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JAMA Network Open Aug 2019Hospital funding reforms for prostate cancer surgery may have altered management of localized prostate cancer in the province of Ontario, Canada.
IMPORTANCE
Hospital funding reforms for prostate cancer surgery may have altered management of localized prostate cancer in the province of Ontario, Canada.
OBJECTIVE
To determine whether changes in hospital funding policy aimed at improving health care quality and value were associated with changes in the management of localized prostate cancer or the characteristics of patients receiving radical prostatectomy (RP) for localized prostate cancer.
DESIGN, SETTING, AND PARTICIPANTS
This population-based, interrupted time series study used linked population-based administrative data regarding adults in Ontario with incidental localized prostate cancer and those who underwent RP for localized prostate cancer. Patients who underwent RP were compared with patients who underwent surgical procedures for localized renal cell carcinoma, which was not included in the policy change but was subjected to similar secular trends and potential confounders. Monthly outcomes were analyzed using interventional autoregressive integrated moving average models. Data were collected from January 2011 to November 2017 and analyzed in January 2019.
EXPOSURES
Funding policy change in April 2015 from flexible block funding for all hospital-based care to prespecified payment amounts per procedure for treatment of localized prostate cancer, coupled with the dissemination of a diagnosis-specific handbook outlining best practices.
MAIN OUTCOMES AND MEASURES
Initial management (RP vs radiation therapy vs active surveillance) and tumor risk profiles per management strategy among incident cases of localized prostate cancer. Additional outcomes were case volume, mean length of stay, proportion of patients returning to hospital or emergency department within 30 days, proportion of patients older than 65 years, mean Charlson Comorbidity Index, and proportion of minimally invasive surgical procedures among patients undergoing RP for localized prostate cancer.
RESULTS
A total of 33 128 patients with incident localized prostate cancer (median [interquartile range (IQR)] age, 67 [61-73] years; median [IQR] cases per monthly observation interval, 466 [420-516]), 17 159 patients who received radical prostatectomy (median [IQR] age, 63 [58-68] years; median [IQR] cases per monthly observation interval, 209 [183-225]), and 5762 individuals who underwent surgery for renal cell carcinoma (median [IQR] age, 62 [53-70] years; median [IQR] cases per monthly observation interval, 71 [61-77]) were identified. By the end of the observation period, radical prostatectomy and radiation therapy were used in comparable proportions (30.3% and 28.9%, respectively) and included only a small fraction of low-risk patients (6.4% and 2.9%, respectively). No statistically significant association of the funding policy change with most outcomes was found.
CONCLUSIONS AND RELEVANCE
The implementation of funding reform for hospitals offering RP was not associated with changes in the management of localized prostate cancer, although it may have encouraged more appropriate selection of patients for RP. Mostly preexisting trends toward guideline-conforming practice were observed. Co-occurring policy changes and/or guideline revisions may have weakened signals from the policy change.
Topics: Aged; Carcinoma, Renal Cell; Case-Control Studies; Economics, Hospital; Humans; Interrupted Time Series Analysis; Legislation, Hospital; Length of Stay; Male; Middle Aged; Ontario; Patient Selection; Prostatectomy; Prostatic Neoplasms; Radiotherapy; Retrospective Studies; Watchful Waiting
PubMed: 31469400
DOI: 10.1001/jamanetworkopen.2019.10505 -
Frontiers in Endocrinology 2023This study aims to compare the outcomes of active surveillance (AS) in low-risk papillary thyroid carcinoma (PTC) patients with different tumor sizes and lymph node...
BACKGROUND
This study aims to compare the outcomes of active surveillance (AS) in low-risk papillary thyroid carcinoma (PTC) patients with different tumor sizes and lymph node metastasis status, in order to establish appropriate management strategies. By analyzing these results, this study provides valuable insights for the effective management of such patients, addressing the issues and challenges associated with AS in practical clinical practice.
METHODS
The study utilized the SEER database supported by the National Cancer Institute of the United States, extracting data of PTC diagnosed between 2000 and 2015. Statistical analyses were conducted using inverse probability weighting (IPTW) and propensity score matching (PSM), including Kaplan-Meier survival curves and Cox regression models, to evaluate the impact of different tumor sizes and lymph node metastasis status on thyroid cancer-specific survival (TCSS).
