Differences In Treatment Recommendations Research Articles

All Else Being Equal: Examining Treatment Bias and Stereotypes Based on Patient Ethnicity and Socioeconomic Status With In-Hospital Cardiac Arrest Clinical Vignettes

BackgroundResearch on ethnic and socioeconomic treatment differences following in-hospital cardiac arrest (IHCA) largely draws on register data. Due to the correlational nature of such data, it cannot be concluded whether detected differences reflect treatment bias/discrimination – whereby otherwise identical patients are treated differently solely due to sociodemographic factors. To be able to establish discrimination, experimental research is needed. ObjectiveThe primary aim of this experimental study was to examine whether simulated IHCA patients receive different treatment recommendations based on ethnicity and socioeconomic status (SES), holding all other factors (e.g., health status) constant. Another aim was to examine health care professionals’ (HCP) stereotypical beliefs about these groups. MethodsHCP (N = 235) working in acute care made anonymous treatment recommendations while reading IHCA clinical vignettes wherein the patient's ethnicity (Swedish vs. Middle Eastern) and SES had been manipulated. Afterwards they estimated to what extent hospital staff associate these patient groups with certain traits (stereotypes). ResultsNo significant differences in treatment recommendations for Swedish versus Middle Eastern or high versus low SES patients were found. Reported stereotypes about Middle Eastern patients were uniformly negative. SES-related stereotypes, however, were mixed. High SES patients were believed to be more competent (e.g., respected), but less warm (e.g., friendly) than low SES patients. ConclusionsSwedish HCP do not seem to discriminate against patients with Middle Eastern or low SES backgrounds when recommending treatment for simulated IHCA cases, despite the existence of negative stereotypes about these groups. Implications for health care equality and quality are discussed.

Differences in clinical presentations of patients seeking care for treatment-resistant depression across sexual orientations and gender identities.

Sexual and/or gender minority (SGM) individuals experience higher rates and greater severity of depressive disorders than non-SGM persons. SGM individuals are more likely than non-SGM individuals to seek mental health treatment and to present to treatment with unique characteristics that should be accounted for when considering treatment recommendations. Patients seeking care for treatment-resistant depression (TRD) are offered a variety of evidence-based interventions ranging in modality and invasiveness (eg, psychotherapy and neuromodulation). The current study used data from a TRD clinical research program to examine whether SGM (N = 52) and non-SGM (N = 202) patients differed in their clinical presentations and the treatment recommendations offered to them. We found that SGM patients were younger, had a more severe history of childhood trauma, and reported greater current suicidality than non-SGM patients. There were no significant differences in treatment recommendations between groups. This study adds to nascent literature investigating clinical characteristics of SGM populations seeking mental health care and provides foundational evidence for the unique treatment considerations necessary for SGM individuals seeking treatment for TRD. Research into whether treatment outcomes differ for SGM and non-SGM individuals with TRD is encouraged, given clinical differences in trauma history and suicidality.

Looking Back: International Practice Patterns in Breast Radiation Oncology From a Case-Based Survey Across 54 Countries During the First Surge of the COVID-19 Pandemic.

The COVID-19 pandemic has profoundly affected cancer care worldwide, including radiation therapy (RT) for breast cancer (BC), because of risk-based resource allocation. We report the evolution of international breast RT practices during the beginning of the pandemic, focusing on differences in treatment recommendations between countries. Between July and November 2020, a 58-question survey was distributed to radiation oncologists (ROs) through international professional societies. Changes in RT decision making during the first surge of the pandemic were evaluated across six hypothetical scenarios, including the management of ductal carcinoma in situ (DCIS), early-stage, locally advanced, and metastatic BC. The significance of changes in responses before and during the pandemic was examined using chi-square and McNemar-Bowker tests. One thousand one hundred three ROs from 54 countries completed the survey. Incomplete responses (254) were excluded from the analysis. Most respondents were from the United States (285), Japan (117), Italy (63), Canada (58), and Brazil (56). Twenty-one percent (230) of respondents reported treating at least one patient with BC who was COVID-19-positive. Approximately 60% of respondents reported no change in treatment recommendation during the pandemic, except for patients with metastatic disease, for which 57.7% (636/1,103; P < .0005) changed their palliative practice. Among respondents who noted a change in their recommendation during the first surge of the pandemic, omitting, delaying, and adopting short-course RT were the most frequent changes, with most transitioning to moderate hypofractionation for DCIS and early-stage BC. Early in the COVID-19 pandemic, significant changes in global RT practice patterns for BC were introduced. The impact of published results from the FAST FORWARD trial supporting ultrahypofractionation likely confounded the interpretation of the pandemic's independent influence on RT delivery.

