Hospice & Palliative Medicine

The risks of opioid use for elderly patients with nonmalignant pain vary considerably by different agents and by different durations of use, according to a report in the Dec. 13/27 issue of Archives of Internal Medicine.

Patients taking codeine for more than 180 days are at increased risk for cardiovascular events, and those taking oxycodone or codeine for only 30 days are at increased risk for mortality due to any cause, said Dr. Daniel H. Solomon and his associates in the rheumatology department and the pharmacoepidemiology division at Brigham and Women’s Hospital, Boston.

"This study’s findings do not agree with a commonly held belief that all opioids are associated with similar risk," the investigators noted.

They compared the safety profiles of different opioids for the treatment of nonmalignant pain in elderly patients because "relatively little attention has been paid" to this issue even though the use of these drugs has increased by 50%-100% in recent years. In contrast, patients and physicians are relatively well informed about the toxicities of NSAIDs used for the same indications.

Dr. Solomon and his colleagues analyzed information in two states’ Medicare databases of pharmaceutical coverage for low-income patients (mean age, 79 years) between 1995 and 2005. They were able to match 6,275 subjects who took five of the most commonly prescribed opioids for a variety of baseline factors using propensity scores.

Hydrocodone was used as the reference exposure, to which codeine, oxycodone, propoxyphene, and tramadol were compared.

The risk of cardiovascular events including MI, stroke, heart failure, revascularization, and cardiac death was similar across the five opioid groups after 30 days of use. However, by 180 days the cardiovascular risk with codeine was significantly elevated (risk ratio, 1.62), compared with the other four opioids.

This finding is surprising and requires validation in other study populations, the investigators said (Arch. Intern. Med. 2010;170:1979-86).

All-cause mortality was elevated after only 30 days of use for patients taking oxycodone (RR, 2.43) or codeine (RR, 2.05), but not for those taking other opioids.

In contrast, the risk of fracture of the hip, pelvis, wrist, or humerus was significantly reduced after 30 days of treatment for patients taking tramadol (RR, 0.21) or propoxyphene (RR, 0.54).

The risk of gastrointestinal adverse events – which included upper GI bleeding, lower GI bleeding, and bowel obstruction – did not differ across opioid groups at either 30 days or 180 days.

These risks remained consistent through a range of sensitivity analyses of the data. Importantly, the risks also were consistent regardless of whether patients were taking low, medium, high, or very high doses of the drugs. "The risks were substantial and translated into numbers needed to treat that would be considered clinically significant," Dr. Solomon and his associates wrote.

This study was supported by the Agency for Healthcare Research and Quality. Dr. Solomon reported being an unpaid member of a celecoxib trial executive committee sponsored by Pfizer and an unpaid member of the data safety monitoring board for an analgesic trial sponsored by Pfizer.

The risks of opioid use for elderly patients with nonmalignant pain vary considerably by different agents and by different durations of use, according to a report in the Dec. 13/27 issue of Archives of Internal Medicine.

Patients taking codeine for more than 180 days are at increased risk for cardiovascular events, and those taking oxycodone or codeine for only 30 days are at increased risk for mortality due to any cause, said Dr. Daniel H. Solomon and his associates in the rheumatology department and the pharmacoepidemiology division at Brigham and Women’s Hospital, Boston.

"This study’s findings do not agree with a commonly held belief that all opioids are associated with similar risk," the investigators noted.

They compared the safety profiles of different opioids for the treatment of nonmalignant pain in elderly patients because "relatively little attention has been paid" to this issue even though the use of these drugs has increased by 50%-100% in recent years. In contrast, patients and physicians are relatively well informed about the toxicities of NSAIDs used for the same indications.

Dr. Solomon and his colleagues analyzed information in two states’ Medicare databases of pharmaceutical coverage for low-income patients (mean age, 79 years) between 1995 and 2005. They were able to match 6,275 subjects who took five of the most commonly prescribed opioids for a variety of baseline factors using propensity scores.

Hydrocodone was used as the reference exposure, to which codeine, oxycodone, propoxyphene, and tramadol were compared.

The risk of cardiovascular events including MI, stroke, heart failure, revascularization, and cardiac death was similar across the five opioid groups after 30 days of use. However, by 180 days the cardiovascular risk with codeine was significantly elevated (risk ratio, 1.62), compared with the other four opioids.

This finding is surprising and requires validation in other study populations, the investigators said (Arch. Intern. Med. 2010;170:1979-86).

All-cause mortality was elevated after only 30 days of use for patients taking oxycodone (RR, 2.43) or codeine (RR, 2.05), but not for those taking other opioids.

In contrast, the risk of fracture of the hip, pelvis, wrist, or humerus was significantly reduced after 30 days of treatment for patients taking tramadol (RR, 0.21) or propoxyphene (RR, 0.54).

The risk of gastrointestinal adverse events – which included upper GI bleeding, lower GI bleeding, and bowel obstruction – did not differ across opioid groups at either 30 days or 180 days.

These risks remained consistent through a range of sensitivity analyses of the data. Importantly, the risks also were consistent regardless of whether patients were taking low, medium, high, or very high doses of the drugs. "The risks were substantial and translated into numbers needed to treat that would be considered clinically significant," Dr. Solomon and his associates wrote.

This study was supported by the Agency for Healthcare Research and Quality. Dr. Solomon reported being an unpaid member of a celecoxib trial executive committee sponsored by Pfizer and an unpaid member of the data safety monitoring board for an analgesic trial sponsored by Pfizer.

The risks of opioid use for elderly patients with nonmalignant pain vary considerably by different agents and by different durations of use, according to a report in the Dec. 13/27 issue of Archives of Internal Medicine.

Patients taking codeine for more than 180 days are at increased risk for cardiovascular events, and those taking oxycodone or codeine for only 30 days are at increased risk for mortality due to any cause, said Dr. Daniel H. Solomon and his associates in the rheumatology department and the pharmacoepidemiology division at Brigham and Women’s Hospital, Boston.

"This study’s findings do not agree with a commonly held belief that all opioids are associated with similar risk," the investigators noted.

They compared the safety profiles of different opioids for the treatment of nonmalignant pain in elderly patients because "relatively little attention has been paid" to this issue even though the use of these drugs has increased by 50%-100% in recent years. In contrast, patients and physicians are relatively well informed about the toxicities of NSAIDs used for the same indications.

Dr. Solomon and his colleagues analyzed information in two states’ Medicare databases of pharmaceutical coverage for low-income patients (mean age, 79 years) between 1995 and 2005. They were able to match 6,275 subjects who took five of the most commonly prescribed opioids for a variety of baseline factors using propensity scores.

Hydrocodone was used as the reference exposure, to which codeine, oxycodone, propoxyphene, and tramadol were compared.

The risk of cardiovascular events including MI, stroke, heart failure, revascularization, and cardiac death was similar across the five opioid groups after 30 days of use. However, by 180 days the cardiovascular risk with codeine was significantly elevated (risk ratio, 1.62), compared with the other four opioids.

This finding is surprising and requires validation in other study populations, the investigators said (Arch. Intern. Med. 2010;170:1979-86).

All-cause mortality was elevated after only 30 days of use for patients taking oxycodone (RR, 2.43) or codeine (RR, 2.05), but not for those taking other opioids.

In contrast, the risk of fracture of the hip, pelvis, wrist, or humerus was significantly reduced after 30 days of treatment for patients taking tramadol (RR, 0.21) or propoxyphene (RR, 0.54).

The risk of gastrointestinal adverse events – which included upper GI bleeding, lower GI bleeding, and bowel obstruction – did not differ across opioid groups at either 30 days or 180 days.

These risks remained consistent through a range of sensitivity analyses of the data. Importantly, the risks also were consistent regardless of whether patients were taking low, medium, high, or very high doses of the drugs. "The risks were substantial and translated into numbers needed to treat that would be considered clinically significant," Dr. Solomon and his associates wrote.

This study was supported by the Agency for Healthcare Research and Quality. Dr. Solomon reported being an unpaid member of a celecoxib trial executive committee sponsored by Pfizer and an unpaid member of the data safety monitoring board for an analgesic trial sponsored by Pfizer.

CHICAGO – Resection of liver and lung colorectal metastases produced superior survival, compared with resection of liver metastases alone, in a retrospective analysis of 1,260 consecutive patients.

After a median follow-up of 49 months, 5-year overall survival was 40% in patients with colorectal cancer who underwent resection of liver metastases alone, compared with 50% in those who underwent resection of both liver and lung metastases (P = .01), Dr. Eddie Abdalla reported at the annual meeting of the Western Surgical Association.

"Survival following resection of liver and lung metastases is excellent, and may even be better than [survival] for the general population that undergoes resection for colorectal lung metastases alone," he said.

Overall survival at 5 years is about 40% in patients with resected colorectal lung metastases, and ranges from 11% to 31% in the limited studies involving patients with colorectal liver-plus-lung metastases.

The presumed explanation for the improved survival is that patients with liver and lung metastases had less-extensive recurrence (27%) than did the rest of the cohort (69%), said Dr. Abdalla of the University of Texas M.D. Anderson Cancer Center in Houston. Recurrence also was seen in 33% of patients with lung-only metastases and in 22% with liver-only metastases.

Although recurrence in the study was substantial, it can often be retreated, he observed. Among 78 patients who developed recurrence, 33 (42%) were retreated with resection, radiofrequency ablation, or chemotherapy, resulting in a 5-year disease-free survival of 25%.

Extrahepatic disease, long associated with poor outcome, has been considered a contraindication to resection. More recent studies are challenging this belief, citing advances in systemic chemotherapy and surgical technique as well as improved multidisciplinary management and patient selection.

In multivariate analysis, the only significant predictors of worse survival in patients with resection of both liver and lung metastases were a rectal primary tumor (P = .004; hazard ratio, 2.9) and a carcinoembryonic antigen (CEA) level before resection of liver metastases of more than 5 ng/mL (P = .04; HR, 2.1), Dr. Abdalla said. Interestingly, liver metastasis greater than 5 cm, positive margins at resection of liver metastases, synchronous lung metastases, and even disease-free intervals were not significant.

"Occurrence of lung metastases that are subsequently resected is not a poor prognostic factor or a contraindication to resection of colorectal liver metastases," he said.

