Stage-appropriate Treatment Research Articles

Management of detected syphilis in pregnancy adheres to guideline recommendations, but the crisis of congenital syphilis persists.

Infectious syphilis among women of reproductive age continues to rise in many countries including Australia, with a resultant increase in congenital syphilis. In response, new guidelines for management of syphilis in pregnancy were published in Queensland, Australia in 2018. This study evaluates the management of women diagnosed with syphilis in pregnancy in South-East Queensland (SEQ) after release of this guideline. This retrospective review of notification data identified women in SEQ who had a positive syphilis serology during pregnancy, without evidence of adequate treatment prior to the pregnancy, between January 2019 and December 2021 inclusive. Maternal demographics and pregnancy details including syphilis staging, testing and management were extracted, with management assessed against the 2018 Queensland syphilis in pregnancy guideline. Of the 42 women identified, 79% were diagnosed in the first or second trimester, 69% had early-stage syphilis at the time of diagnosis and 86% were asymptomatic at the time of diagnosis. All, including the eight (19%) Aboriginal and/or Torres Strait Islander women identified, completed stage-appropriate treatment with penicillin, 83% completed treatment four weeks prior to delivery and 60% achieved a four-fold reduction in rapid plasma reagin at time of delivery. Our findings suggest compliance with syphilis in pregnancy management recommendations has improved in SEQ since release of the 2018 guidelines. However, congenital syphilis rates continue to rise; further initiatives addressing barriers to timely testing and management of syphilis in pregnancy are urgently needed at both healthcare system levels and for individual women.

Racialized Economic Segregation and Treatment and Outcomes of Small Cell Lung Cancer.

Little is known about the role of residential segregation in the treatment and outcomes of small cell lung cancer (SCLC), a highly recalcitrant disease, among non-Hispanic White (NHW) and non-Hispanic Black (NHB) patients. We used the Surveillance, Epidemiology, and End Results database to identify men and women diagnosed with SCLC from January 2007 to December 2015 (n = 38,393). An Index of Concentration at the Extremes was computed to measure county-level racialized economic segregation and categorized into Quartile 1 (most privileged: highest concentration of high-income NHW residents) through Quartile 4 (least privileged: highest concentration of low-income NHB residents). Multilevel logistic regression was used to estimate the ORs for extensive-stage diagnosis and nonadherence to guideline-recommended treatment. HRs for lung cancer-specific and overall mortalities were computed using multilevel Cox regression. Patients in the least privileged counties had higher risks of nonadherence to guideline-recommended treatment [OR = 1.23; 95% confidence interval (CI): 1.08-1.40; Ptrend < 0.01], lung cancer-specific mortality (HR = 1.08; 95% CI: 1.04-1.12; Ptrend < 0.01), and all-cause mortality (HR = 1.13; 95% CI: 1.09-1.17; Ptrend < 0.0001) compared with patients in the most privileged counties. Adjustment for treatment did not significantly reduce the association with mortality. These associations were comparable between NHB and NHW patients. Segregation was not significantly associated with extensive-stage diagnosis. The results suggest that living in the neighborhoods with higher proportions of low-income households and Black residents had adverse impacts on stage-appropriate treatment of and survival from SCLC. This highlights the need for improving the access to quality lung cancer care in the less privileged neighborhoods.

Treatment of acute ankle distortion in footballers : Are we doing it particularly right or particularly wrong?

Despite the high incidence of ankle sprains, the ideal treatment is controversial and asignificant percentage of patients who have suffered an ankle sprain never fully recover. Even professional athletes are affected by this post-traumatic complication. There is strong evidence that permanent impairment after an ankle injury is often due to an inadequate rehabilitation and training program and too early return to sport. Therefore, athletes should start acriteria-based rehabilitation after ankle sprain and gradually progress through the programmed activities, including e.g. cryotherapy, edema reduction, optimal load management, range of motion exercises to improve ankle dorsiflexion and digital guidance, stretching of the triceps surae with isometric exercises and strengthening of the peroneus muscles, balance and proprioception training, and bracing/taping. The fact that this is professional sport does not exempt it from consistent, stage-appropriate treatment and acautious increase in load. However, there are anumber of measures and tools that can be used in the intensive care of athletes to improve treatment and results.