Multidisciplinary prostate cancer consultation at home: Does the virtual visit platform adversely affect care for elderly patients or impact treatment recommendations?

1521 Background: Amidst the COVID-19 pandemic, Hartford Healthcare (HHC) implemented a multidisciplinary virtual visit prostate cancer clinic (MDVV) to allow patients to receive cancer consultations at home. This clinic has shown significant logistical advantages for provision of coordinated cancer care. To evaluate concerns regarding usability of the telehealth platform for elderly patients, and the absence of in person physical exam at initial consult, we evaluated the MDVV in terms of patient satisfaction based on age, as well as for differences in treatment recommendations after patients were seen in-person at a pre-treatment follow up visit. Methods: Patients with newly diagnosed or progressive prostate cancer were offered a MDVV consultation. Those who assented had sequential virtual consultations with a urologic surgeon, a radiation oncologist, and a medical oncologist, followed by a group conference with all 3 specialists, and were guided through the visit by a nurse navigator. Patients then completed a 7 item satisfaction survey using a 5 point Likert scale evaluating their perception of the efficacy, efficiency, coordination, and overall value of the clinic. Responses were stratified by age group and compared. Chart review determined the impact of subsequent in person office visit on treatment recommendations, and the proportion of patients who underwent staging imaging according to NCCN guidelines. This was compared with a cohort of consecutive patients who completed traditional consults with two high volume prostate cancer surgeons immediately before the pandemic. Results: A total of 161 patients with newly diagnosed or progressive prostate cancer received a MDVV consultation from August 2020 – February 2023. Patient age ranged from 47-84 years (9% &lt; 60 yrs, 52% 60-70 yrs, 34% 70-80 yrs, 5% &gt;80 yrs). The median score for patient satisfaction on all 7 domains was 1 (strongly agree), and did not differ between age groups. There were no instances of a change in treatment recommendation after follow up in person office visit. While 100% of the MDVV cohort received multidisciplinary consultation before treatment, only 14/50 traditional cohort patients (28%) ultimately received the same (p&lt;.001). 100% of MDVV patients underwent imaging according to NCCN guidelines, compared with 33/50 (66%) of traditional patients (p&lt;.001). Conclusions: A virtual format for a multidisciplinary prostate cancer clinic is a logistically advantageous, effective means of offering in-home consultation to prostate cancer patients, leading to high patient satisfaction, regardless of age. The absence of in-person physical examination at initial consultation did not ultimately impact treatment recommendations. This format also improved access to multidisciplinary consultation and increased adherence to imaging guidelines.

The Impact of Social Determinants of Health on Vestibular Schwannoma Management: A Single Institution Review.

To evaluate social determinants of health and their effect on the management of vestibular schwannoma (VS). Retrospective chart review. Tertiary referral center. Patients >18 years old with sporadic VS newly diagnosed between January 1, 2010, and December 31, 2020. Magnetic resonance imaging; audiogram; treatment recommendations. Differences in treatment recommendations for patients based on their social determinants of health, including race, ethnicity, and socioeconomic status. A total of 811 patients were included in analysis. Patients with a higher area deprivation index (ADI) presented with larger tumors. A higher ADI was associated with a higher likelihood of recommending radiation (or the option of surgery or radiation) compared with a recommendation of surgery alone. Tumor grade and patient age were significantly associated with treatment recommendation. Older age was associated with a recommendation of observation alone or a recommendation of radiation. Higher tumor grade was associated with a recommendation of surgery. There was a trend for higher hearing class to be associated with a recommendation of surgery, but this did not reach statistical significance. Race, ethnicity, and gender were not significantly associated with treatment recommendation. Patients with higher levels of disadvantage presented with higher tumor grade, suggesting that access to care influences diagnosis. Factors including age, ADI, and tumor grade were associated with treatment recommendation.