In all, 32 of the 112 patients with liver-plus-lung metastases had a rectal primary tumor, compared with 254 of the 1,148 patients with liver-only metastases. Their median preoperative CEA levels were 3.2 and 3.7, respectively. Preoperative chemotherapy was used in 69% of patients before resection of liver metastases and in 50% of patients before resection of lung metastases.

Invited discussant Dr. John Brems of Loyola University Medical Center in Maywood, Ill., asked whether the survival outcomes were influenced by selecting patients with a higher rate of chemotherapy utilization in the liver-plus-lung group, and by considering patients for surgery if they had no increase in tumor size on chemotherapy.

"There’s no question that we are selecting patients, and the objective of selection is to deliver treatment to patients who will benefit," Dr. Abdalla said. "Response to chemotherapy appears to be a good way to select patients for resection of colorectal liver metastases."

Dr. Abdalla referenced a recent study he coauthored that reported a significantly longer overall survival among patients with colorectal liver metastases who had an optimal morphological response on imaging to bevacizumab-containing chemotherapy prior to hepatic resection, compared with those who had an incomplete or no response (median, 31 months vs. 19 months) (JAMA. 2009;302:2338-44).

During the discussion, Dr. Anton Bilchik of the University of California, Los Angeles, asked whether the researchers treat disappearing lung and liver lesions in the same manner.

Dr. Abdalla said that they tend to follow the disappearing lung lesion, but resect the disappearing liver lesion. "At this point, if you have a patient with a tiny liver lesion that disappears, it’s difficult to propose a major hepatectomy to take out a central disappearing lesion," he said. "However, we know from follow-up and resection studies that most of those – certainly over 90% – will recur. We don’t have that kind of data in the lung."

None of the speakers disclosed any conflicts of interest.

CHICAGO – Resection of liver and lung colorectal metastases produced superior survival, compared with resection of liver metastases alone, in a retrospective analysis of 1,260 consecutive patients.

After a median follow-up of 49 months, 5-year overall survival was 40% in patients with colorectal cancer who underwent resection of liver metastases alone, compared with 50% in those who underwent resection of both liver and lung metastases (P = .01), Dr. Eddie Abdalla reported at the annual meeting of the Western Surgical Association.

"Survival following resection of liver and lung metastases is excellent, and may even be better than [survival] for the general population that undergoes resection for colorectal lung metastases alone," he said.

Overall survival at 5 years is about 40% in patients with resected colorectal lung metastases, and ranges from 11% to 31% in the limited studies involving patients with colorectal liver-plus-lung metastases.

The presumed explanation for the improved survival is that patients with liver and lung metastases had less-extensive recurrence (27%) than did the rest of the cohort (69%), said Dr. Abdalla of the University of Texas M.D. Anderson Cancer Center in Houston. Recurrence also was seen in 33% of patients with lung-only metastases and in 22% with liver-only metastases.

Although recurrence in the study was substantial, it can often be retreated, he observed. Among 78 patients who developed recurrence, 33 (42%) were retreated with resection, radiofrequency ablation, or chemotherapy, resulting in a 5-year disease-free survival of 25%.

Extrahepatic disease, long associated with poor outcome, has been considered a contraindication to resection. More recent studies are challenging this belief, citing advances in systemic chemotherapy and surgical technique as well as improved multidisciplinary management and patient selection.

In multivariate analysis, the only significant predictors of worse survival in patients with resection of both liver and lung metastases were a rectal primary tumor (P = .004; hazard ratio, 2.9) and a carcinoembryonic antigen (CEA) level before resection of liver metastases of more than 5 ng/mL (P = .04; HR, 2.1), Dr. Abdalla said. Interestingly, liver metastasis greater than 5 cm, positive margins at resection of liver metastases, synchronous lung metastases, and even disease-free intervals were not significant.

"Occurrence of lung metastases that are subsequently resected is not a poor prognostic factor or a contraindication to resection of colorectal liver metastases," he said.

In all, 32 of the 112 patients with liver-plus-lung metastases had a rectal primary tumor, compared with 254 of the 1,148 patients with liver-only metastases. Their median preoperative CEA levels were 3.2 and 3.7, respectively. Preoperative chemotherapy was used in 69% of patients before resection of liver metastases and in 50% of patients before resection of lung metastases.

Invited discussant Dr. John Brems of Loyola University Medical Center in Maywood, Ill., asked whether the survival outcomes were influenced by selecting patients with a higher rate of chemotherapy utilization in the liver-plus-lung group, and by considering patients for surgery if they had no increase in tumor size on chemotherapy.

"There’s no question that we are selecting patients, and the objective of selection is to deliver treatment to patients who will benefit," Dr. Abdalla said. "Response to chemotherapy appears to be a good way to select patients for resection of colorectal liver metastases."

Dr. Abdalla referenced a recent study he coauthored that reported a significantly longer overall survival among patients with colorectal liver metastases who had an optimal morphological response on imaging to bevacizumab-containing chemotherapy prior to hepatic resection, compared with those who had an incomplete or no response (median, 31 months vs. 19 months) (JAMA. 2009;302:2338-44).

During the discussion, Dr. Anton Bilchik of the University of California, Los Angeles, asked whether the researchers treat disappearing lung and liver lesions in the same manner.

Dr. Abdalla said that they tend to follow the disappearing lung lesion, but resect the disappearing liver lesion. "At this point, if you have a patient with a tiny liver lesion that disappears, it’s difficult to propose a major hepatectomy to take out a central disappearing lesion," he said. "However, we know from follow-up and resection studies that most of those – certainly over 90% – will recur. We don’t have that kind of data in the lung."

None of the speakers disclosed any conflicts of interest.

CHICAGO – Resection of liver and lung colorectal metastases produced superior survival, compared with resection of liver metastases alone, in a retrospective analysis of 1,260 consecutive patients.

After a median follow-up of 49 months, 5-year overall survival was 40% in patients with colorectal cancer who underwent resection of liver metastases alone, compared with 50% in those who underwent resection of both liver and lung metastases (P = .01), Dr. Eddie Abdalla reported at the annual meeting of the Western Surgical Association.

"Survival following resection of liver and lung metastases is excellent, and may even be better than [survival] for the general population that undergoes resection for colorectal lung metastases alone," he said.

Overall survival at 5 years is about 40% in patients with resected colorectal lung metastases, and ranges from 11% to 31% in the limited studies involving patients with colorectal liver-plus-lung metastases.

The presumed explanation for the improved survival is that patients with liver and lung metastases had less-extensive recurrence (27%) than did the rest of the cohort (69%), said Dr. Abdalla of the University of Texas M.D. Anderson Cancer Center in Houston. Recurrence also was seen in 33% of patients with lung-only metastases and in 22% with liver-only metastases.

Although recurrence in the study was substantial, it can often be retreated, he observed. Among 78 patients who developed recurrence, 33 (42%) were retreated with resection, radiofrequency ablation, or chemotherapy, resulting in a 5-year disease-free survival of 25%.

Extrahepatic disease, long associated with poor outcome, has been considered a contraindication to resection. More recent studies are challenging this belief, citing advances in systemic chemotherapy and surgical technique as well as improved multidisciplinary management and patient selection.

In multivariate analysis, the only significant predictors of worse survival in patients with resection of both liver and lung metastases were a rectal primary tumor (P = .004; hazard ratio, 2.9) and a carcinoembryonic antigen (CEA) level before resection of liver metastases of more than 5 ng/mL (P = .04; HR, 2.1), Dr. Abdalla said. Interestingly, liver metastasis greater than 5 cm, positive margins at resection of liver metastases, synchronous lung metastases, and even disease-free intervals were not significant.

"Occurrence of lung metastases that are subsequently resected is not a poor prognostic factor or a contraindication to resection of colorectal liver metastases," he said.

In all, 32 of the 112 patients with liver-plus-lung metastases had a rectal primary tumor, compared with 254 of the 1,148 patients with liver-only metastases. Their median preoperative CEA levels were 3.2 and 3.7, respectively. Preoperative chemotherapy was used in 69% of patients before resection of liver metastases and in 50% of patients before resection of lung metastases.

Invited discussant Dr. John Brems of Loyola University Medical Center in Maywood, Ill., asked whether the survival outcomes were influenced by selecting patients with a higher rate of chemotherapy utilization in the liver-plus-lung group, and by considering patients for surgery if they had no increase in tumor size on chemotherapy.

"There’s no question that we are selecting patients, and the objective of selection is to deliver treatment to patients who will benefit," Dr. Abdalla said. "Response to chemotherapy appears to be a good way to select patients for resection of colorectal liver metastases."

Dr. Abdalla referenced a recent study he coauthored that reported a significantly longer overall survival among patients with colorectal liver metastases who had an optimal morphological response on imaging to bevacizumab-containing chemotherapy prior to hepatic resection, compared with those who had an incomplete or no response (median, 31 months vs. 19 months) (JAMA. 2009;302:2338-44).

During the discussion, Dr. Anton Bilchik of the University of California, Los Angeles, asked whether the researchers treat disappearing lung and liver lesions in the same manner.

Dr. Abdalla said that they tend to follow the disappearing lung lesion, but resect the disappearing liver lesion. "At this point, if you have a patient with a tiny liver lesion that disappears, it’s difficult to propose a major hepatectomy to take out a central disappearing lesion," he said. "However, we know from follow-up and resection studies that most of those – certainly over 90% – will recur. We don’t have that kind of data in the lung."

None of the speakers disclosed any conflicts of interest.

MONTREAL – The tyrosine kinase inhibitors vatalanib and sunitinib may offer alternative approaches to treating patients with recurrent, high-grade meningioma who have failed surgery and radiation therapy, according to two separate phase II studies.

Photo credit: WikiCommons user Dr. Tomas Dvorak, Creative Commons

Both drugs significantly improved survival compared with what is generally expected in this patient population, most of whom had grade II or III tumors. Progression-free survival at 6 months occurred in 57% of 25 patients with meningioma who received the investigational drug vatalanib in one study, and in 36% of 36 patients who received sunitinib in another study. Both drugs are inhibitors of receptors for vascular endothelial growth factor and platelet-derived growth factor.