RESULTS
A total of 57,000 PTC patients were included, with most covariates having standardized mean differences below 10% after IPTW and PSM adjustments. The TCSS of PTC with a diameter smaller than 13mm is significantly better than that of tumors with a diameter larger than 13mm, regardless of the presence of lymph node metastasis. Among PTC cases with a diameter smaller than 13mm, the TCSS of patients is similar, regardless of the presence of lymph node metastasis. However, in PTC cases with a diameter larger than 13mm, the presence of lateral neck lymph node metastasis (N1b stage) significantly impacts the TCSS, although the absolute impact on TCSS rate is minimal.
CONCLUSION
The treatment strategy of AS is safe for patients with T1a stage papillary thyroid microcarcinoma (PTMC). However, for patients with T1b stage, if the tumor diameter exceeds 13mm or there is lymph node metastasis in the lateral neck region, the TCSS will be significantly affected. Nevertheless, the absolute impact on survival is relatively small.
Topics: Humans; Thyroid Cancer, Papillary; Lymphatic Metastasis; Watchful Waiting; Thyroid Neoplasms
PubMed: 37745712
DOI: 10.3389/fendo.2023.1235006 -
Cancer Treatment Reviews Mar 2020Various methods categorize tumour response after neoadjuvant therapy, including down-staging and tumour regression grading. Response categories allow comparison of... (Review)
Review
Various methods categorize tumour response after neoadjuvant therapy, including down-staging and tumour regression grading. Response categories allow comparison of different treatments within clinical trials and predict outcome. A reproducible response categorization could identify subgroups with high or low risk for the most appropriate subsequent treatments, like watch and wait. Lack of standardization and interpretation difficulties currently limit the usability of these approaches. In this review we describe these difficulties for the evaluation of chemoradiation in rectal cancer. An alternative approach of tumour response is based on patterns of residual disease, including fragmentation. We summarise the evidence behind this alternative method of response categorisation, which explains a number of very relevant clinical discrepancies. These issues include differences between downstaging and tumour regression, high local regrowth in advanced tumours during watchful waiting procedures, the importance of resection margins, the limited value of post-treatment biopsies and the relatively poor outcome of patients with a near complete pathological response. Recognition of these patterns of response can allow meaningful development of novel biomarkers in the future.
Topics: Humans; Neoadjuvant Therapy; Neoplasm Staging; Neoplasm, Residual; Rectal Neoplasms; Treatment Outcome; Watchful Waiting
PubMed: 32000055
DOI: 10.1016/j.ctrv.2020.101964 -
Ugeskrift For Laeger May 2018In male patients with asymptomatic or minimally symptomatic ventral and inguinal hernias, a watchful waiting strategy should be considered. Even though one third to two... (Review)
Review
In male patients with asymptomatic or minimally symptomatic ventral and inguinal hernias, a watchful waiting strategy should be considered. Even though one third to two thirds of these patients will eventually undergo hernia repair, they may still benefit from a watchful waiting strategy, as hernia repair is associated with a range of complications, e.g. wound infection, haematoma, seroma, fistulas and chronic pain. Delay of hernia repair in these patients is not associated with any significant increase in morbidity or mortality, and the risk of incarceration is very low.
Topics: Algorithms; Female; Hernia, Inguinal; Hernia, Ventral; Herniorrhaphy; Humans; Incisional Hernia; Male; Watchful Waiting
PubMed: 29808816
DOI: No ID Found -
Cleveland Clinic Journal of Medicine Apr 2016Asymptomatic but hemodynamically severe aortic stenosis often poses a dilemma: should the aortic valve be replaced, or is watchful waiting acceptable? Patients with this... (Review)
Review
Asymptomatic but hemodynamically severe aortic stenosis often poses a dilemma: should the aortic valve be replaced, or is watchful waiting acceptable? Patients with this condition are a diverse group with varying prognoses. Here, we review the guidelines for valve replacement in this situation and highlight the variables useful in establishing which patients should be considered for early intervention even if they have no symptoms.
Topics: Aortic Valve; Aortic Valve Stenosis; Echocardiography; Heart Valve Prosthesis Implantation; Humans; Patient Selection; Practice Guidelines as Topic; Watchful Waiting
PubMed: 27055201
DOI: 10.3949/ccjm.83a.15069 -
The British Journal of General Practice... May 2018Safety netting is an important diagnostic strategy for patients presenting to primary care with potential (low-risk) cancer symptoms. Typically, this involves asking...
