Sanjay Aneja

Association of Increased Dermatologist Density With Lower Melanoma Mortality

OBJECTIVE To determine whether there is an association between dermatologist density and melanoma mortality. DESIGN A regression model was developed to test the association between melanoma mortality and dermatologist density, controlling for county demographics, health care infrastructure, and socioeconomic factors. Data were collected from the Area Resource File, US Centers for Disease Control and Prevention, and National Cancer Institutes Surveillance, Epidemiology, and End Results program and National Program for Cancer Registries. SETTING US counties. PATIENTS Melanoma mortality and incidence data were reported as age-adjusted mean rates per 100 000 people from January 2002, through December 2006. MAIN OUTCOME MEASURE The primary outcome measure was melanoma mortality rate per 100 000 people at the county level. RESULTS Geographic variation exists in the distribution of dermatologists across the United States. Multivariate analysis demonstrated that the presence of 0.001 to 1 dermatologist per 100 000 people was associated with a 35.0% reduction in the melanoma mortality rate (95% CI, 13.4%-56.6%) when compared with counties with no dermatologist. The presence of 1.001 to 2 dermatologists per 100 000 people was associated with a 53.0% reduction in the melanoma mortality rate (95% CI, 30.6%-75.4%). Having more than 2 dermatologists per 100 000 people did not further lower melanoma mortality rates. CONCLUSION Within a given county, a greater dermatologist density is associated with lower melanoma mortality rates compared with counties that lacked a dermatologist.

US Cardiologist Workforce From 1995 To 2007: Modest Growth, Lasting Geographic Maldistribution Especially In Rural Areas

A sufficient cardiology workforce is necessary to ensure access to cardiovascular care. Specifically, access to cardiologists is important in the management and treatment of chronic cardiovascular disease. Given this, we examined the supply and distribution of the cardiologist workforce. In doing so, we mapped the ratios of cardiologists, primary care physicians, and total physicians to the population age sixty-five or older within different Hospital Referral Regions from the years 1995 and 2007. We found that within the twelve-year span of our study, the cardiology workforce grew modestly compared with the primary care physician and total physician workforces. Also, despite increases in the number of cardiologists, there was a persistent geographic maldistribution of the workforce. For example, approximately 60 percent of the elderly population had access to only 38 percent of the cardiologists. Our results suggest that large segments of the US population, specifically in rural and socioeconomically disadvantaged areas, continue to have a lower concentration of cardiologists. This maldistribution could be addressed through a variety of strategies, including the use of telemedicine and economic incentives.

Comparative Effectiveness Research in Radiation Oncology: Stereotactic Radiosurgery, Hypofractionation, and Brachytherapy

Radiation oncology encompasses a diverse spectrum of treatment modalities, including stereotactic radiosurgery, hypofractionated radiotherapy, and brachytherapy. Though all these modalities generally aim to do the same thing-treat cancer with therapeutic doses of radiation while relatively sparing normal tissue from excessive toxicity, the general radiobiology and physics underlying each modality are distinct enough that their equivalence is not a given. Given the continued innovation in radiation oncology, the comparative effectiveness of these modalities is important to review. Given the broad scope of radiation oncology, this article focuses on the 3 most common sites requiring radiation treatment: breast, prostate, and lung cancer.

Concurrent chemoradiotherapy versus radiotherapy alone for “biopsy‐only” glioblastoma multiforme

Combined temozolomide and radiotherapy (RT) is the standard postoperative therapy for glioblastoma multiforme (GBM). However, the clearest benefit of concurrent chemoradiotherapy (CRT) observed in clinical trials has been among patients who undergo surgical resection. Whether the improved survival with CRT extends to patients who undergo “biopsy only” is less certain. The authors compared overall survival (OS) in a national cohort of patients with GBM who underwent biopsy and received either RT alone or CRT during the temozolomide era.

Computerized Interactive Educational Tools Used to Improve Use of Sun-Protective Clothing and Sunscreen: A Randomized Controlled Study

cells that have a compensatory amplification of genes downstream from SMO such as Gli. In individuals with multiple resistant BCCs, the isogenic background of a single individual may facilitate molecular studies of these resistant BCCs because some of the tumors may become resistant through multiple mechanisms. Future efforts to attack or prevent resistance in BCCs may involve the use of more than 1 drug at a time to target multiple pathways that contribute to abnormal basal cell growth. We were surprised that our case series did not show secondary resistance in the 8 patients with mBCC. It is possible that with longer follow-up times, mBCCs may be observed to acquire resistance while the patient is undergoing vismodegib treatment. In addition, larger sample sizes may be needed to observe this phenomenon: the regrowth rate we observed was only 1 in 5 in patients with laBCC. Because of the risk of regrowth, frequent skin examinations of patients undergoing treatment with vismodegib are essential to monitor for acquired resistance, even if the original tumor appears to be gone on clinical examination. When identified and biopsied early, these secondarily resistant BCCs are more likely to be treated effectively. Non-SMO inhibitor treatments such as surgical excision can be essential to optimize patient outcomes. With increased vismodegib usage, it is likely that tumor regrowth may be an increasing phenomenon. Future studies with larger numbers of patients observed for longer periods are needed confirm our observations, identify factors associated with regrowth, and characterize the molecular mechanisms by which regrowth occurs.