Sunitinib is marketed by the brand name Sutent and has been approved by the Food and Drug Administration for the treatment of advanced renal cell carcinoma and gastrointestinal stromal tumor after disease progression on – or intolerance to – imatinib mesylate (Gleevec).

Progression-free survival (PFS) for patients with recurrent grade II and III tumors is usually considered to occur in fewer than 5%, said Dr. Jeffrey Raizer, who presented the vatalanib study at the annual meeting of the Society for Neuro-Oncology.

"For recurrence of meningioma, treatment options are limited once patients have failed surgery and radiation, and chemotherapies have been very limited to date," said Dr. Raizer, director of medical neuro-oncology at the cancer center of Northwestern University and Northwestern Memorial Hospital, both in Chicago.

Despite the encouraging findings of the two studies, a lack of information on the natural history of these tumors makes it difficult to interpret the studies, said Dr. Michael Vogelbaum, who chaired the session in which the studies were presented.

"While the studies suggest there may be some promise, we don’t really know what to expect from that mix of grade II and III tumors on their own," Dr. Vogelbaum said in an interview. He is chair of neuro-oncology and associate director of the brain tumor and neuro-oncology center at the Cleveland Clinic Neurological Institute.

Dr. Fred Barker of the department of neurosurgery at Massachusetts General Hospital, Boston, echoed Dr. Vogelbaum’s comments. "There’s been very little organized effort to do chemotherapy trials for meningiomas, so these studies are important because they are the first. The results are interesting, but we don’t know exactly what the natural history would be without treatment, so whether there’s a benefit to giving these drugs will require further study."

In Dr. Raizer’s Pfizer-sponsored study of vatalanib in meningioma patients, the median PFS was 5.9 months, and the median overall survival (OS) was 22.3 months. Of the 25 patients in the study, 22 had grade II and III tumors and 14 were men. The PFS at 6 months was comparable between patients with grade II (39%) or grade III disease only (43%).

Dosing of vatalanib began at 250 mg twice daily and increased by 250 mg/day every 7 days until the dosage reached 500 mg twice daily, he said.

For 21 patients with available imaging data, tumors partially responded to treatment in 1, remained stable in 15, and progressed in 5 patients.

The most common adverse events observed were fatigue, rash, and elevated transaminases.

The sunitinib study, sponsored by Novartis, included 36 patients (median age, 62 years) with recurrent grade II and III meningiomas who had exhausted all surgical and radiation options. The patients had a median of five recurrences.

The primary end point of PFS at 6 months was 36% and the median PFS was 5.1 months. The overall survival rate is not known, as only eight patients have died, reported Dr. Thomas Kaley, codirector of the neuro-oncology fellowship program at Memorial Sloan-Kettering Cancer Center in New York.

Imaging was available for 34 patients and showed stable disease in 26, a partial response in 1, and progressive disease in 7 patients, he said.

The dose of sunitinib was 50 mg orally per day on a 4-week-on, 2-week-off cycle.

"The toxicity was high with this drug," Dr. Kaley commented.

A total of 18 patients required dose reductions, and 6 patients withdrew from the study because of toxicity. There was one fatal grade 5 intratumoral hemorrhage and two nonfatal intratumoral hemorrhages (grades 3 and 4). The most common toxicities included myelosuppression, fatigue, headache, and GI side effects.

The investigators reported having no relevant conflicts of interest.*

* CORRECTION, 1/17/2011: An earlier version of this story included incorrect information about the investigators' disclosures. The error has been corrected.

MONTREAL – The tyrosine kinase inhibitors vatalanib and sunitinib may offer alternative approaches to treating patients with recurrent, high-grade meningioma who have failed surgery and radiation therapy, according to two separate phase II studies.

Photo credit: WikiCommons user Dr. Tomas Dvorak, Creative Commons

Both drugs significantly improved survival compared with what is generally expected in this patient population, most of whom had grade II or III tumors. Progression-free survival at 6 months occurred in 57% of 25 patients with meningioma who received the investigational drug vatalanib in one study, and in 36% of 36 patients who received sunitinib in another study. Both drugs are inhibitors of receptors for vascular endothelial growth factor and platelet-derived growth factor.

Sunitinib is marketed by the brand name Sutent and has been approved by the Food and Drug Administration for the treatment of advanced renal cell carcinoma and gastrointestinal stromal tumor after disease progression on – or intolerance to – imatinib mesylate (Gleevec).

Progression-free survival (PFS) for patients with recurrent grade II and III tumors is usually considered to occur in fewer than 5%, said Dr. Jeffrey Raizer, who presented the vatalanib study at the annual meeting of the Society for Neuro-Oncology.

"For recurrence of meningioma, treatment options are limited once patients have failed surgery and radiation, and chemotherapies have been very limited to date," said Dr. Raizer, director of medical neuro-oncology at the cancer center of Northwestern University and Northwestern Memorial Hospital, both in Chicago.

Despite the encouraging findings of the two studies, a lack of information on the natural history of these tumors makes it difficult to interpret the studies, said Dr. Michael Vogelbaum, who chaired the session in which the studies were presented.

"While the studies suggest there may be some promise, we don’t really know what to expect from that mix of grade II and III tumors on their own," Dr. Vogelbaum said in an interview. He is chair of neuro-oncology and associate director of the brain tumor and neuro-oncology center at the Cleveland Clinic Neurological Institute.

Dr. Fred Barker of the department of neurosurgery at Massachusetts General Hospital, Boston, echoed Dr. Vogelbaum’s comments. "There’s been very little organized effort to do chemotherapy trials for meningiomas, so these studies are important because they are the first. The results are interesting, but we don’t know exactly what the natural history would be without treatment, so whether there’s a benefit to giving these drugs will require further study."

In Dr. Raizer’s Pfizer-sponsored study of vatalanib in meningioma patients, the median PFS was 5.9 months, and the median overall survival (OS) was 22.3 months. Of the 25 patients in the study, 22 had grade II and III tumors and 14 were men. The PFS at 6 months was comparable between patients with grade II (39%) or grade III disease only (43%).

Dosing of vatalanib began at 250 mg twice daily and increased by 250 mg/day every 7 days until the dosage reached 500 mg twice daily, he said.

For 21 patients with available imaging data, tumors partially responded to treatment in 1, remained stable in 15, and progressed in 5 patients.

The most common adverse events observed were fatigue, rash, and elevated transaminases.

The sunitinib study, sponsored by Novartis, included 36 patients (median age, 62 years) with recurrent grade II and III meningiomas who had exhausted all surgical and radiation options. The patients had a median of five recurrences.

The primary end point of PFS at 6 months was 36% and the median PFS was 5.1 months. The overall survival rate is not known, as only eight patients have died, reported Dr. Thomas Kaley, codirector of the neuro-oncology fellowship program at Memorial Sloan-Kettering Cancer Center in New York.

Imaging was available for 34 patients and showed stable disease in 26, a partial response in 1, and progressive disease in 7 patients, he said.

The dose of sunitinib was 50 mg orally per day on a 4-week-on, 2-week-off cycle.

"The toxicity was high with this drug," Dr. Kaley commented.

A total of 18 patients required dose reductions, and 6 patients withdrew from the study because of toxicity. There was one fatal grade 5 intratumoral hemorrhage and two nonfatal intratumoral hemorrhages (grades 3 and 4). The most common toxicities included myelosuppression, fatigue, headache, and GI side effects.

The investigators reported having no relevant conflicts of interest.*

* CORRECTION, 1/17/2011: An earlier version of this story included incorrect information about the investigators' disclosures. The error has been corrected.

MONTREAL – The tyrosine kinase inhibitors vatalanib and sunitinib may offer alternative approaches to treating patients with recurrent, high-grade meningioma who have failed surgery and radiation therapy, according to two separate phase II studies.

Photo credit: WikiCommons user Dr. Tomas Dvorak, Creative Commons

Both drugs significantly improved survival compared with what is generally expected in this patient population, most of whom had grade II or III tumors. Progression-free survival at 6 months occurred in 57% of 25 patients with meningioma who received the investigational drug vatalanib in one study, and in 36% of 36 patients who received sunitinib in another study. Both drugs are inhibitors of receptors for vascular endothelial growth factor and platelet-derived growth factor.

Sunitinib is marketed by the brand name Sutent and has been approved by the Food and Drug Administration for the treatment of advanced renal cell carcinoma and gastrointestinal stromal tumor after disease progression on – or intolerance to – imatinib mesylate (Gleevec).

Progression-free survival (PFS) for patients with recurrent grade II and III tumors is usually considered to occur in fewer than 5%, said Dr. Jeffrey Raizer, who presented the vatalanib study at the annual meeting of the Society for Neuro-Oncology.

"For recurrence of meningioma, treatment options are limited once patients have failed surgery and radiation, and chemotherapies have been very limited to date," said Dr. Raizer, director of medical neuro-oncology at the cancer center of Northwestern University and Northwestern Memorial Hospital, both in Chicago.

Despite the encouraging findings of the two studies, a lack of information on the natural history of these tumors makes it difficult to interpret the studies, said Dr. Michael Vogelbaum, who chaired the session in which the studies were presented.

"While the studies suggest there may be some promise, we don’t really know what to expect from that mix of grade II and III tumors on their own," Dr. Vogelbaum said in an interview. He is chair of neuro-oncology and associate director of the brain tumor and neuro-oncology center at the Cleveland Clinic Neurological Institute.

Dr. Fred Barker of the department of neurosurgery at Massachusetts General Hospital, Boston, echoed Dr. Vogelbaum’s comments. "There’s been very little organized effort to do chemotherapy trials for meningiomas, so these studies are important because they are the first. The results are interesting, but we don’t know exactly what the natural history would be without treatment, so whether there’s a benefit to giving these drugs will require further study."

In Dr. Raizer’s Pfizer-sponsored study of vatalanib in meningioma patients, the median PFS was 5.9 months, and the median overall survival (OS) was 22.3 months. Of the 25 patients in the study, 22 had grade II and III tumors and 14 were men. The PFS at 6 months was comparable between patients with grade II (39%) or grade III disease only (43%).

Dosing of vatalanib began at 250 mg twice daily and increased by 250 mg/day every 7 days until the dosage reached 500 mg twice daily, he said.

