal anecdote to illustrate the point. Matthew Ellis, MD, PhD, recalled that he spent 13 years at Washington University in St. Louis, serving one of the more segregated cities in the United States. The city hospital closed, and Washington University and the Siteman Cancer Center signed a contract to treat the underserved population that was suddenly without a source of care. “Subsequent to that, we over-accrued relative to the population of African American patients. What that taught me is it’s nothing to do with the lack of willingness of African Americans to participate in clinical trials. Quite the opposite. It’s the question of access to clinical trials, access to great care, and not creating health care systems that segregate patients into places where they’re not getting access,” he said.

Breast cancer treatments have made great strides in recent years with significant reductions in overall mortality. However, the incidence of breast cancer has increased just slightly in recent years after a dip in the early 2000s.

“The good news is that mortality is decreasing, but it still remains high. We still have a long way to go to tackle this problem of breast cancer incidence as well as the number of deaths,” said Angela DeMichele, MD, co-leader of the breast cancer research program at the University of Pennsylvania’s Abramson Cancer Center. She participated in a session on obstacles in breast cancer treatment held in December at the San Antonio Breast Cancer Symposium. She joined other oncologists in outlining key challenges that need to be addressed to improve breast cancer diagnosis and treatment.

They highlighted six obstacles: The need for more prevention/early detection strategies; the underutilization of artificial intelligence; underuse of precision oncology such as targeted therapies; the need for innovation in clinical trials; a widening gap in cancer disparities; and the need to align incentives and funding for research collaboration, training, and retention.

Since 2012, the Food and Drug Administration has approved 20 new therapeutics to treat breast cancer. Nadia Harbeck, MD, PhD, director of the breast center at LMU University Hospital, Munich, said that the development of new therapies has in a way become a victim of its own success. Therapies and survival have improved, making it harder to compare novel therapies to the standard of care and prove a benefit. Treatment guidelines are changing so quickly that clinical trials are sometimes obsolete by the time they are published because of changes to the standard of care. That places a need on more real-world evidence that can be designed to be useful in the clinic, and AI can help here. “We need to convince regulators to act upon cleverly planned real world evidence analysis. You can randomize them, you can use registries, and you should also be able to change labels because of [new] data,” Dr. Harbeck said.

There are many risk factors that drive breast cancer, and it is very heterogeneous, said Christine Ambrosone, PhD, chair of the department of cancer prevention and control at Roswell Park Comprehensive Cancer Center, Buffalo, N.Y. She called for identifying patients who are at risk for a poor prognosis, such as patients with hormone receptor–negative breast cancer, high-grade, and triple-negative breast cancer. Otherwise there is a risk of overtreatment of low-risk tumors, which could potentially be identified with new tools in precision oncology such as liquid biopsy tests, also known as multicancer early detection tests. These tests can detect cancers long before they become symptomatic. The first such test was launched this year and many more are in clinical trials.

Regina Barzilay, PhD, professor and expert in the use of artificial intelligence in health at the Massachusetts Institute of Technology, pointed out that machine learning is used in many fields, but hardly at all in breast cancer. It could be applied to data on biomarkers and other factors collected from retrospective analyses and clinical trials. She added that machine learning is often applied to biochemistry and single cell analysis of other tumor types, but rarely in breast cancer. “It is severely underutilized,” Dr. Barzilay said. One challenge is that researchers are not necessarily familiar with the techniques of machine learning and AI. Another issue is that breast cancer data are not easy to share and may not be readily available to AI researchers. “An investment in interchangeable data is crucially important,” she said.

Artificial intelligence could assist in identifying and modeling factors that contribute to cancer risk by teasing apart complicated relationships, such as the association between pregnancy, breastfeeding, and breast cancer risk. Pregnancy reduces the risk of hormone receptor–positive disease, but increases the risk of hormone receptor–negative disease.

Another key challenge is the underuse of “omics” technologies, which measure large scale patterns in biological characteristics such as gene variation or protein expression. That has roots in the history of breast cancer being considered as a separate entity from other solid tumors such as lung or pancreatic cancer. Fabrice André, MD, PhD, an oncologist with Gustave Roussy Cancer Center, France, emphasized that breast cancer shouldn’t be considered an entity when it’s metastatic. Instead, tumors should be defined by molecular characteristics they share. He anticipates a personalized medicine future where academic and industry groups collaborate to create an individualized therapy for patients based on genetic factors.
 