Risk of Clinically Significant Prostate Cancer Associated With Prostate Imaging Reporting and Data System Category 3 (Equivocal) Lesions Identified on Multiparametric Prostate MRI

OBJECTIVE The objective of this study is to determine the frequency of clinically significant cancer (CSC) in Prostate Imaging Reporting and Data System (PI-RADS) category 3 (equivocal) lesions prospectively identified on multiparametric prostate MRI and to identify risk factors (RFs) for CSC that may aid in decision making. MATERIALS AND METHODS Between January 2015 and July 2016, a total of 977 consecutively seen men underwent multiparametric prostate MRI, and 342 underwent MRI-ultrasound (US) fusion targeted biopsy. A total of 474 lesions were retrospectively reviewed, and 111 were scored as PI-RADS category 3 and were visualized using a 3-T MRI scanner. Multiparametric prostate MR images were prospectively interpreted by body subspecialty radiologists trained to use PI-RADS version 2. CSC was defined as a Gleason score of at least 7 on targeted biopsy. A multivariate logistic regression model was constructed to identify the RFs associated with CSC. RESULTS Of the 111 PI-RADS category 3 lesions, 81 (73.0%) were benign, 11 (9.9%) were clinically insignificant (Gleason score, 6), and 19 (17.1%) were clinically significant. On multivariate analysis, three RFs were identified as significant predictors of CSC: older patient age (odds ratio [OR], 1.13; p = 0.002), smaller prostate volume (OR, 0.94; p = 0.008), and abnormal digital rectal examination (DRE) findings (OR, 3.92; p = 0.03). For PI-RADS category 3 lesions associated with zero, one, two, or three RFs, the risk of CSC was 4%, 16%, 62%, and 100%, respectively. PI-RADS category 3 lesions for which two or more RFs were noted (e.g., age ≥ 70 years, gland size ≤ 36 mL, or abnormal DRE findings) had a CSC detection rate of 67% with a sensitivity of 53%, a specificity of 95%, a positive predictive value of 67%, and a negative predictive value of 91%. CONCLUSION Incorporating clinical parameters into risk stratification algorithms may improve the ability to detect clinically significant disease among PI-RADS category 3 lesions and may aid in the decision to perform biopsy.

Differences in Funding Sources of Phase III Oncology Clinical Trials by Treatment Modality and Cancer Type.

Objectives: Given the limited resources available to conduct clinical trials, it is important to understand how trial sponsorship differs among different therapeutic modalities and cancer types and to consider the ramifications of these differences. Methods: We searched clinicaltrials.gov for a cross-sectional register of active, phase III, randomized controlled trials (RCTs) studying treatment-related endpoints such as survival and recurrence for the 24 most prevalent malignancies. We classified the RCTs into 7 categories of therapeutic modality: (1) chemotherapy/other cancer-directed drugs, (2) targeted therapy, (3) surgery, (4) radiation therapy (RT), (5) RT with other modalities, (6) multimodality therapy without RT, and (7) other. RCTs were categorized as being funded by one or more of the following groups: (1) government, (2) hospital/university, (3) industry, and (4) other. &khgr;2 analysis was performed to detect differences in funding source distribution between modalities and cancer types. Results: The percentage of multimodality trials (5%) and radiation RCTs (4%) funded by industry was less than that for chemotherapy (32%, P<0.01) or targeted therapy (48%, P<0.01). Trials studying targeted therapy were less likely to have hospital/university funding than any of the other modalities (P<0.01 in each comparison). Trials of chemotherapy were more likely to be funded by industry if they also studied targeted therapy (P<0.01). Conclusion: RCTs studying targeted therapies are more likely to be funded by industry than trials studying multimodality therapy or radiation. The impact of industry funding versus institutional or governmental sources of funding for cancer research is unclear and requires further study.