BACKGROUND
Safety netting is an important diagnostic strategy for patients presenting to primary care with potential (low-risk) cancer symptoms. Typically, this involves asking patients to return if symptoms persist. However, this relies on patients re-appraising their symptoms and making follow-up appointments, which could contribute to delays in diagnosis. Text messaging is increasingly used in primary care to communicate with patients, and could be used to improve safety netting.
AIM
To explore the acceptability and feasibility of using text messages to safety net patients presenting with low-risk cancer symptoms in GP primary care (txt-netting).
DESIGN AND SETTING
Qualitative focus group and interview study with London-based GPs.
METHOD
Participants were identified using convenience sampling methods. Five focus groups and two interviews were conducted with 22 GPs between August and December 2016. Sessions were audiorecorded, transcribed verbatim, and analysed using thematic analysis.
RESULTS
GPs were amenable to the concept of using text messages in cancer safety netting, identifying it as an additional tool that could help manage patients and promote symptom awareness. There was wide variation in GP preferences for text message content, and a number of important potential barriers to txt-netting were identified. Concerns were raised about the difficulties of conveying complex safety netting advice within the constraints of a text message, and about confidentiality, widening inequalities, and workload implications.
CONCLUSION
Text messages were perceived to be an acceptable potential strategy for safety netting patients with low-risk cancer symptoms. Further work is needed to ensure it is cost-effective, user friendly, confidential, and acceptable to patients.
Topics: Attitude of Health Personnel; Feasibility Studies; Focus Groups; General Practice; General Practitioners; Humans; Patient Safety; Patient Satisfaction; Physician-Patient Relations; Practice Patterns, Physicians'; Precancerous Conditions; Qualitative Research; Text Messaging; United Kingdom; Watchful Waiting
PubMed: 29581127
DOI: 10.3399/bjgp18X695741 -
Diseases of the Colon and Rectum Jan 2017Radical surgery is associated with significant perioperative mortality in elderly and comorbid populations. Emerging data suggest for patients with a clinical complete...
BACKGROUND
Radical surgery is associated with significant perioperative mortality in elderly and comorbid populations. Emerging data suggest for patients with a clinical complete response after neoadjuvant chemoradiotherapy that a watch-and-wait approach may provide equivalent survival and oncological outcomes.
OBJECTIVE
The purpose of this study was to compare the cost-effectiveness of watch and wait and radical surgery for patients with rectal cancer after a clinical complete response following chemoradiotherapy.
DESIGN
Decision analytical modeling and a Markov simulation were used to model long-term costs, quality-adjusted life-years, and cost-effectiveness after watch and wait and radical surgery. Sensitivity analysis was used to investigate the effect of uncertainty in model parameters.
SETTINGS
A third-party payer perspective was adopted.
PATIENTS
Patients included in the study were a 60-year-old male cohort with no comorbidities, 80-year-old male cohorts with no comorbidities, and 80-year-old male cohorts with significant comorbidities.
INTERVENTIONS
Radical surgery and watch-and-wait approaches were studied.
MAIN OUTCOME MEASURES
Incremental cost, effectiveness, and cost-effectiveness ratio over the entire lifetime of the hypothetical patient cohorts were measured.
RESULTS
Watch and wait was more effective (60-year-old male cohort with no comorbidities = 0.63 quality-adjusted life-years (95% CI, 2.48-3.65 quality-adjusted life-years); 80-year-old male cohort with no comorbidities = 0.56 quality-adjusted life-years (95% CI, 0.52-1.59 quality-adjusted life-years); 80-year-old male cohort with significant comorbidities = 0.72 quality-adjusted life-years (95% CI, 0.34-1.76 quality-adjusted life-years)) and less costly (60-year-old male cohort with no comorbidities = $11,332.35 (95% CI, $668.50-$23,970.20); 80-year-old male cohort with no comorbidities = $8783.93 (95% CI, $2504.26-$21,900.66); 80-year-old male cohort with significant comorbidities = $10,206.01 (95% CI, $2762.014-$24,135.31)) independent of patient cohort age and comorbidity. Consequently, watch and wait was more cost-effective with a high degree of certainty (range, 69.6%-89.2%) at a threshold of $50,000/quality-adjusted life-year.