For 21 patients with available imaging data, tumors partially responded to treatment in 1, remained stable in 15, and progressed in 5 patients.

The most common adverse events observed were fatigue, rash, and elevated transaminases.

The sunitinib study, sponsored by Novartis, included 36 patients (median age, 62 years) with recurrent grade II and III meningiomas who had exhausted all surgical and radiation options. The patients had a median of five recurrences.

The primary end point of PFS at 6 months was 36% and the median PFS was 5.1 months. The overall survival rate is not known, as only eight patients have died, reported Dr. Thomas Kaley, codirector of the neuro-oncology fellowship program at Memorial Sloan-Kettering Cancer Center in New York.

Imaging was available for 34 patients and showed stable disease in 26, a partial response in 1, and progressive disease in 7 patients, he said.

The dose of sunitinib was 50 mg orally per day on a 4-week-on, 2-week-off cycle.

"The toxicity was high with this drug," Dr. Kaley commented.

A total of 18 patients required dose reductions, and 6 patients withdrew from the study because of toxicity. There was one fatal grade 5 intratumoral hemorrhage and two nonfatal intratumoral hemorrhages (grades 3 and 4). The most common toxicities included myelosuppression, fatigue, headache, and GI side effects.

The investigators reported having no relevant conflicts of interest.*

* CORRECTION, 1/17/2011: An earlier version of this story included incorrect information about the investigators' disclosures. The error has been corrected.

Approximately 29% of Medicare patients with cancer died in a hospital, and hospice care was inconsistent among medical centers in the United States, according to a report published Nov. 16 by the Dartmouth Institute for Health Policy & Clinical Practice.

The rate of hospital deaths varied widely by region, ranging from 47% in Manhattan (New York City) to 7% in Mason City, Iowa.

"The bottom line is that the care patients receive has less to do with what they want and more to do with the hospital they seek care from," Dr. David Goodman of Dartmouth University, Hanover, N.H., said in a press briefing. "We as physicians often make assumptions about what patients and families want for their lives. What patients really want is for a physician to be honest with them and to share the full range of options with them."

The report, "Quality of End-of-Life Cancer Care for Medicare Beneficiaries: Regional and Hospital-Specific Analyses," is the first to focus on cancer care at the end of life for the Medicare population in particular. The report was produced by the Dartmouth Atlas Project, which has been documenting the use of medical resources in the United States for more than 2 decades.

Researchers reviewed data from 235,821 Medicare patients (aged 65 years and older) with metastatic or aggressive cancer who died in 2003-2007. They identified regional trends as well as information about specific academic medical centers.

Nationwide, approximately 61% of cancer patients were hospitalized at least once during their last month of life. Hospital admissions varied from approximately 70% of cancer patients in Detroit to 46% of cancer patients in San Angelo, Tex.

The researchers identified the highest rates of hospitalization during the last month of life (more than 75%) among cancer patients at two hospitals in Detroit: St. John Hospital and Medical Center and Sinai-Grace Hospital. The lowest rate of hospitalization during the last month of life was 45% of cancer patients at the University of Washington Medical Center in Seattle.

Chemotherapy was part of care during the last 2 weeks of life in approximately 6% of patients nationwide, but the rate exceeded 10% in eight areas, including Olympia, Wash. (12%), and San Antonio (11%).

The researchers also found that fewer than 50% of cancer patients with a poor prognosis received hospice care, and some centers provided hospice care only in the last few days of life.

The degree of variation in the findings is too great to be explained by racial or ethnic preferences for aggressive end-of-life care, and adjustment for socioeconomic status does not change the results, said Dr. Goodman said.

But the data show that investment in beds, ICU facilities, and palliative care services is quite different from one health care system to another, he said.

The report highlights the need for doctors and health systems "to take a look at themselves and examine where they need to make their investments," said Dr. Goodman, who added that clinicians "need to look at ourselves in terms of how we communicate with patients" about cancer care options.

In a commentary accompanying the report, Dr. Joan Teno of Brown University in Providence, R.I., emphasized the need for health care providers to educate patients about their prognoses and to provide hospice options.

"If opportunities to improve are identified, hospitals should work with the local hospice or existing palliative care consult service, and/or start a palliative care consult service," to ensure that the institution is delivering high-quality care, Dr. Teno wrote.

Conversations about end-of-life care need to be started early in the course of treatment, Dr. Goodman said. "Our preferences can certainly change, but opening up the conversation early allows the conversation to evolve over time. The tragedy is when those conversations start near the end."

In a statement, Dr. George W. Sledge Jr., president of the American Society of Clinical Oncology said, "While saving lives is the oncologist’s goal, helping individuals live their final days in comfort and dignity is one of the most valuable and important responsibilities of our profession.

"Options to enhance a patient’s quality of life should be discussed throughout the course of their treatment. It is critical that we increase medical training in end-of-life patient communication and planning, and that Medicare and other insurers cover the costs of these essential conversations," Dr. Sledge noted.

The study was supported in part by the Robert Wood Johnson Foundation.

Approximately 29% of Medicare patients with cancer died in a hospital, and hospice care was inconsistent among medical centers in the United States, according to a report published Nov. 16 by the Dartmouth Institute for Health Policy & Clinical Practice.

The rate of hospital deaths varied widely by region, ranging from 47% in Manhattan (New York City) to 7% in Mason City, Iowa.

"The bottom line is that the care patients receive has less to do with what they want and more to do with the hospital they seek care from," Dr. David Goodman of Dartmouth University, Hanover, N.H., said in a press briefing. "We as physicians often make assumptions about what patients and families want for their lives. What patients really want is for a physician to be honest with them and to share the full range of options with them."

The report, "Quality of End-of-Life Cancer Care for Medicare Beneficiaries: Regional and Hospital-Specific Analyses," is the first to focus on cancer care at the end of life for the Medicare population in particular. The report was produced by the Dartmouth Atlas Project, which has been documenting the use of medical resources in the United States for more than 2 decades.

Researchers reviewed data from 235,821 Medicare patients (aged 65 years and older) with metastatic or aggressive cancer who died in 2003-2007. They identified regional trends as well as information about specific academic medical centers.

Nationwide, approximately 61% of cancer patients were hospitalized at least once during their last month of life. Hospital admissions varied from approximately 70% of cancer patients in Detroit to 46% of cancer patients in San Angelo, Tex.

The researchers identified the highest rates of hospitalization during the last month of life (more than 75%) among cancer patients at two hospitals in Detroit: St. John Hospital and Medical Center and Sinai-Grace Hospital. The lowest rate of hospitalization during the last month of life was 45% of cancer patients at the University of Washington Medical Center in Seattle.

Chemotherapy was part of care during the last 2 weeks of life in approximately 6% of patients nationwide, but the rate exceeded 10% in eight areas, including Olympia, Wash. (12%), and San Antonio (11%).

The researchers also found that fewer than 50% of cancer patients with a poor prognosis received hospice care, and some centers provided hospice care only in the last few days of life.

The degree of variation in the findings is too great to be explained by racial or ethnic preferences for aggressive end-of-life care, and adjustment for socioeconomic status does not change the results, said Dr. Goodman said.

But the data show that investment in beds, ICU facilities, and palliative care services is quite different from one health care system to another, he said.

The report highlights the need for doctors and health systems "to take a look at themselves and examine where they need to make their investments," said Dr. Goodman, who added that clinicians "need to look at ourselves in terms of how we communicate with patients" about cancer care options.

In a commentary accompanying the report, Dr. Joan Teno of Brown University in Providence, R.I., emphasized the need for health care providers to educate patients about their prognoses and to provide hospice options.

"If opportunities to improve are identified, hospitals should work with the local hospice or existing palliative care consult service, and/or start a palliative care consult service," to ensure that the institution is delivering high-quality care, Dr. Teno wrote.

Conversations about end-of-life care need to be started early in the course of treatment, Dr. Goodman said. "Our preferences can certainly change, but opening up the conversation early allows the conversation to evolve over time. The tragedy is when those conversations start near the end."

In a statement, Dr. George W. Sledge Jr., president of the American Society of Clinical Oncology said, "While saving lives is the oncologist’s goal, helping individuals live their final days in comfort and dignity is one of the most valuable and important responsibilities of our profession.

"Options to enhance a patient’s quality of life should be discussed throughout the course of their treatment. It is critical that we increase medical training in end-of-life patient communication and planning, and that Medicare and other insurers cover the costs of these essential conversations," Dr. Sledge noted.

The study was supported in part by the Robert Wood Johnson Foundation.

Approximately 29% of Medicare patients with cancer died in a hospital, and hospice care was inconsistent among medical centers in the United States, according to a report published Nov. 16 by the Dartmouth Institute for Health Policy & Clinical Practice.

The rate of hospital deaths varied widely by region, ranging from 47% in Manhattan (New York City) to 7% in Mason City, Iowa.

"The bottom line is that the care patients receive has less to do with what they want and more to do with the hospital they seek care from," Dr. David Goodman of Dartmouth University, Hanover, N.H., said in a press briefing. "We as physicians often make assumptions about what patients and families want for their lives. What patients really want is for a physician to be honest with them and to share the full range of options with them."

The report, "Quality of End-of-Life Cancer Care for Medicare Beneficiaries: Regional and Hospital-Specific Analyses," is the first to focus on cancer care at the end of life for the Medicare population in particular. The report was produced by the Dartmouth Atlas Project, which has been documenting the use of medical resources in the United States for more than 2 decades.

Researchers reviewed data from 235,821 Medicare patients (aged 65 years and older) with metastatic or aggressive cancer who died in 2003-2007. They identified regional trends as well as information about specific academic medical centers.

Nationwide, approximately 61% of cancer patients were hospitalized at least once during their last month of life. Hospital admissions varied from approximately 70% of cancer patients in Detroit to 46% of cancer patients in San Angelo, Tex.

The researchers identified the highest rates of hospitalization during the last month of life (more than 75%) among cancer patients at two hospitals in Detroit: St. John Hospital and Medical Center and Sinai-Grace Hospital. The lowest rate of hospitalization during the last month of life was 45% of cancer patients at the University of Washington Medical Center in Seattle.