Annual Facility Treatment Volume and Patient Survival for Mycosis Fungoides and Sézary Syndrome

Background: Management of mycosis fungoides and Sézary syndrome (MF/SS) is complex, and randomized evidence to guide treatment is lacking. The institutional treatment volumes for MF/SS might vary widely nationally and influence patient survival. Patients and Methods: Using the National Cancer Database, we identified patients with a diagnosis of MF/SS from 2004 to 2011 in the United States who had received treatment at a reporting facility. The patients were grouped into quintiles according to their treatment facilitys average annual treatment volume (ATV). The characteristics associated with ATV were identified and compared using χ2 tests. Overall survival (OS) was compared among the ATV quintiles using the Kaplan‐Meier method with log‐rank tests and multivariable Cox regression with hazard ratios (HRs). OS was also analyzed using the annual patient volume as a continuous variable. Results: A total of 2205 patients treated at 374 facilities were included for analysis. The ATV quintile cutoffs were 1, 3, 6, and 9 patients. With a median follow‐up period of 59 months, the 5‐year estimated OS survival increased with ATV from 56.7% in the lowest quintile (≤ 1 patient annually) to 83.8% in the highest quintile (> 9 patients annually; P < .001). On multivariable analysis, greater ATV was associated with improved survival when analyzed as a continuous variable (HR, 0.96 per patient per year; 95% confidence interval, 0.94‐0.98; P < .001) and when comparing the highest quintile to the lowest quintile (HR, 0.46; 95% confidence interval, 0.39‐0.55). Conclusion: The present national database analysis demonstrated that higher facility ATV is associated with improved OS for patients with MF/SS. Further study is needed to determine the underlying reasons for improved survival with higher facility ATV. &NA; Mycosis fungoides and Sézary syndrome (MF/SS) management is complex, with heterogeneous treatments. We analyzed a national registry of > 2200 MF/SS patients divided into cohorts by the annual treatment volume quintile of their treatment facility. A greater facility annual treatment volume was associated with improved survival for patients with MF/SS.

Pretreatment Identification of Head and Neck Cancer Nodal Metastasis and Extranodal Extension Using Deep Learning Neural Networks

Identification of nodal metastasis and tumor extranodal extension (ENE) is crucial for head and neck cancer management, but currently only can be diagnosed via postoperative pathology. Pretreatment, radiographic identification of ENE, in particular, has proven extremely difficult for clinicians, but would be greatly influential in guiding patient management. Here, we show that a deep learning convolutional neural network can be trained to identify nodal metastasis and ENE with excellent performance that surpasses what human clinicians have historically achieved. We trained a 3-dimensional convolutional neural network using a dataset of 2,875 CT-segmented lymph node samples with correlating pathology labels, cross-validated and fine-tuned on 124 samples, and conducted testing on a blinded test set of 131 samples. On the blinded test set, the model predicted ENE and nodal metastasis each with area under the receiver operating characteristic curve (AUC) of 0.91 (95%CI: 0.85–0.97). The model has the potential for use as a clinical decision-making tool to help guide head and neck cancer patient management.

MRI-Ultrasound Fusion Targeted Biopsy of Prostate Imaging Reporting and Data System Version 2 Category 5 Lesions Found False-Positive at Multiparametric Prostate MRI

OBJECTIVE The purpose of this study was to determine imaging and clinical features associated with Prostate Imaging Reporting and Data System (PI-RADS) category 5 lesions identified prospectively at multiparametric MRI (mpMRI) that were found benign at MRI-ultrasound fusion targeted biopsy. MATERIALS AND METHODS Between January 2015 and July 2016, 325 men underwent prostate mpMRI followed by MRI-ultrasound fusion targeted biopsy of 420 lesions prospectively identified and assessed with PI-RADS version 2. The frequency of clinically significant prostate cancer (defined as Gleason score ≥ 7) among PI-RADS 5 lesions was determined. Lesions with benign pathologic results were retrospectively reassessed by three abdominal radiologists and categorized as concordant or discordant between mpMRI and biopsy results. Multivariate logistic regression was used to identify factors associated with benign disease. Bonferroni correction was used. RESULTS Of the 98 PI-RADS 5 lesions identified in 89 patients, 18% (18/98) were benign, 10% (10/98) were Gleason 6 disease, and 71% (70/98) were clinically significant prostate cancer. Factors associated with benign disease at multivariate analysis were lower prostate-specific antigen density (odds ratio [OR], 0.88; p < 0.001) and apex (OR, 3.54; p = 0.001) or base (OR, 7.11; p = 0.012) location. On secondary review of the 18 lesions with benign pathologic results, 39% (7/18) were scored as benign prostatic hyperplasia nodules, 28% (5/18) as inflammatory changes, 5% (1/18) as normal anatomic structures, and 28% (5/18) as discordant with imaging findings. CONCLUSION PI-RADS 5 lesions identified during routine clinical interpretation are associated with a high risk of clinically significant prostate cancer. A benign pathologic result was significantly correlated with lower prostate-specific antigen density and apex or base location and most commonly attributed to a benign prostatic hyperplasia nodule. Integration of these clinical features may improve the interpretation of high-risk lesions identified with mpMRI.