LIMITATIONS
Long-term outcomes were derived from modeled cohorts. Analysis was performed for a United Kingdom third-party payer perspective, limiting generalizability to other healthcare contexts.
CONCLUSIONS
Watch and wait is likely to be cost-effective compared with radical surgery. These findings strongly support the discussion of organ-preserving strategies with suitable patients.
Topics: Aged, 80 and over; Chemoradiotherapy; Cohort Studies; Comorbidity; Cost-Benefit Analysis; Decision Support Techniques; Digestive System Surgical Procedures; Humans; Insurance, Health, Reimbursement; Male; Middle Aged; Neoadjuvant Therapy; Neoplasm, Residual; Quality-Adjusted Life Years; Rectal Neoplasms; Remission Induction; United Kingdom; Watchful Waiting
PubMed: 27926555
DOI: 10.1097/DCR.0000000000000708 -
Human Reproduction (Oxford, England) Jul 2019Which couples with unexplained subfertility can expect increased chances of ongoing pregnancy with IVF compared to expectant management?
STUDY QUESTION
Which couples with unexplained subfertility can expect increased chances of ongoing pregnancy with IVF compared to expectant management?
SUMMARY ANSWER
For couples in which the woman is under 40 years of age, IVF is associated with higher chances of conception than expectant management.
WHAT IS KNOWN ALREADY
The clinical indications for IVF have expanded over time from bilateral tubal blockage to include unexplained subfertility in which there is no identifiable barrier to conception. Yet, there is little evidence from randomized controlled trials that IVF is effective in these couples.
STUDY DESIGN, SIZE, DURATION
We compared outcomes in British couples with unexplained subfertility undergoing IVF (n = 40 921) from registry data to couples with the same type of subfertility on expectant management. Those couples on expectant management (defined as no intervention aside from the advice to have intercourse) comprised a prospective nation-wide Dutch cohort (n = 4875) and a retrospective regional cohort from Aberdeen, Scotland (n = 975). We excluded couples who had tried for <1 year to conceive and also those with anovulation, uni- or bilateral tubal occlusion, mild or severe endometriosis or male subfertility i.e. impaired semen quality according to World Health Organization criteria.
PARTICIPANTS/MATERIALS, SETTING, METHODS
We matched couples who received IVF and couples on expectant management based on their characteristics to control for confounding. We fitted a Cox proportional hazards model including patient characteristics, IVF treatment and their interactions to estimate the individualized chance of conception over 1 year-either following IVF or expectant management for all combinations of patient characteristics. The endpoint was conception leading to ongoing pregnancy, defined as a foetus reaching a gestational age of at least 12 weeks.
MAIN RESULTS AND THE ROLE OF CHANCE
The adjusted 1-year chance of conception was 47.9% (95% CI: 45.0-50.9) after IVF and 26.1% (95% CI: 24.2-28.0) after expectant management. The absolute difference in the average adjusted 1-year chances of conception was 21.8% (95%CI: 18.3-25.3) in favour of IVF. The effectiveness of IVF was influenced by female age, duration of subfertility and previous pregnancy. IVF was effective in women under 40 years, but the 1-year chance of an IVF conception declined sharply in women over 34 years. In contrast, in woman over 40 years of age, IVF was less effective, with an absolute difference in chance compared to expectant management of 10% or lower. Regardless of female age, IVF was also less effective in couples with a short period of secondary subfertility (1 year) who had chances of natural conception of 30% or above.
LIMITATIONS, REASONS FOR CAUTION
The 1-year chances of conception were based on three cohorts with different sampling mechanisms. Despite adjustment for the three most important prognostic patient characteristics, namely female age, duration of subfertility and primary or secondary subfertility, our estimates might not be free from residual confounding.
WIDER IMPLICATIONS OF THE FINDINGS
IVF should be used selectively based on judgements on gain compared to continuing expectant management for a given couple. Our results can be used by clinicians to counsel couples with unexplained subfertility, to inform their expectations and facilitate evidence-based, shared decision making.
STUDY FUNDING/COMPETING INTEREST(S)
This work was supported by Tenovus Scotland [grant G17.04]. Travel for RvE was supported by the Amsterdam Reproduction & Development Research Group [grant V.000296]. SB reports acting as editor-in-chief of HROpen. Other authors have no conflicts.