Chemotherapy was part of care during the last 2 weeks of life in approximately 6% of patients nationwide, but the rate exceeded 10% in eight areas, including Olympia, Wash. (12%), and San Antonio (11%).

The researchers also found that fewer than 50% of cancer patients with a poor prognosis received hospice care, and some centers provided hospice care only in the last few days of life.

The degree of variation in the findings is too great to be explained by racial or ethnic preferences for aggressive end-of-life care, and adjustment for socioeconomic status does not change the results, said Dr. Goodman said.

But the data show that investment in beds, ICU facilities, and palliative care services is quite different from one health care system to another, he said.

The report highlights the need for doctors and health systems "to take a look at themselves and examine where they need to make their investments," said Dr. Goodman, who added that clinicians "need to look at ourselves in terms of how we communicate with patients" about cancer care options.

In a commentary accompanying the report, Dr. Joan Teno of Brown University in Providence, R.I., emphasized the need for health care providers to educate patients about their prognoses and to provide hospice options.

"If opportunities to improve are identified, hospitals should work with the local hospice or existing palliative care consult service, and/or start a palliative care consult service," to ensure that the institution is delivering high-quality care, Dr. Teno wrote.

Conversations about end-of-life care need to be started early in the course of treatment, Dr. Goodman said. "Our preferences can certainly change, but opening up the conversation early allows the conversation to evolve over time. The tragedy is when those conversations start near the end."

In a statement, Dr. George W. Sledge Jr., president of the American Society of Clinical Oncology said, "While saving lives is the oncologist’s goal, helping individuals live their final days in comfort and dignity is one of the most valuable and important responsibilities of our profession.

"Options to enhance a patient’s quality of life should be discussed throughout the course of their treatment. It is critical that we increase medical training in end-of-life patient communication and planning, and that Medicare and other insurers cover the costs of these essential conversations," Dr. Sledge noted.

The study was supported in part by the Robert Wood Johnson Foundation.

CHICAGO - Oncologists can navigate the sensitive and arduous communication of painful news to patients with greater honesty and compassion by expressing wishes in response to their patients’ sense of loss, futility, or unrealistic hope, Dr. Timothy E. Quill, told attendees at the annual Chicago Supportive Oncology Conference.

Communicating with statements such as "I wish there was more we could do for you," "I wish I had better news to give you," "I wish things had turned out better," or "I wish our palliative care was more effective" communicates empathy and caring without distorting the truth, fostering a false sense of hope, or emotionally bludgeoning the patient, said Dr. Quill, director of the center for ethics, humanities, and palliative care at the University of Rochester (N.Y.).

Wishes are effective because they acknowledge the emotional impact of the patient’s illness and allow the physician to respond as a human being to the patient’s emotional distress, while communicating with gentleness and compassion that the hoped-for outcome is unlikely, explained Dr. Quill, a professor of medicine, psychiatry, and medical humanities at the university. Simultaneously – and paradoxically – wishes enable the physician to identify with the patient’s hope while casting that hope in a realistic light.

Dr. Quill stressed, however, that wish statements should be used only as the beginning of an important dialogue. Wishes acknowledge that a desired result probably will not happen, and can elicit anger, hopelessness, terror, and despair. It is essential to talk with patients about their feelings and experiences, he said. The failure to do so could cause emotional harm.

Questions following wish statements – such as "What has been the hardest part for you?" "What are your biggest concerns?" and "How is your family managing this?" – can help to guide meaningful communication. Also critical are statements that validate the patient’s experience ("Anyone going through this would have such feelings") and express empathy ("I can imagine that must have been frightening"), as well as efforts to facilitate opportunities for growth and closure in addressing short-term medical decisions, financial and legal affairs, unfinished personal and family business, and, possibly, spiritual, religious, and existential issues.

He emphasized that this communication must be accompanied by the search for new treatment direction and hope through the appropriate use of standard treatment options, experimental treatment, palliative care, or hospice care.

In responding to an expression of loss, grief, and hopelessness ("I do not see how I can go on"), Dr. Quill noted that the clinician does not have to have all the answers. A statement such as "I wish I had a simple formula" allows the physician to take the same emotional stance as the patient, whereas expressions of empathy ("Tell me about the scariest part," "We can work on this together") can help patients deal with intense emotions, such as fear of abandonment.

In responding to a patient’s expression of unrealistic hope ("I want to live to see the birth of my grandchild"), Dr. Quill suggested that responding with a wish ("I wish I could promise that") and statements of empathy ("It must be hard to contemplate missing that; in case you cannot, perhaps you could ...") can provide support without creating unrealistic expectations.

Dr. Quill had no disclosures. The conference was sponsored by Elsevier Oncology, a company that is affiliated with this news organization.

CHICAGO - Oncologists can navigate the sensitive and arduous communication of painful news to patients with greater honesty and compassion by expressing wishes in response to their patients’ sense of loss, futility, or unrealistic hope, Dr. Timothy E. Quill, told attendees at the annual Chicago Supportive Oncology Conference.

Communicating with statements such as "I wish there was more we could do for you," "I wish I had better news to give you," "I wish things had turned out better," or "I wish our palliative care was more effective" communicates empathy and caring without distorting the truth, fostering a false sense of hope, or emotionally bludgeoning the patient, said Dr. Quill, director of the center for ethics, humanities, and palliative care at the University of Rochester (N.Y.).

Wishes are effective because they acknowledge the emotional impact of the patient’s illness and allow the physician to respond as a human being to the patient’s emotional distress, while communicating with gentleness and compassion that the hoped-for outcome is unlikely, explained Dr. Quill, a professor of medicine, psychiatry, and medical humanities at the university. Simultaneously – and paradoxically – wishes enable the physician to identify with the patient’s hope while casting that hope in a realistic light.

Dr. Quill stressed, however, that wish statements should be used only as the beginning of an important dialogue. Wishes acknowledge that a desired result probably will not happen, and can elicit anger, hopelessness, terror, and despair. It is essential to talk with patients about their feelings and experiences, he said. The failure to do so could cause emotional harm.

Questions following wish statements – such as "What has been the hardest part for you?" "What are your biggest concerns?" and "How is your family managing this?" – can help to guide meaningful communication. Also critical are statements that validate the patient’s experience ("Anyone going through this would have such feelings") and express empathy ("I can imagine that must have been frightening"), as well as efforts to facilitate opportunities for growth and closure in addressing short-term medical decisions, financial and legal affairs, unfinished personal and family business, and, possibly, spiritual, religious, and existential issues.

He emphasized that this communication must be accompanied by the search for new treatment direction and hope through the appropriate use of standard treatment options, experimental treatment, palliative care, or hospice care.

In responding to an expression of loss, grief, and hopelessness ("I do not see how I can go on"), Dr. Quill noted that the clinician does not have to have all the answers. A statement such as "I wish I had a simple formula" allows the physician to take the same emotional stance as the patient, whereas expressions of empathy ("Tell me about the scariest part," "We can work on this together") can help patients deal with intense emotions, such as fear of abandonment.

In responding to a patient’s expression of unrealistic hope ("I want to live to see the birth of my grandchild"), Dr. Quill suggested that responding with a wish ("I wish I could promise that") and statements of empathy ("It must be hard to contemplate missing that; in case you cannot, perhaps you could ...") can provide support without creating unrealistic expectations.

Dr. Quill had no disclosures. The conference was sponsored by Elsevier Oncology, a company that is affiliated with this news organization.

CHICAGO - Oncologists can navigate the sensitive and arduous communication of painful news to patients with greater honesty and compassion by expressing wishes in response to their patients’ sense of loss, futility, or unrealistic hope, Dr. Timothy E. Quill, told attendees at the annual Chicago Supportive Oncology Conference.

Communicating with statements such as "I wish there was more we could do for you," "I wish I had better news to give you," "I wish things had turned out better," or "I wish our palliative care was more effective" communicates empathy and caring without distorting the truth, fostering a false sense of hope, or emotionally bludgeoning the patient, said Dr. Quill, director of the center for ethics, humanities, and palliative care at the University of Rochester (N.Y.).

Wishes are effective because they acknowledge the emotional impact of the patient’s illness and allow the physician to respond as a human being to the patient’s emotional distress, while communicating with gentleness and compassion that the hoped-for outcome is unlikely, explained Dr. Quill, a professor of medicine, psychiatry, and medical humanities at the university. Simultaneously – and paradoxically – wishes enable the physician to identify with the patient’s hope while casting that hope in a realistic light.

Dr. Quill stressed, however, that wish statements should be used only as the beginning of an important dialogue. Wishes acknowledge that a desired result probably will not happen, and can elicit anger, hopelessness, terror, and despair. It is essential to talk with patients about their feelings and experiences, he said. The failure to do so could cause emotional harm.

Questions following wish statements – such as "What has been the hardest part for you?" "What are your biggest concerns?" and "How is your family managing this?" – can help to guide meaningful communication. Also critical are statements that validate the patient’s experience ("Anyone going through this would have such feelings") and express empathy ("I can imagine that must have been frightening"), as well as efforts to facilitate opportunities for growth and closure in addressing short-term medical decisions, financial and legal affairs, unfinished personal and family business, and, possibly, spiritual, religious, and existential issues.

He emphasized that this communication must be accompanied by the search for new treatment direction and hope through the appropriate use of standard treatment options, experimental treatment, palliative care, or hospice care.

In responding to an expression of loss, grief, and hopelessness ("I do not see how I can go on"), Dr. Quill noted that the clinician does not have to have all the answers. A statement such as "I wish I had a simple formula" allows the physician to take the same emotional stance as the patient, whereas expressions of empathy ("Tell me about the scariest part," "We can work on this together") can help patients deal with intense emotions, such as fear of abandonment.

In responding to a patient’s expression of unrealistic hope ("I want to live to see the birth of my grandchild"), Dr. Quill suggested that responding with a wish ("I wish I could promise that") and statements of empathy ("It must be hard to contemplate missing that; in case you cannot, perhaps you could ...") can provide support without creating unrealistic expectations.

Dr. Quill had no disclosures. The conference was sponsored by Elsevier Oncology, a company that is affiliated with this news organization.

Reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Hemorrhoid or Cancerous Mass?
In May 2000, a 35-year-old woman gave birth to her second child at a Massachusetts hospital. She sustained a second-degree vaginal tear. During repair of the tear, a large hemorrhoid was visualized by the physician, who instructed a nurse-midwife to have the hemorrhoid evaluated, with a possible gastroenterology consult to rule out a mass.

The next day, the patient was examined by another doctor and another nurse-midwife. It was agreed by the clinicians and the patient that she would defer a gastroenterology consult and follow up with her primary care provider in a few weeks. When she saw her primary care physician three weeks after the delivery, her examination was negative for hemorrhoids, and the patient was instructed to call back if she had a recurrence. Since she experienced no recurrence, she did not follow up with the primary care provider. Over the next four years, the woman received medical care from her gynecologist but at no time underwent a rectal examination.

In February 2005, the plaintiff went to her primary care physician with complaints of rectal bleeding during bowel movements. No external hemorrhoids were found, but a rectal mass was present.

The woman was referred for a gastroenterology consult and biopsy, through which an intramucosal adenocarcinoma was identified. Chest CT revealed a nodule in the patient’s right lower lung lobe, which was suspicious for metastasis. Abdominal CT and positron emission tomography showed likely liver metastases. A liver biopsy performed in mid-March 2005 confirmed adenocarcinoma of the liver.

The patient received chemotherapy and chemoradiation. In September 2005, she underwent an abdominal perineal resection, left lateral segmentectomy of the liver, cholecystectomy, and appendectomy. By the time of settlement, she was doing well and was no longer receiving treatment for cancer.

The plaintiff claimed that her primary care provider should have followed up on the initial rectal finding, which would have led to an earlier diagnosis and treatment of her cancer.

The defendant argued that the lesion noted at the time of the delivery was a simple hemorrhoid, which resolved after delivery. The defendant also contended that the absence of any symptoms for nearly five years indicated that the cancer could not have been present in 2000. The defendant further claimed that the cancer found at diagnosis and the hemorrhoid that was originally noted were in different locations.

A $1 million settlement was reached.

Diagnosis, Treatment Delayed by Suspicion of Abuse
A seven-week-old boy was taken to the pediatrician by his parents. They said he had been crying inconsolably all day, with decreased food intake, limited urinary output, and bruising. The pediatrician suspected meningitis and sent them to the emergency department (ED) at a children’s hospital in Georgia. The intake staff and emergency physician, Dr. C., were informed that the pediatrician suspected meningitis.

A blood culture, chest x-ray, and ultrasound were performed. The infant’s white blood cell count was normal, and his condition improved during the ED stay. He was afebrile, and the defendants maintained that he had no symptoms that would indicate meningitis.

Bruising was found on the child’s rib cage and one knee, and an ultrasound indicated that the bruising was due to trauma; thus, a mandatory report was filed with the authorities, and the physician made a diagnosis of abuse. The parents were forced to leave the child at the hospital and were told not to return because the child was in the hospital’s custody. The child was transferred out of the ED and the care of Dr. C.

Subsequently, the blood culture was reported as positive and showed gram-positive cocci. This report was returned about 26 hours after the child’s symptoms had begun at home. The report on the blood culture was relayed to one of the doctors, but no orders were given to evaluate the child. The child was not given antibiotics to treat the meningitis until the following day. The police dropped the report of abuse shortly after the investigation into the allegations began.

The child experienced a severe seizure with catastrophic brain damage, which the plaintiffs attributed to a delay in diagnosis and treatment for meningitis. The child was unable to roll over by age 2 years and would require extensive care and treatment for the remainder of his life.

The defendants claimed that the actions taken were proper and that there was no reason to suspect infection because the child did not have a fever and his condition improved while he was in the ED.

According to a published report, a defense verdict was returned.

Failure to Recognize Adrenal Crisis
A 26-year-old Massachusetts woman had a history of type 2 diabetes and newly diagnosed adrenal insufficiency, for which she was taking hydrocortisone. She presented to an emergency department (ED) complaining of cold symptoms and abdominal pain.

She was evaluated by an emergency physician, who noted moderate pain and tachycardia, a heart rate of 100 beats/min, and tenderness in the woman’s sinuses, neck, and left lower quadrant of the abdomen. Laboratory test results included a positive pregnancy test and an abnormal potassium level. Subsequent cardiac monitoring revealed atrial tachycardia. ECG revealed a rapid heart rate and diffuse, nonspecific abnormalities.

A second physician assumed care of the patient and treated her with potassium chloride, IV fluids of dextrose and sodium chloride, and ondansetron for nausea and vomiting. Neither physician had noted the medications being taken by the patient.  

She returned to the ED two days after her initial admission with complaints of vomiting, chest pain, and abdominal pain. Her vital signs were abnormal. A different emergency physician evaluated the patient and noted tachycardia and vitiligo (consistent with adrenal insufficiency). Laboratory study results revealed metabolic abnormalities, and the woman was diagnosed with pregnancy-related nausea and vomiting and poorly controlled diabetes.  

Over the following week, five additional physicians examined and/or treated the woman, one of whom was told that she had been taking hydrocortisone but stopped when she learned she was pregnant. The woman’s condition worsened, involving blindness, severe metabolic acidosis, and respiratory arrest. The family agreed to a transfer to a tertiary care facility.

At this time, during conversations between the patient’s family and her physicians, the physicians were made aware that she was taking hydrocortisone for adrenal insufficiency. The physicians immediately began treatment with methylprednisolone. The patient’s neurologic status continued to decline, however, and CT revealed findings consistent with a diffuse anoxic injury. She was placed on comfort measures only, and she died nine days after her original ED admission.

The plaintiffs alleged negligence in the ED staff’s failure to take a thorough medical history. The defendant claimed that the decedent’s symptoms were not consistent with adrenal crisis and that she had not fully disclosed her use of hydrocortisone.

According to a published account, a $3 million settlement was reached.

High-Dose Morphine After DNR Order
At age 79, a woman with chronic obstructive pulmonary disease was admitted to a hospital in Georgia with breathing difficulties. During her hospitalization, the patient experienced respiratory arrest. A code was called and the defendant, the critical care pulmonologist on duty, responded.

Once bag ventilation was implemented, the patient started to breathe and the code was stopped. After the incident, the attending physician, who had also responded to the code, initiated a discussion with the patient’s daughter about the plan of treatment and the patient’s prognosis. At the conclusion of this conversation, the patient’s daughter agreed to a “do-not-resuscitate” order. The attending physician ordered 2 mg morphine as needed to keep the patient comfortable.

Five minutes later, the pulmonologist overrode this order and ordered 20 mg morphine pushed. Shortly after the medication was administered, the patient, who was talking to her daughter and granddaughter, lost consciousness. She died about three hours later without regaining consciousness.

The plaintiff claimed that the decedent’s condition improved during her hospitalization until the night before her arrest, when she was not given her scheduled breathing treatments. The plaintiff also alleged that the defendant pulmonologist was negligent in ordering the 20-mg dose of morphine and that the hospital nurse was negligent in administering such a high dose.

The defendants claimed that no negligence occurred and that the woman would have died sooner than three hours after the morphine was administered, if that indeed was the cause of her death.

According to a published account, a $3 million verdict was returned.

Reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Hemorrhoid or Cancerous Mass?
In May 2000, a 35-year-old woman gave birth to her second child at a Massachusetts hospital. She sustained a second-degree vaginal tear. During repair of the tear, a large hemorrhoid was visualized by the physician, who instructed a nurse-midwife to have the hemorrhoid evaluated, with a possible gastroenterology consult to rule out a mass.

The next day, the patient was examined by another doctor and another nurse-midwife. It was agreed by the clinicians and the patient that she would defer a gastroenterology consult and follow up with her primary care provider in a few weeks. When she saw her primary care physician three weeks after the delivery, her examination was negative for hemorrhoids, and the patient was instructed to call back if she had a recurrence. Since she experienced no recurrence, she did not follow up with the primary care provider. Over the next four years, the woman received medical care from her gynecologist but at no time underwent a rectal examination.

In February 2005, the plaintiff went to her primary care physician with complaints of rectal bleeding during bowel movements. No external hemorrhoids were found, but a rectal mass was present.

The woman was referred for a gastroenterology consult and biopsy, through which an intramucosal adenocarcinoma was identified. Chest CT revealed a nodule in the patient’s right lower lung lobe, which was suspicious for metastasis. Abdominal CT and positron emission tomography showed likely liver metastases. A liver biopsy performed in mid-March 2005 confirmed adenocarcinoma of the liver.

The patient received chemotherapy and chemoradiation. In September 2005, she underwent an abdominal perineal resection, left lateral segmentectomy of the liver, cholecystectomy, and appendectomy. By the time of settlement, she was doing well and was no longer receiving treatment for cancer.

The plaintiff claimed that her primary care provider should have followed up on the initial rectal finding, which would have led to an earlier diagnosis and treatment of her cancer.

The defendant argued that the lesion noted at the time of the delivery was a simple hemorrhoid, which resolved after delivery. The defendant also contended that the absence of any symptoms for nearly five years indicated that the cancer could not have been present in 2000. The defendant further claimed that the cancer found at diagnosis and the hemorrhoid that was originally noted were in different locations.

A $1 million settlement was reached.

Diagnosis, Treatment Delayed by Suspicion of Abuse
A seven-week-old boy was taken to the pediatrician by his parents. They said he had been crying inconsolably all day, with decreased food intake, limited urinary output, and bruising. The pediatrician suspected meningitis and sent them to the emergency department (ED) at a children’s hospital in Georgia. The intake staff and emergency physician, Dr. C., were informed that the pediatrician suspected meningitis.

A blood culture, chest x-ray, and ultrasound were performed. The infant’s white blood cell count was normal, and his condition improved during the ED stay. He was afebrile, and the defendants maintained that he had no symptoms that would indicate meningitis.

Bruising was found on the child’s rib cage and one knee, and an ultrasound indicated that the bruising was due to trauma; thus, a mandatory report was filed with the authorities, and the physician made a diagnosis of abuse. The parents were forced to leave the child at the hospital and were told not to return because the child was in the hospital’s custody. The child was transferred out of the ED and the care of Dr. C.