Abstract 2153: The impact of socioeconomic and racial segregation on cancer stage at diagnosis, treatment and mortality among patients with small cell lung cancer

Abstract Background: Although studies have revealed the adverse impact of residential segregation on early detection, treatment, and survival of non-small cell lung cancer―a predominant type of lung cancers, it remains unknown regarding the role of residential segregation in treatment and outcomes of small cell lung cancer (SCLC)―a rare type of lung cancer characterized by rapid growth and poor prognosis. Therefore, we examined the associations of racialized socioeconomic segregation with risks of extensive-stage diagnosis, non-adherence to guideline-recommended treatment, and mortality among non-Hispanic White (NHW) and non-Hispanic Black (NHB) patients with SCLC. Methods: This population-based retrospective cohort study included patients who were diagnosed with SCLC as a first primary malignancy at age 20 and older between January 2007 and December 2015, followed through December 2016, and identified from the Surveillance, Epidemiology, and End Results. County-level racialized socioeconomic segregation was measured using the Index of Concentration at the Extremes (ICE). Multilevel logistic regression accounting for county-level clustering was used to estimate odds ratios (ORs) for extensive-stage diagnosis and non-adherence to guideline-recommended treatment. Hazard ratios (HRs) for lung cancer-specific mortality and all-cause mortality were computed using multilevel Cox regression. Results: Among 38,393 patients, 90.1% were NHW and 9.9% were NHB. Patients dwelling in the counties with the highest concentration of low-income NHB households (highest ICE quartile) had higher risks of non-adherence to guideline-recommended treatment (OR=1.23, 95% CI: 1.08-1.40; Ptrend &amp;lt;0.01), lung cancer-specific mortality (HR=1.08, 95% CI: 1.04-1.12; Ptrend &amp;lt;0.01), and all-cause mortality (HR=1.13, 95% CI: 1.09-1.17; Ptrend &amp;lt;0.0001) as compared with patients dwelling in the counties with the highest concentration of high-income NHW households (lowest ICE quartile). These associations were comparable between NHB and NHW patients. Racialized economic segregation was not significantly associated with extensive-stage diagnosis. Conclusions: Residing in the segregated, low-income NHB counties had adverse impacts on stage-appropriate treatment for SCLC and survival outcomes. Future research on the pathway(s) linking residential segregation to SCLC treatment underutilization and poor outcomes is warranted. Citation Format: Bayu B. Bekele, Min Lian, Ying Liu. The impact of socioeconomic and racial segregation on cancer stage at diagnosis, treatment and mortality among patients with small cell lung cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 2153.

Abstract A036: Associations between area-level social determinants and late-stage diagnosis of colorectal cancers

Abstract Introduction Systemic policies and disinvestment in some communities have created deep inequities in the social and economic conditions in which some communities live. There are documented disparities in the detection and diagnosis of colorectal cancer (CRC) and stage-appropriate treatment, which drives cancer outcomes, such as survival. Using the Andersen-Aday model of access to healthcare, prior researchers have identified person-specific factors associated with late-stage diagnosis. In this study, we investigated whether area-level measures that may related to CRC screening barriers were associated with late-stage CRC diagnoses. Methods We used data from the Surveillance, Epidemiology, and End Results (SEER) and selected cases of adult (18+ years) colorectal cancer diagnosed from 2006-2013 (most recent years available; n=234,232). This data was linked to Medicaid enrollment information. We merged census-tract level data from the American Community Survey (2010 midpoint) capturing transportation access (% utilizing public transit for commuting), housing quality and cost (more than 1 person occupying per room and rent &amp;gt; 30% of income), language proficiency (% speaking English less than well), receipt of SNAP benefits, as well as poverty rate and educational attainment (% in tract attaining a high school education or less). We tested these variables as separate multivariable logistic regression models using late-stage CRC diagnosis (AJCC Stage IV vs Stages 0-III) as the dependent variable to test the association between each area factor, controlling for age, sex, race, marital status, and others. Results In all, 24% of CRC cases were diagnosed in Stage IV. High poverty areas (20+% poverty compared vs. &amp;lt;5% poverty OR = 1.10, CI: 1.07-1.15) and areas with lower educational attainment (lowest educational quartile vs. highest OR = 1.11 CI: 1.07-1.15) are associated with higher odds of Stage IV CRC diagnosis. Areas utilizing more public transit (most use quartile vs. least use quartile, OR = 1.04, CI: 1.01-1.07) and more SNAP benefits (most use vs. least use quartile, OR = 1.13, CI = 1.09-1.17), are also associated with higher odds of Stage IV diagnosis. High occupancy housing areas were associated with higher odds of Stage IV CRC diagnosis (highest occupancy quartile vs. lowest OR = 1.04, CI = 1.01-1.07), while affordability of rent was not. Area-level English proficiency was also not associated with later diagnosis. Conclusions Area-level social determinants are important factors in CRC detection and control. Early diagnosis is a key factor in better survival after CRC. It is important to understand specifically which area-level factors are most important in early detection to inform interventions to reduce disparities in late-stage CRC diagnosis. Citation Format: Manami Bhattacharya, Lindsey Enewold, Amy Davidoff. Associations between area-level social determinants and late-stage diagnosis of colorectal cancers [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A036.