Shared decision making in recurrent ovarian cancer: Implementation of patient decision aids across three departments of oncology in Denmark.

Patients with relapsed ovarian cancer are offered multiple treatment options. To match treatment with the individual patient's life situation and preferences, healthcare professionals can apply shared decision making (SDM) including patient decision aids (PtDAs).This study aimed to evaluate the implementation of two different PtDAs in consultations with patients suffering from relapsed ovarian cancer. We analyzed the following data before and after implementation of the PtDAs: 1) observed SDM using the OPTION instrument, 2) physician treatment recommendations, and 3) patients' and physicians' evaluations of SDM in consultations using the CollaboRATE, SDM-Q-9, and SDM-Q-Doc. Significant improvement in observed SDM was found after the implementation (p = 0.002). Improvement of SDM was detected in consultations conducted by physicians reporting more than two hours of SDM-training (p < 0.001), but not when physicians reported less than two hours of SDM-training.No before/after differences in treatment recommendations and in patients' and physicians' evaluations were found. Implementation of PtDAs improved the level of observed SDM. Training of physicians in SDM is necessary for improved SDM practice. Discussing oncological treatment options with the use of PtDAs is not standard practice in Denmark. The present study is one of the first Danish studies focusing on how to implement SDM and PtDAs in oncological consultations.

Variations in Radioiodine Therapy in Europe: Decision-Making after Total Thyroidectomy

The role of radioiodine therapy (RIT) (used as ablation therapy or adjuvant therapy) following total thyroidectomy for differentiated thyroid cancer (DTC) changed. Major revisions of the American Thyroid Association (ATA) Guidelines in 2015 resulted in significant differences in treatment recommendations in comparison to the European Association of Nuclear Medicine (EANM) 2008 guidelines. Recently, we presented the effects on daily practice for RIT among Swiss Nuclear Medicine centres. We now performed a study at the European level and hypothesized that there is also considerable variability among European experts. We performed a decision-tree-based analysis of management strategies from all members of the EANM thyroid committee to map current practice among experts. We collected data on whether or not RIT is administered, on which criteria these decisions are based and collected details on treatment activities and patient preparation. Our study shows discrepancies for low-risk DTC, where “follow-up only” is recommended by some experts, while RIT with significant doses is used by other experts. E.g., for pT1b tumours without evidence of metastases, the level of agreement for the use of RIT is as low as 50%. If RIT is administered, activities of I-131 range from 1.1 GBq to 3.0 GBq. In other constellations (e.g., pT1a), experts diverge from current clinical guidelines as up to 75% administer RIT in certain cases. For intermediate and high-risk patients, RIT is generally recommended. However, dosing and treatment preparation (rhTSH vs. thyroid hormone withdrawal) vary distinctly. In comparison to the Swiss study, the general level of agreement is higher among the European experts. The recently proposed approach on the use of RIT, based on integrated post-surgery assessment (Martinique article) and results of ongoing prospective randomized studies are likely to reduce uncertainty in approaching RIT treatment. In certain constellations, consensus identified among European experts might be helpful in formulating future guidelines.

QOL-57. SOUTHERN CALIFORNIA KAISER PERMANENTE PEDIATRIC NEURO-ONCOLOGY PROGRAM DEVELOPMENT

KEY MESSAGEStandardization of care for subspecialty patients require centralization and support across multi-disciplinary groups within the Kaiser Permanente medical group, which is a large health maintenance organization (HMO) in the United States.BACKGROUNDPrior to the development of a Pediatric Neuro-Oncology program, Southern California Kaiser Permanente pediatric neuro-oncology patients were routinely referred to respective regional academic centers for consultation. The process was not standard across the region, resulting in additional costs and differences in treatment recommendations, potentially affecting outcomes.METHODSA Pediatric Neuro-Oncology program was established, July 2017, based at the Kaiser Permanente Los Angeles Medical Center (LAMC), consisting of pediatric neuro-oncology, pediatric neurosurgery, pediatric neuro-radiology, pediatric radiation oncology, and pediatric neuro-oncology case management.RESULTSA Pediatric Neuro-Oncology tumor board was established to meet on a bi-monthly basis. Pediatric neuro-oncology patients across the Southern California now have their magnetic resonance imaging (MRI) reviewed by the same pediatric neuro radiologists. Neuropathology is standardized and sent to Children’s Hospital Los Angeles and reviewed at the molecular neuropathology tumor board attended by the pediatric neuro-oncologist. Cases discussions regarding the patients include the regional pediatric neurosurgeons, the pediatric radiation oncologists, and the pediatric neuro-oncologist, and treatment plans are recommended and recorded by the case manager.CONCLUSIONSCentralization of care has allowed for more consistent and standard care across the Southern California Region, but requires support from multi-disciplinary groups.