Subsequently, the blood culture was reported as positive and showed gram-positive cocci. This report was returned about 26 hours after the child’s symptoms had begun at home. The report on the blood culture was relayed to one of the doctors, but no orders were given to evaluate the child. The child was not given antibiotics to treat the meningitis until the following day. The police dropped the report of abuse shortly after the investigation into the allegations began.

The child experienced a severe seizure with catastrophic brain damage, which the plaintiffs attributed to a delay in diagnosis and treatment for meningitis. The child was unable to roll over by age 2 years and would require extensive care and treatment for the remainder of his life.

The defendants claimed that the actions taken were proper and that there was no reason to suspect infection because the child did not have a fever and his condition improved while he was in the ED.

According to a published report, a defense verdict was returned.

Failure to Recognize Adrenal Crisis
A 26-year-old Massachusetts woman had a history of type 2 diabetes and newly diagnosed adrenal insufficiency, for which she was taking hydrocortisone. She presented to an emergency department (ED) complaining of cold symptoms and abdominal pain.

She was evaluated by an emergency physician, who noted moderate pain and tachycardia, a heart rate of 100 beats/min, and tenderness in the woman’s sinuses, neck, and left lower quadrant of the abdomen. Laboratory test results included a positive pregnancy test and an abnormal potassium level. Subsequent cardiac monitoring revealed atrial tachycardia. ECG revealed a rapid heart rate and diffuse, nonspecific abnormalities.

A second physician assumed care of the patient and treated her with potassium chloride, IV fluids of dextrose and sodium chloride, and ondansetron for nausea and vomiting. Neither physician had noted the medications being taken by the patient.  

She returned to the ED two days after her initial admission with complaints of vomiting, chest pain, and abdominal pain. Her vital signs were abnormal. A different emergency physician evaluated the patient and noted tachycardia and vitiligo (consistent with adrenal insufficiency). Laboratory study results revealed metabolic abnormalities, and the woman was diagnosed with pregnancy-related nausea and vomiting and poorly controlled diabetes.  

Over the following week, five additional physicians examined and/or treated the woman, one of whom was told that she had been taking hydrocortisone but stopped when she learned she was pregnant. The woman’s condition worsened, involving blindness, severe metabolic acidosis, and respiratory arrest. The family agreed to a transfer to a tertiary care facility.

At this time, during conversations between the patient’s family and her physicians, the physicians were made aware that she was taking hydrocortisone for adrenal insufficiency. The physicians immediately began treatment with methylprednisolone. The patient’s neurologic status continued to decline, however, and CT revealed findings consistent with a diffuse anoxic injury. She was placed on comfort measures only, and she died nine days after her original ED admission.

The plaintiffs alleged negligence in the ED staff’s failure to take a thorough medical history. The defendant claimed that the decedent’s symptoms were not consistent with adrenal crisis and that she had not fully disclosed her use of hydrocortisone.

According to a published account, a $3 million settlement was reached.

High-Dose Morphine After DNR Order
At age 79, a woman with chronic obstructive pulmonary disease was admitted to a hospital in Georgia with breathing difficulties. During her hospitalization, the patient experienced respiratory arrest. A code was called and the defendant, the critical care pulmonologist on duty, responded.

Once bag ventilation was implemented, the patient started to breathe and the code was stopped. After the incident, the attending physician, who had also responded to the code, initiated a discussion with the patient’s daughter about the plan of treatment and the patient’s prognosis. At the conclusion of this conversation, the patient’s daughter agreed to a “do-not-resuscitate” order. The attending physician ordered 2 mg morphine as needed to keep the patient comfortable.

Five minutes later, the pulmonologist overrode this order and ordered 20 mg morphine pushed. Shortly after the medication was administered, the patient, who was talking to her daughter and granddaughter, lost consciousness. She died about three hours later without regaining consciousness.

The plaintiff claimed that the decedent’s condition improved during her hospitalization until the night before her arrest, when she was not given her scheduled breathing treatments. The plaintiff also alleged that the defendant pulmonologist was negligent in ordering the 20-mg dose of morphine and that the hospital nurse was negligent in administering such a high dose.

The defendants claimed that no negligence occurred and that the woman would have died sooner than three hours after the morphine was administered, if that indeed was the cause of her death.

According to a published account, a $3 million verdict was returned.

Reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Hemorrhoid or Cancerous Mass?
In May 2000, a 35-year-old woman gave birth to her second child at a Massachusetts hospital. She sustained a second-degree vaginal tear. During repair of the tear, a large hemorrhoid was visualized by the physician, who instructed a nurse-midwife to have the hemorrhoid evaluated, with a possible gastroenterology consult to rule out a mass.

The next day, the patient was examined by another doctor and another nurse-midwife. It was agreed by the clinicians and the patient that she would defer a gastroenterology consult and follow up with her primary care provider in a few weeks. When she saw her primary care physician three weeks after the delivery, her examination was negative for hemorrhoids, and the patient was instructed to call back if she had a recurrence. Since she experienced no recurrence, she did not follow up with the primary care provider. Over the next four years, the woman received medical care from her gynecologist but at no time underwent a rectal examination.

In February 2005, the plaintiff went to her primary care physician with complaints of rectal bleeding during bowel movements. No external hemorrhoids were found, but a rectal mass was present.

The woman was referred for a gastroenterology consult and biopsy, through which an intramucosal adenocarcinoma was identified. Chest CT revealed a nodule in the patient’s right lower lung lobe, which was suspicious for metastasis. Abdominal CT and positron emission tomography showed likely liver metastases. A liver biopsy performed in mid-March 2005 confirmed adenocarcinoma of the liver.

The patient received chemotherapy and chemoradiation. In September 2005, she underwent an abdominal perineal resection, left lateral segmentectomy of the liver, cholecystectomy, and appendectomy. By the time of settlement, she was doing well and was no longer receiving treatment for cancer.

The plaintiff claimed that her primary care provider should have followed up on the initial rectal finding, which would have led to an earlier diagnosis and treatment of her cancer.

The defendant argued that the lesion noted at the time of the delivery was a simple hemorrhoid, which resolved after delivery. The defendant also contended that the absence of any symptoms for nearly five years indicated that the cancer could not have been present in 2000. The defendant further claimed that the cancer found at diagnosis and the hemorrhoid that was originally noted were in different locations.

A $1 million settlement was reached.

Diagnosis, Treatment Delayed by Suspicion of Abuse
A seven-week-old boy was taken to the pediatrician by his parents. They said he had been crying inconsolably all day, with decreased food intake, limited urinary output, and bruising. The pediatrician suspected meningitis and sent them to the emergency department (ED) at a children’s hospital in Georgia. The intake staff and emergency physician, Dr. C., were informed that the pediatrician suspected meningitis.

A blood culture, chest x-ray, and ultrasound were performed. The infant’s white blood cell count was normal, and his condition improved during the ED stay. He was afebrile, and the defendants maintained that he had no symptoms that would indicate meningitis.

Bruising was found on the child’s rib cage and one knee, and an ultrasound indicated that the bruising was due to trauma; thus, a mandatory report was filed with the authorities, and the physician made a diagnosis of abuse. The parents were forced to leave the child at the hospital and were told not to return because the child was in the hospital’s custody. The child was transferred out of the ED and the care of Dr. C.

Subsequently, the blood culture was reported as positive and showed gram-positive cocci. This report was returned about 26 hours after the child’s symptoms had begun at home. The report on the blood culture was relayed to one of the doctors, but no orders were given to evaluate the child. The child was not given antibiotics to treat the meningitis until the following day. The police dropped the report of abuse shortly after the investigation into the allegations began.

The child experienced a severe seizure with catastrophic brain damage, which the plaintiffs attributed to a delay in diagnosis and treatment for meningitis. The child was unable to roll over by age 2 years and would require extensive care and treatment for the remainder of his life.

The defendants claimed that the actions taken were proper and that there was no reason to suspect infection because the child did not have a fever and his condition improved while he was in the ED.

According to a published report, a defense verdict was returned.

Failure to Recognize Adrenal Crisis
A 26-year-old Massachusetts woman had a history of type 2 diabetes and newly diagnosed adrenal insufficiency, for which she was taking hydrocortisone. She presented to an emergency department (ED) complaining of cold symptoms and abdominal pain.

She was evaluated by an emergency physician, who noted moderate pain and tachycardia, a heart rate of 100 beats/min, and tenderness in the woman’s sinuses, neck, and left lower quadrant of the abdomen. Laboratory test results included a positive pregnancy test and an abnormal potassium level. Subsequent cardiac monitoring revealed atrial tachycardia. ECG revealed a rapid heart rate and diffuse, nonspecific abnormalities.

A second physician assumed care of the patient and treated her with potassium chloride, IV fluids of dextrose and sodium chloride, and ondansetron for nausea and vomiting. Neither physician had noted the medications being taken by the patient.  

She returned to the ED two days after her initial admission with complaints of vomiting, chest pain, and abdominal pain. Her vital signs were abnormal. A different emergency physician evaluated the patient and noted tachycardia and vitiligo (consistent with adrenal insufficiency). Laboratory study results revealed metabolic abnormalities, and the woman was diagnosed with pregnancy-related nausea and vomiting and poorly controlled diabetes.  

Over the following week, five additional physicians examined and/or treated the woman, one of whom was told that she had been taking hydrocortisone but stopped when she learned she was pregnant. The woman’s condition worsened, involving blindness, severe metabolic acidosis, and respiratory arrest. The family agreed to a transfer to a tertiary care facility.

At this time, during conversations between the patient’s family and her physicians, the physicians were made aware that she was taking hydrocortisone for adrenal insufficiency. The physicians immediately began treatment with methylprednisolone. The patient’s neurologic status continued to decline, however, and CT revealed findings consistent with a diffuse anoxic injury. She was placed on comfort measures only, and she died nine days after her original ED admission.

The plaintiffs alleged negligence in the ED staff’s failure to take a thorough medical history. The defendant claimed that the decedent’s symptoms were not consistent with adrenal crisis and that she had not fully disclosed her use of hydrocortisone.

According to a published account, a $3 million settlement was reached.

High-Dose Morphine After DNR Order
At age 79, a woman with chronic obstructive pulmonary disease was admitted to a hospital in Georgia with breathing difficulties. During her hospitalization, the patient experienced respiratory arrest. A code was called and the defendant, the critical care pulmonologist on duty, responded.