Access to therapies for all patients

Novel and effective therapies can make a difference only if patients have access to them, and a key obstacle to improving breast cancer care is racism and inequities in health care. “We have to acknowledge that there is racism in medicine. I think once we acknowledge that, then we can look at things in our practices that we need to change. We can think very broadly and look at things that perhaps disadvantage one population over another,” said Lori Pierce, MD, a radiation oncologist with the University of Michigan, Ann Arbor.

Dr. Pierce also emphasized the need to recruit more underrepresented groups to participate in clinical trials. For example, of six breast cancer clinical trials – for margetuximab (Margenza), sacituzumab govitecan (Trodelvy), tucatinib (Tukysa), trastuzumab deruxtecan (Enhertu), alpelisib (Piqray), and talazoparib (Talzenna), only a small percentage included Black, Asian, and Hispanic women. For trastuzumab deruxtecan, which is widely recognized as a best-in-class HER2-targeting antibody drug conjugate, 51% were White, 42% Asian, 6% Hispanic, and 3% Black. For sacituzumab govitecan, a blockbuster drug for triple-negative breast cancer (TNBC), an aggressive subtype of breast cancer that disproportionately affects Black women, only 7% of women enrolled in clinical trials were Black. In clinical trials for margetuximab, approved to treat HER2-positive breast cancer, 80% of participants were White, 5% Black, 6% Asian, and 9% Hispanic.

There is a perception that minorities may be unwilling to participate in clinical trials, but that’s not true, according to Patty Spears, a research manager of the Patient Advocates for Research Council at the University of North Carolina. “We know that there are data that clearly show that patients will go on clinical trials at the same rate, whether they’re Black, White, Asian, or whatever. You have to be able to have them in your system and ask them to go on trial,” she said.

Another panelist told a personal anecdote to illustrate the point. Matthew Ellis, MD, PhD, recalled that he spent 13 years at Washington University in St. Louis, serving one of the more segregated cities in the United States. The city hospital closed, and Washington University and the Siteman Cancer Center signed a contract to treat the underserved population that was suddenly without a source of care. “Subsequent to that, we over-accrued relative to the population of African American patients. What that taught me is it’s nothing to do with the lack of willingness of African Americans to participate in clinical trials. Quite the opposite. It’s the question of access to clinical trials, access to great care, and not creating health care systems that segregate patients into places where they’re not getting access,” he said.

Breast cancer treatments have made great strides in recent years with significant reductions in overall mortality. However, the incidence of breast cancer has increased just slightly in recent years after a dip in the early 2000s.

“The good news is that mortality is decreasing, but it still remains high. We still have a long way to go to tackle this problem of breast cancer incidence as well as the number of deaths,” said Angela DeMichele, MD, co-leader of the breast cancer research program at the University of Pennsylvania’s Abramson Cancer Center. She participated in a session on obstacles in breast cancer treatment held in December at the San Antonio Breast Cancer Symposium. She joined other oncologists in outlining key challenges that need to be addressed to improve breast cancer diagnosis and treatment.

They highlighted six obstacles: The need for more prevention/early detection strategies; the underutilization of artificial intelligence; underuse of precision oncology such as targeted therapies; the need for innovation in clinical trials; a widening gap in cancer disparities; and the need to align incentives and funding for research collaboration, training, and retention.

Since 2012, the Food and Drug Administration has approved 20 new therapeutics to treat breast cancer. Nadia Harbeck, MD, PhD, director of the breast center at LMU University Hospital, Munich, said that the development of new therapies has in a way become a victim of its own success. Therapies and survival have improved, making it harder to compare novel therapies to the standard of care and prove a benefit. Treatment guidelines are changing so quickly that clinical trials are sometimes obsolete by the time they are published because of changes to the standard of care. That places a need on more real-world evidence that can be designed to be useful in the clinic, and AI can help here. “We need to convince regulators to act upon cleverly planned real world evidence analysis. You can randomize them, you can use registries, and you should also be able to change labels because of [new] data,” Dr. Harbeck said.