Assessing success in transitioning of young adults from pediatric to adult kidney practice

BackgroundTransfer from a pediatric to an adult medical setting is associated with many barriers. Additionally, there are little data on patients’ assessment of the transition process itself. 3 years ago at Lurie Children’s Hospital of Chicago, we established a kidney transition program with the help of an adult nephrologist, physician assistant (PA) and social worker (LCSW). After 18 months, we evaluated the patients’ perception of the program as part of a continuous quality initiative process.MethodsPatients who had transitioned from pediatric care and were seen at least once in the adult nephrology clinic were anonymized and asked to take an established 5-point Likert scale survey. Survey questions addressed readiness to transition, the transition process itself, and the perception of adult care. Surveys were followed with semi-structured interviews. 3 readers rated each response as either “negative,” “neutral,” or “positive.” Average, standard deviation and reader reliability were calculated. The readers also selected a word that best depicted each response and those most-common words were counted by question and overall.Results17 out of 42 patients (40%) completed the survey. Average age at transition (mean + SD) was 20 + 2 years; the majority of patients (82%) felt ready to transfer to adult care but only 59% felt they were consulted on the timing. 88% of patients felt having a transition appointment and meeting the adult care providers in the pediatric setting to be valuable. Although 94% of patients ultimately felt comfortable in the adult care environment, 18% experienced noticeable differences in treatment recommendations. 13 semi-structured interviews were conducted. Overall, the patients responded positively (3 + 0, 100% reader reliability) to the transition. But, when asked what could have improved the transition, the word the patients used most was, “earlier.”ConclusionYoung adults (YA) transitioning to adult care often feel ready to transition earlier than their transfer of care date. They subjectively benefit from a transition program that outlines the process of transferring their care. Many YA patients would benefit from a transition program that bolsters patient independence during early adult care visits.

Assessment and Treatment Recommendations for Pediatric Pain: The Influence of Patient Race, Patient Gender, and Provider Pain-Related Attitudes

Previous studies have documented that racial minorities and women receive poorer pain care than their demographic counterparts. Providers contribute to these disparities when their pain-related decision-making systematically varies across patient groups. Less is known about racial and gender disparities in children with pain or the extent to which providers contribute to these disparities. In a sample of 129 medical students (henceforth referred to as "providers"), Virtual Human methodology and a pain-related version of the Implicit Association Test (IAT) were used to examine the effects of patient race/gender on providers’ pain assessment/treatment decisions for pediatric chronic abdominal pain, as well as the moderating role of provider implicit pain-related race/gender attitudes. Findings indicated that providers rated Black patients as more distressed (mean difference [MD] = 2.33, P < .01, standard error [SE] = .71, 95% confidence interval [CI] = .92, 3.73) and as experiencing more pain-related interference (MD = 3.14, P < .01, SE = .76, 95% CI = 1.63, 4.64) compared to White patients. Providers were more likely to recommend opioids for Black patients than White patients (MD = 2.41, P < .01, SE = .58, 95% CI = 1.05, 3.76). Female patients were perceived to be more distressed by their pain (MD = 2.14, P < .01, SE = .79, 95% CI = .58, 3.70) than male patients, however there were no gender differences in treatment recommendations. IAT results indicated that providers held implicit attitudes that Black Americans (M = .19, standard deviation [SD] = .29) and males (M = .38, SD = .29) were more pain-tolerant than their demographic counterparts; however, these implicit attitudes did not significantly moderate their pain assessment/treatment decisions. Future studies are needed to elucidate specific paths through which the pain experience and care of children differ across racial and gender groups. PerspectiveProviders’ pain assessment (ie, pain distress/pain interference) and treatment (ie, opioids) of pediatric pain differs across patient race and to a lesser extent, patient gender. This study represents a critical step in research on pain-related disparities in pediatric pain.