Once bag ventilation was implemented, the patient started to breathe and the code was stopped. After the incident, the attending physician, who had also responded to the code, initiated a discussion with the patient’s daughter about the plan of treatment and the patient’s prognosis. At the conclusion of this conversation, the patient’s daughter agreed to a “do-not-resuscitate” order. The attending physician ordered 2 mg morphine as needed to keep the patient comfortable.

Five minutes later, the pulmonologist overrode this order and ordered 20 mg morphine pushed. Shortly after the medication was administered, the patient, who was talking to her daughter and granddaughter, lost consciousness. She died about three hours later without regaining consciousness.

The plaintiff claimed that the decedent’s condition improved during her hospitalization until the night before her arrest, when she was not given her scheduled breathing treatments. The plaintiff also alleged that the defendant pulmonologist was negligent in ordering the 20-mg dose of morphine and that the hospital nurse was negligent in administering such a high dose.

The defendants claimed that no negligence occurred and that the woman would have died sooner than three hours after the morphine was administered, if that indeed was the cause of her death.

According to a published account, a $3 million verdict was returned.

A “meaningful proportion” of patients aged 65 years and older who have advanced cancer and a limited life expectancy undergo unnecessary screening for other cancers, needlessly exposing them to physical risk and psychological distress, according to a report in the Oct. 13 issue of JAMA.

Dr. Camelia S. Sima of the department of epidemiology and biostatistics at Memorial Sloan-Kettering Cancer Center, New York, and her associates said the terminally ill patients “have essentially no chance of benefiting from these procedures,” which they said were the result of a “culture of screening on ‘autopilot.’?”

They noted, however, that current guidelines “do not directly address the appropriateness of screening for individuals with terminal illnesses.”

The screening rates were one-third to one-half the rates in a matched control population of healthy adults who were followed over the same time period. Dr. Sima and her colleagues noted that rates of unnecessary cancer screening are likely to be even higher in the general population of patients with advanced cancer, which would include younger patients and those who are commercially insured (JAMA 2010;304:1584-91).

The investigators analyzed 1998-2005 data from the Surveillance, Epidemiology, and End Results (SEER) cancer registry, which is linked with Medicare claims. They identified 87,736 Medicare patients (median age, 77 years) who survived at least 2 months after a diagnosis of advanced lung, colorectal, breast, gastroesophageal, or pancreatic cancer, and were followed until death or 2008.

Although such cancers have a median survival of less than 2 years, 15% of the men had PSA testing. About 9% of the women underwent screening mammography and 6% underwent Pap testing. Two percent of men and women underwent lower GI endoscopy screening for colorectal cancer.

The data did not indicate whether this screening was ordered by oncologists or primary care physicians, nor whether it was driven by patient demand. But “whatever the impetus, screening utilization by patients with advanced cancer adds to the mounting concern about overdiagnosis,” the researchers said.

“The most plausible interpretation of our data is that efforts to foster adherence to screening have led to deeply ingrained habits. Patients and their health care practitioners accustomed to obtaining screening tests at regular intervals continue to do so even when the benefits have been rendered futile in the face of competing risk from advanced cancer,” Dr. Sima and her associates said.

As an example of this “autopilot” screening, they noted that 20% of the study population continued to undergo regular testing of cholesterol levels even though their life expectancy was drastically limited.

“Furthermore, we hypothesize that neither primary care physicians nor oncologists routinely engage in the difficult discussions that require explanation of why continuation of procedures to which patients have become accustomed is no longer necessary.

“There is substantial evidence that even when physicians recognize that life expectancy is limited, they do not consistently communicate prognosis, and patients may use denial as a coping strategy to face impending loss. Our findings represent one manifestation of this communication deficit.”

Any attempt to limit patient care “is routinely met with vocal opposition,” but this overuse of cancer screening “is likely to be relatively uncontroversial,” the investigators said.

“Each medical specialty needs to engage in thoughtful self-scrutiny to identify episodes of unnecessary care. We suggest that the road to a high-performing, high-value health care system will be paved with small stones such as the example we have identified.”

This study was supported in part by a grant from the National Cancer Institute. Dr. Sima and her colleagues did not report any financial disclosures.

A “meaningful proportion” of patients aged 65 years and older who have advanced cancer and a limited life expectancy undergo unnecessary screening for other cancers, needlessly exposing them to physical risk and psychological distress, according to a report in the Oct. 13 issue of JAMA.

Dr. Camelia S. Sima of the department of epidemiology and biostatistics at Memorial Sloan-Kettering Cancer Center, New York, and her associates said the terminally ill patients “have essentially no chance of benefiting from these procedures,” which they said were the result of a “culture of screening on ‘autopilot.’?”

They noted, however, that current guidelines “do not directly address the appropriateness of screening for individuals with terminal illnesses.”

The screening rates were one-third to one-half the rates in a matched control population of healthy adults who were followed over the same time period. Dr. Sima and her colleagues noted that rates of unnecessary cancer screening are likely to be even higher in the general population of patients with advanced cancer, which would include younger patients and those who are commercially insured (JAMA 2010;304:1584-91).

The investigators analyzed 1998-2005 data from the Surveillance, Epidemiology, and End Results (SEER) cancer registry, which is linked with Medicare claims. They identified 87,736 Medicare patients (median age, 77 years) who survived at least 2 months after a diagnosis of advanced lung, colorectal, breast, gastroesophageal, or pancreatic cancer, and were followed until death or 2008.

Although such cancers have a median survival of less than 2 years, 15% of the men had PSA testing. About 9% of the women underwent screening mammography and 6% underwent Pap testing. Two percent of men and women underwent lower GI endoscopy screening for colorectal cancer.

The data did not indicate whether this screening was ordered by oncologists or primary care physicians, nor whether it was driven by patient demand. But “whatever the impetus, screening utilization by patients with advanced cancer adds to the mounting concern about overdiagnosis,” the researchers said.

“The most plausible interpretation of our data is that efforts to foster adherence to screening have led to deeply ingrained habits. Patients and their health care practitioners accustomed to obtaining screening tests at regular intervals continue to do so even when the benefits have been rendered futile in the face of competing risk from advanced cancer,” Dr. Sima and her associates said.

As an example of this “autopilot” screening, they noted that 20% of the study population continued to undergo regular testing of cholesterol levels even though their life expectancy was drastically limited.

“Furthermore, we hypothesize that neither primary care physicians nor oncologists routinely engage in the difficult discussions that require explanation of why continuation of procedures to which patients have become accustomed is no longer necessary.

“There is substantial evidence that even when physicians recognize that life expectancy is limited, they do not consistently communicate prognosis, and patients may use denial as a coping strategy to face impending loss. Our findings represent one manifestation of this communication deficit.”

Any attempt to limit patient care “is routinely met with vocal opposition,” but this overuse of cancer screening “is likely to be relatively uncontroversial,” the investigators said.

“Each medical specialty needs to engage in thoughtful self-scrutiny to identify episodes of unnecessary care. We suggest that the road to a high-performing, high-value health care system will be paved with small stones such as the example we have identified.”

This study was supported in part by a grant from the National Cancer Institute. Dr. Sima and her colleagues did not report any financial disclosures.

A “meaningful proportion” of patients aged 65 years and older who have advanced cancer and a limited life expectancy undergo unnecessary screening for other cancers, needlessly exposing them to physical risk and psychological distress, according to a report in the Oct. 13 issue of JAMA.

Dr. Camelia S. Sima of the department of epidemiology and biostatistics at Memorial Sloan-Kettering Cancer Center, New York, and her associates said the terminally ill patients “have essentially no chance of benefiting from these procedures,” which they said were the result of a “culture of screening on ‘autopilot.’?”

They noted, however, that current guidelines “do not directly address the appropriateness of screening for individuals with terminal illnesses.”

The screening rates were one-third to one-half the rates in a matched control population of healthy adults who were followed over the same time period. Dr. Sima and her colleagues noted that rates of unnecessary cancer screening are likely to be even higher in the general population of patients with advanced cancer, which would include younger patients and those who are commercially insured (JAMA 2010;304:1584-91).

The investigators analyzed 1998-2005 data from the Surveillance, Epidemiology, and End Results (SEER) cancer registry, which is linked with Medicare claims. They identified 87,736 Medicare patients (median age, 77 years) who survived at least 2 months after a diagnosis of advanced lung, colorectal, breast, gastroesophageal, or pancreatic cancer, and were followed until death or 2008.

Although such cancers have a median survival of less than 2 years, 15% of the men had PSA testing. About 9% of the women underwent screening mammography and 6% underwent Pap testing. Two percent of men and women underwent lower GI endoscopy screening for colorectal cancer.

The data did not indicate whether this screening was ordered by oncologists or primary care physicians, nor whether it was driven by patient demand. But “whatever the impetus, screening utilization by patients with advanced cancer adds to the mounting concern about overdiagnosis,” the researchers said.

“The most plausible interpretation of our data is that efforts to foster adherence to screening have led to deeply ingrained habits. Patients and their health care practitioners accustomed to obtaining screening tests at regular intervals continue to do so even when the benefits have been rendered futile in the face of competing risk from advanced cancer,” Dr. Sima and her associates said.

As an example of this “autopilot” screening, they noted that 20% of the study population continued to undergo regular testing of cholesterol levels even though their life expectancy was drastically limited.

“Furthermore, we hypothesize that neither primary care physicians nor oncologists routinely engage in the difficult discussions that require explanation of why continuation of procedures to which patients have become accustomed is no longer necessary.

“There is substantial evidence that even when physicians recognize that life expectancy is limited, they do not consistently communicate prognosis, and patients may use denial as a coping strategy to face impending loss. Our findings represent one manifestation of this communication deficit.”

Any attempt to limit patient care “is routinely met with vocal opposition,” but this overuse of cancer screening “is likely to be relatively uncontroversial,” the investigators said.

“Each medical specialty needs to engage in thoughtful self-scrutiny to identify episodes of unnecessary care. We suggest that the road to a high-performing, high-value health care system will be paved with small stones such as the example we have identified.”

This study was supported in part by a grant from the National Cancer Institute. Dr. Sima and her colleagues did not report any financial disclosures.