Topics: Adult; Female; Fertilization in Vitro; Humans; Infertility; Maternal Age; Pregnancy; Pregnancy Rate; Retrospective Studies; Watchful Waiting
PubMed: 31194864
DOI: 10.1093/humrep/dez072 -
BMC Cancer Mar 2022Rectal Cancer is a common malignancy. The current treatment approach for patients with locally advanced rectal cancer involves neoadjuvant chemoradiotherapy followed by...
BACKGROUND
Rectal Cancer is a common malignancy. The current treatment approach for patients with locally advanced rectal cancer involves neoadjuvant chemoradiotherapy followed by surgical resection of the rectum. The resection can lead to complications and long-term consequences. A clinical complete response is observed in some patients after chemoradiotherapy. A number of recent studies have shown that patients can be observed safely after completing chemoradiotherapy (without surgery), provided clinical complete response has been achieved. In this approach, resection is reserved for cases of regrowth. This is called the watch and wait approach. This approach potentially avoids unnecessary surgical resection of the rectum and the resulting complications. In this study, we will prospectively investigate this approach.
METHODS
Adult patients with a diagnosis of rectal cancer planned to receive neoadjuvant long course chemoradiotherapy (± subsequent combination chemotherapy) will be consented into the study prior to commencing treatment. After completing the chemoradiotherapy (± subsequent combination chemotherapy), based on the clinical response, subjects will be allocated to one of the following arms: subjects who achieved a clinical complete response will be allocated to the watch and wait arm and others to the standard management arm (which includes resection). The aim of the study is to determine the rate of local failure and other safety and efficacy outcomes in the watch and wait arm. Patient reported outcome measures and the use of biomarkers as part of the clinical monitoring will be studied in both arms of the study.
DISCUSSION
This study will prospectively investigate the safety of the watch and wait approach. We will investigate predictive biomarkers (molecular biomarkers and imaging biomarkers) and patient reported outcome measures in the study population and the cost effectiveness of the watch and wait approach. This study will also help evaluate a defined monitoring schedule for patients managed with the watch and wait approach. This protocol covers the first two years of follow up, we are planning a subsequent study which covers year 3-5 follow up for the study population.
TRIAL REGISTRATION
Name of the registry: Australia and New Zealand Clinical Trials Registry (ANZCTR).
TRIAL REGISTRATION NUMBER
Trial ID: ACTRN12619000207112 Registered 13 February 2019, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376810.
Topics: Adult; Biomarkers, Tumor; Female; Humans; Longitudinal Studies; Male; Middle Aged; Neoadjuvant Therapy; Prospective Studies; Rectal Neoplasms; Survival Rate; Treatment Outcome; Watchful Waiting
PubMed: 35232427
DOI: 10.1186/s12885-022-09304-x -
Journal of Medical Entomology Sep 2022The invasive Asian longhorned tick, Haemaphysalis longicornis, has rapidly spread across the northeastern United States and is associated with pathogens of public health...
The invasive Asian longhorned tick, Haemaphysalis longicornis, has rapidly spread across the northeastern United States and is associated with pathogens of public health and veterinary concern. Despite its importance in pathogen dynamics, H. longicornis blood-feeding behavior in nature, specifically the likelihood of interrupted feeding, remains poorly documented. Here, we report the recovery of partially engorged, questing H. longicornis from active tick surveillance in Pennsylvania. Significantly more engorged H. longicornis nymphs (1.54%) and adults (3.07%) were recovered compared to Ixodes scapularis nymphs (0.22%) and adults (zero). Mean Scutal Index difference between unengorged and engorged nymph specimens was 0.65 and 0.42 for I. scapularis and H. longicornis, respectively, suggesting the questing, engorged H. longicornis also engorged to a comparatively lesser extent. These data are among the first to document recovery of engorged, host-seeking H. longicornis ticks and provide initial evidence for interrupted feeding and repeated successful questing events bearing implications for pathogen transmission and warranting consideration in vector dynamics models.
Topics: Animals; Disease Vectors; Ixodes; Ixodidae; Nymph; Watchful Waiting
PubMed: 35851919
DOI: 10.1093/jme/tjac099