856P - Differences in treatment recommendations for advanced prostate cancer according to region and medical specialization: Analysis of the APCCC 2017 voting results

856P - Differences in treatment recommendations for advanced prostate cancer according to region and medical specialization: Analysis of the APCCC 2017 voting results

A survey of the practice and attitudes of surgeons regarding the treatment of appendicitis

BackgroundWe surveyed surgeons to document their attitudes, practice, and risk tolerance regarding the treatment of appendicitis. MethodsA web-based survey was sent to the EAST membership. The primary composite endpoint was defined as 1-year incidence of perioperative complications, antibiotic failure, infections, ED visits, and readmissions. ResultsA total of 563 of 1645 surveys were completed (34% response). Mean age was 47 ± 10 years and 98% were from the United States. Most (72%) were employed at academic teaching hospitals and 66% practiced in an urban setting. There were significant differences in treatment recommendations for different presentations of appendicitis. Regarding the primary composite endpoint, surgeons would tolerate a median 17% [10%–25%] excess morbidity in order to avoid an operation (i.e. non-inferiority) and would require a median 24% [10%–50% lower morbidity for the surgical approach in order to declare it a superior treatment (i.e. superiority). ConclusionsTo be considered non-inferior, antibiotic therapy of appendicitis cannot have >17% excess morbidity and appendectomy must have at least 24% lower morbidity to be considered superior.

A national survey of radiation oncologists and urologists on active surveillance for low-risk prostate cancer.

133 Background: Due to the growing concerns about over-diagnosis and overtreatment of localized prostate cancer (PCa), active surveillance (AS) has become an integral part of clinical practice guidelines. However, many men with low-risk PCa still receive primary therapy with surgery or radiation. Little is known about the barriers regarding the use of AS in clinical practice. To address this, we performed a national survey of radiation oncologists and urologists assessing the current attitudes and treatment for patients diagnosed with low-risk PCa. Methods: From January to July of 2017, 915 radiation oncologists and 940 urologists were surveyed about perceptions of AS for low-risk PCa. The survey queried respondents about their opinions and attitudes towards AS and treatment recommendations for a patient having low-risk PCa with clinical factors varying from patient age (55, 65 and 75 years old), PSA (4 and 8 ng per dl), and tumor volume for Gleason 3+3 disease (2, 4 and 6 cores). Pearson chi-square and multivariable logistic regression were used to identify respondent differences in treatment recommendations for low-risk PCa. Results: Overall, the response rate was 37.3% (n = 691) and similar for radiation oncologists and urologists (35.7% vs. 38.7%; p = 0.18). While both radiation oncologists and urologists viewed AS as effective for low-risk PCa (86.5% vs. 92.0%; p = 0.04), radiation oncologists were more likely to respond that AS increases patient anxiety (49.5% vs. 29.5%; p &lt; 0.001). Overall, recommendations varied markedly based on patient age, PSA, number of cores positive for Gleason 3+3 prostate cancer and respondent specialty. For a 55-year-old male patient with a PSA 8 and 6 cores of Gleason 6 PCa, recommendations of AS were low for both radiation oncologists and urologists (4.4 % vs. 5.2%; adjusted OR: 0.6; p = 0.28). For a 75-year-old patient with a PSA 4 and 2 cores of Gleason 6 PCa, radiation oncologists and urologists most often recommended AS (89.6% vs. 83.4%; adjusted OR: 0.5; p = 0.07). Conclusions: While both radiation oncologists and urologists consider AS effective in the clinical management of low-risk PCa, its use varies markedly by patient age, PCa volume, PSA and physician specialty.