There are many risk factors that drive breast cancer, and it is very heterogeneous, said Christine Ambrosone, PhD, chair of the department of cancer prevention and control at Roswell Park Comprehensive Cancer Center, Buffalo, N.Y. She called for identifying patients who are at risk for a poor prognosis, such as patients with hormone receptor–negative breast cancer, high-grade, and triple-negative breast cancer. Otherwise there is a risk of overtreatment of low-risk tumors, which could potentially be identified with new tools in precision oncology such as liquid biopsy tests, also known as multicancer early detection tests. These tests can detect cancers long before they become symptomatic. The first such test was launched this year and many more are in clinical trials.

Regina Barzilay, PhD, professor and expert in the use of artificial intelligence in health at the Massachusetts Institute of Technology, pointed out that machine learning is used in many fields, but hardly at all in breast cancer. It could be applied to data on biomarkers and other factors collected from retrospective analyses and clinical trials. She added that machine learning is often applied to biochemistry and single cell analysis of other tumor types, but rarely in breast cancer. “It is severely underutilized,” Dr. Barzilay said. One challenge is that researchers are not necessarily familiar with the techniques of machine learning and AI. Another issue is that breast cancer data are not easy to share and may not be readily available to AI researchers. “An investment in interchangeable data is crucially important,” she said.

Artificial intelligence could assist in identifying and modeling factors that contribute to cancer risk by teasing apart complicated relationships, such as the association between pregnancy, breastfeeding, and breast cancer risk. Pregnancy reduces the risk of hormone receptor–positive disease, but increases the risk of hormone receptor–negative disease.

Another key challenge is the underuse of “omics” technologies, which measure large scale patterns in biological characteristics such as gene variation or protein expression. That has roots in the history of breast cancer being considered as a separate entity from other solid tumors such as lung or pancreatic cancer. Fabrice André, MD, PhD, an oncologist with Gustave Roussy Cancer Center, France, emphasized that breast cancer shouldn’t be considered an entity when it’s metastatic. Instead, tumors should be defined by molecular characteristics they share. He anticipates a personalized medicine future where academic and industry groups collaborate to create an individualized therapy for patients based on genetic factors.
 

Access to therapies for all patients

Novel and effective therapies can make a difference only if patients have access to them, and a key obstacle to improving breast cancer care is racism and inequities in health care. “We have to acknowledge that there is racism in medicine. I think once we acknowledge that, then we can look at things in our practices that we need to change. We can think very broadly and look at things that perhaps disadvantage one population over another,” said Lori Pierce, MD, a radiation oncologist with the University of Michigan, Ann Arbor.

Dr. Pierce also emphasized the need to recruit more underrepresented groups to participate in clinical trials. For example, of six breast cancer clinical trials – for margetuximab (Margenza), sacituzumab govitecan (Trodelvy), tucatinib (Tukysa), trastuzumab deruxtecan (Enhertu), alpelisib (Piqray), and talazoparib (Talzenna), only a small percentage included Black, Asian, and Hispanic women. For trastuzumab deruxtecan, which is widely recognized as a best-in-class HER2-targeting antibody drug conjugate, 51% were White, 42% Asian, 6% Hispanic, and 3% Black. For sacituzumab govitecan, a blockbuster drug for triple-negative breast cancer (TNBC), an aggressive subtype of breast cancer that disproportionately affects Black women, only 7% of women enrolled in clinical trials were Black. In clinical trials for margetuximab, approved to treat HER2-positive breast cancer, 80% of participants were White, 5% Black, 6% Asian, and 9% Hispanic.

There is a perception that minorities may be unwilling to participate in clinical trials, but that’s not true, according to Patty Spears, a research manager of the Patient Advocates for Research Council at the University of North Carolina. “We know that there are data that clearly show that patients will go on clinical trials at the same rate, whether they’re Black, White, Asian, or whatever. You have to be able to have them in your system and ask them to go on trial,” she said.

Another panelist told a personal anecdote to illustrate the point. Matthew Ellis, MD, PhD, recalled that he spent 13 years at Washington University in St. Louis, serving one of the more segregated cities in the United States. The city hospital closed, and Washington University and the Siteman Cancer Center signed a contract to treat the underserved population that was suddenly without a source of care. “Subsequent to that, we over-accrued relative to the population of African American patients. What that taught me is it’s nothing to do with the lack of willingness of African Americans to participate in clinical trials. Quite the opposite. It’s the question of access to clinical trials, access to great care, and not creating health care systems that segregate patients into places where they’re not getting access,” he said.