Racial/ethnic differences in treatment recommendations: lifestyle changes and medication prescriptions for high cholesterol

ABSTRACTObjective: High cholesterol is a common condition in the United States, affecting nearly one third of adults, and is a leading precursor to coronary heart disease. This study investigates race/ethnic differences in treatment recommendations for patients with high cholesterol, including prescription medication and lifestyle changes such as eating less fat, losing weight, or exercising more.Design: Data were obtained from the 2005 to 2010 National Health and Nutrition Examination Survey (N = 4846), a representative sample of adults in the United States, and the 2005–2010 National Ambulatory Medical Care Survey (N = 12,113), a representative sample of patient visits in the United States. Logistic regression analyses were used to assess whether health professionals recommended lifestyle changes or medication prescriptions differently by patient race/ethnicity and age. Models adjusted for demographic characteristics, socioeconomic status, health behaviors, health care access/utilization, and comorbidities.Results: Non-Hispanic Black and Hispanic patients with high cholesterol were significantly and substantially more likely to receive recommendations for lifestyle changes compared to non-Hispanic White patients. These differences were exacerbated at younger ages and largely diminished for adults over the age of 65. These patterns were reflected in both datasets. However, non-Hispanic Black patients from the NHANES analysis were less likely than non-Hispanic White patients to receive medication prescriptions for high cholesterol, particularly at younger ages. There were no race/ethnic differences in odds of medication prescriptions for Hispanic patients compared to White patients.Conclusions: Results suggest widespread and pervasive race/ethnic differences in recommending lifestyle changes for patients with high cholesterol. Although lifestyle changes may lower cholesterol they are often less effective than prescription medication. Because differences in lifestyle recommendations were not reflected in prescription practices, results may indicate a form of discrimination within physician-patient interactions that could be addressed by increased provider education about most effective treatment practices.

143P - A comparison of treatment recommendations by molecular tumor boards worldwide

Background: Precision oncology holds promise to improve patient outcome. Yet, a benefit of personalized therapy in comparison to standard therapy has not been shown in prospective trials. We asked molecular tumor boards (MTB) worldwide to make treatment recommendations for sample patients to assess standards and differences in the precision oncology approach. Methods: 4 fictional patients with various degrees of genomic information (mutation, gene expression, copy number and gene fusion data, somatic and germline events) were created. A questionnaire was designed to identify methods and structures of the respective molecular tumor board’s recommendation process. 29 molecular tumor boards from 9 countries were identified and asked to participate in the survey between August 2016 and March 2017. A qualitative interpretation of the results was performed. Results: 5 MTBs from 4 countries completed the questionnaire and provided therapy recommendations. An identical treatment recommendation by all 5 MTB was not made for any one of the patients. In only one patient an overlapping treatment recommendation was made by three MTBs. Heterogeneity was larger for patients with more complex genomic information. The availability of clinical trials did not influence the recommendation heterogeneity. The setup of MTBs showed similarities in participating specialties (e.g. medical oncology, pathology, molecular biology), duration of discussion, testing methods and number of discussed patients. Differences were seen in the interpretation process. Further differences were identified in the interpretation of germline aberrations and interpretation of variant allele frequency. Comments by MTBs helped to identify minimum reporting standards for genetic testing. Conclusions: Several differences in treatment recommendations were observed. In cases with obvious recommendations there was higher concordance among assessments. However, differences in treatment recommendations were observed in complex cases, and such heterogeneity contributes to the complexity of precision oncology. Larger studies are necessary for rational and stepwise development of principles and practice of MTB procedures. Legal entity responsible for the study: Damian Rieke Funding: None Disclosure: U. Keilholz: Speaker honoraria and advisory board roles are with AstraZeneca, Bristol-Myers Squibb, Merck, MSD, Pfizer, Novartis, Innate. Corporate-sponsored research with AstraZeneca and Merck. All other authors have declared no conflicts of interest.

The MAGIC survey in hormone receptor positive (HR+), HER2-negative (HER2−) breast cancer: When might multigene assays be of value?

BackgroundA modest proportion of patients with early stage hormone receptor-positive (HR+), HER2-negative (HER2−) breast cancer benefit from adjuvant chemotherapy. Traditionally, treatment recommendations are based on clinical/pathologic criteria that are not predictive of chemotherapy benefit. Multigene assays provide prognostic and predictive information that can help to make more informed treatment decisions. The MAGIC survey evaluated international differences in treatment recommendations, how traditional parameters are used for making treatment choices, and for which patients treating physicians feel most uncertain about their decisions. MethodsThe MAGIC survey captured respondents' demographics, practice patterns, relevance of traditional parameters for treatment decisions, and use of or interest in using multigene assays. Using this information, a predictive model was created to simulate treatment recommendations for 672 patient profiles. ResultsThe survey was completed by 911 respondents (879 clinicians, 32 pathologists) from 52 countries. Chemo-endocrine therapy was recommended more often than endocrine therapy alone, but there was substantial heterogeneity in treatment recommendations in 52% of the patient profiles; approximately every fourth physician provided a different treatment recommendation. The majority of physicians indicated they wanted to use multigene assays clinically. Lack of reimbursement/availability were the main reasons for non-usage. ConclusionsThe survey reveals substantial heterogeneity in treatment recommendations. Physicians have uncertainty in treatment recommendations in a high proportion of patients with intermediate risk features using traditional parameters. In HR+, HER2− patients with early disease the findings highlight the need for additional markers that are both prognostic and predictive of chemotherapy benefit that may support more-informed treatment decisions.

Non-surgical treatment of hallux valgus: a current practice survey of Australian podiatrists.

BackgroundPatients with hallux valgus (HV) frequently present to podiatrists for non-surgical management, with a wide range of concerns including pain, footwear difficulty and quality of life impacts. There is little research evidence guiding podiatrists’ clinical decisions surrounding non-surgical management of HV. Thus practitioners rely largely upon clinical experience and expert opinion. This survey was conducted to determine whether a consensus exists among Australian podiatrists regarding non-surgical treatment of HV, and secondly to explore common presenting concerns and physical examination findings associated with HV.MethodsAn online survey was distributed to Australian podiatrists in mid-2013 via the professional association in each state (approximately 1900 members). Podiatrists indicated common treatments recommended, presenting problems and physical examination findings associated with HV in juveniles, adults and older adults. Proportions were calculated to determine the most common responses, and Chi-squared tests were used to examine differences in treatment recommendations according to HV patient age group and podiatrist demographics.ResultsOf 210 survey respondents, 65 % (136) were female and 80 % (168) were private practitioners. Complete survey responses were received from 159 podiatrists for juvenile HV, 146 for adults and 141 for older adults. Seven different non-surgical treatment options were commonly recommended (by >50 % podiatrists), although recommendations differed between adult, older adult and juvenile HV. Common treatments included footwear advice or modification, custom and prefabricated orthotic devices, addition of padding, and muscle strengthening/retraining exercises. Padding was more likely to be utilised in older adults, while exercises were more likely to be prescribed for juveniles. A diverse range of presenting problems and physical examination findings were reported to be associated with HV.ConclusionsDespite the lack of empirical evidence in this area, there appears to be a consensus among Australian podiatrists regarding non-surgical management of HV, and these recommendations are largely aligned with available clinical consensus documents. Presenting concerns and physical examination findings associated with HV are diverse and have implications for treatment decisions. Management strategies differ across patient age groups, thus any updated clinical guidelines should differentiate between adult and juvenile HV. This study provides useful data to inform clinical practice, education, policy and future research.Electronic supplementary materialThe online version of this article (doi:10.1186/s13047-016-0146-5) contains supplementary material, which is available to authorized users.

Discordance in routine second opinion pathology review of head and neck oncology specimens: A single-center five year retrospective review

Second opinion review of pathology specimens is a common institutional practice, supported by large retrospective studies demonstrating significant histologic discordance. Since the most recent study of head and neck-specific pathology review was conducted, routine HPV and EBV testing is now recommended for certain specimens. We describe the frequency of and reasons for discordant reports and their potential impact on treatment recommendations and prognosis in a five-year retrospective cohort study at a single academic referral institution from 2005 to 2010. Following institutional review board review, 1003 cases referred to the Head and Neck Oncology Service were identified using a retrospective database search. Discordance between outside and second review pathology report was assessed by a board-certified medical oncologist. 667 cases were included, of which 22% were discordant. Discordance was associated with adenocarcinomas (AOR [adjusted odds ratio] 0.09, 95% CI 0.03-0.31; p<0.001), poorly differentiated carcinomas (AOR 0.14, 95% CI 0.06-0.39; p<0.001), and specimens of uncommon histology (AOR 0.18, 95% CI 0.07-0.45; p<0.001) but not biopsy site in a multivariate model. The most common reasons for discordance included histology (61%), followed by the results of special studies (36%), and the presence or absence of stromal invasion (14%). Differences in tumor HPV status comprised 16% of discordant cases and were associated with better prognosis (p<0.001) following second opinion review. Routine second opinion pathology review may lead to clinically significant differences in treatment recommendations and prognosis.

Variation in Treatment Recommendations of Adjuvant Radiation Therapy for High-risk Prostate Cancer by Physician Specialty

To assess the treatment recommendations from a nationally representative sample of radiation oncologists and urologists on adjuvant radiotherapy for patients with pathologically advanced prostate cancer after radical prostatectomy. From a random sample of 1422 physicians (n= 711 radiation oncologists; n= 711 urologists) in the American Medical Association Masterfile, a mail survey queried treatment recommendations for adjuvant radiotherapy that varied by the following pathologic features: extraprostatic extension (pT3a) vs seminal vesicle invasion (pT3b), Gleason 7 vs Gleason 8-10, and margin negative (MN) vs margin positive (MP). Pearson chi-square and multivariable logistic regression were used to test for differences in treatment recommendations by physician specialty. Response rates for radiation oncologists and urologists were similar (44% vs 46%; P= .42). Radiation oncologists were more likely to recommend adjuvant radiotherapy than urologists for all the varying pathologic scenarios from pT3a, Gleason 7, and MN (42.5% vs 9.7%; adjusted odds ratio [OR]: 7.82, P<.001) to pT3b, Gleason 8-10, and MP disease (94.5% vs 89.1%, adjusted OR: 2.46, P<.001). Compared with radiation oncologists, urologists were more likely to recommend salvage radiotherapy pT3a, Gleason 7, and MN (90.3% vs 57.7%; adjusted OR: 7.72, P<.001) to pT3b, Gleason 8-10, and MP disease (10.9% vs 5.5%; adjusted OR: 2.22, P<.001). In this national survey, radiation oncologists and urologists have markedly different treatment recommendations for adjuvant and salvage radiotherapy. Patients with adverse pathologic features after radical prostatectomy should consult with both a urologist and radiation oncologist to hear a diversity of opinions to make the most informed decision possible.

Differences in the Management of Adolescents with Polycystic Ovary Syndrome across Pediatric Specialties

Study ObjectiveEvaluate for differences in the management of adolescents with polycystic ovarian syndrome (PCOS) across 3 pediatric specialties. DesignRetrospective review of medical records. SettingAcademic children’s hospital. Participants181 adolescents seen between July 2008 and June 2010 by providers in Pediatric Endocrinology (PEndo), Adolescent Medicine (AMed), or Pediatric and Adolescent Gynecology (PGyn) identified via billing data (ICD-9 code for PCOS, 256.4). InterventionsNone. Main Outcome Measures(1) Percentage of adolescents with a billing diagnosis of PCOS who met diagnostic criteria; (2) Percentage of individuals screened for comorbidities and differences across specialties; (3) Differences in treatment recommendations across specialties; (4) Factors associated with recommendation for metformin and hormonal contraceptives. ResultsThirteen percent of PEndo patients did not meet diagnostic criteria for PCOS; 20% of AMed and PGyn patients did not meet criteria. There were significant differences in rates of screening for obesity, insulin resistance, and Type 2 diabetes. There were significant differences in treatment recommendations for lifestyle changes, metformin, and anti-androgen therapy across specialties. Specialty and obesity were significant predictors of metformin recommendation; specifically PEndo predicted metformin recommendation. PGyn and AMed specialties predicted hormonal contraceptive recommendation. ConclusionsThe variability observed among specialties may be due to differences in training, accounting for a range of comfort with aspects of PCOS. Formulation of consensus guidelines for diagnosis and management of PCOS are needed, along with broad educational efforts. By correctly diagnosing, screening for comorbidities, and managing PCOS appropriately during adolescence, providers may reduce the risk for long-term consequences.