Prospective Comparative Effectiveness Trial of Multidisciplinary Lung Cancer Care Within a Community-Based Health Care System.

Multidisciplinary lung cancer care is assumed to improve care delivery by increasing transparency, objectivity, and shared decision making; however, there is a lack of high-level evidence demonstrating its benefits, especially in community-based health care systems. We used implementation and team science principles to establish a colocated multidisciplinary lung cancer clinic in a large community-based health care system and evaluated patient experience and outcomes within and outside this clinic. We conducted a prospective frequency-matched comparative effectiveness study (ClinicalTrials.gov identifier: NCT02123797) evaluating the thoroughness of lung cancer staging, receipt of stage-appropriate treatment, and survival between patients receiving care in the multidisciplinary clinic and those receiving usual serial care. Target enrollment was 150 patients on the multidisciplinary arm and 300 on the serial care arm. We frequency-matched patients by clinical stage, performance status, insurance type, race, and age. A total of 526 patients were enrolled: 178 on the multidisciplinary arm and 348 on the serial care arm. After adjusting for other factors, multidisciplinary patients had significantly higher odds (odds ratio [OR]: 2.3 [95% CI, 1.5 to 3.4]) of trimodality staging compared with serial care. Patients on the multidisciplinary arm also had higher odds of receiving invasive stage confirmation (OR: 2.0 [95% CI, 1.4 to 3.1]) and mediastinal stage confirmation (OR: 1.9 [95% CI, 1.3 to 2.8]). Additionally, patients receiving multidisciplinary care were significantly more likely to receive stage-appropriate treatment (OR: 1.8 [95% CI, 1.1 to 3.0]). We found no significant difference in overall or progression-free survival between study arms. The multidisciplinary clinic delivered significant improvements in evidence-based quality care on multiple levels. Even in the absence of a demonstrable survival benefit, these findings provide a strong rationale for recommending this model of care.

Sex-Related Differences in Outcomes for Oropharyngeal Squamous Cell Carcinoma by HPV Status.

Background Overall survival for HPV-associated oropharyngeal squamous cell carcinoma (OPSCC) has differed by sex, but little is known regarding cancer-specific outcomes. We assessed the independent association of sex with cancer-specific survival in patients with HPV-associated oropharyngeal squamous cell carcinoma (OPSCC). Methods We identified 14,183 patients from the Surveillance, Epidemiology, and End Results (SEER) program with OPSCC and tumor HPV status. We used Kaplan–Meier methods to compare overall survival (OS) and OPSCC-specific survival (HNCSS) by patient sex and by tumor HPV status. We then separately fit multivariable survival and competing risk models evaluating the association of sex on these outcomes by tumor HPV status and stratified by the use of guideline-concordant OPSCC treatment. Results A total of 10,210 persons with HPV-positive tumors (72.0%) and 3,973 with HPV-negative tumors (28.0%) were identified. A larger proportion of women had HPV-negative tumors (24.0%) versus HPV-positive tumors (13.2%; p < 0.001). Women with HPV-positive tumors were less likely to receive guideline-concordant treatment compared to men. In unadjusted survival analyses, women did not differ in OS or HNCSS compared to men for HPV-positive tumors but had worse OS and HNCSS for HPV-negative tumors. After adjustment, men and women with HPV-positive OPSCC did not differ in OS or HNCSS. However, women with HPV-negative tumors faced worse overall survival (hazard ratio (HR) 1.15, 95% CI 1.02–1.29) that persisted even after stratifying for stage-appropriate treatment (HR 1.28, 95% CI 1.11–1.47). Conclusions Women with HPV-positive OPSCC had similar survival outcomes compared to men, but those with HPV-negative tumors have worse overall and cancer-specific survival.

Impact of Diagnostic Delays on Lung Cancer Survival Outcomes: A Population Study of the US SEER-Medicare Database.

Time from diagnosis to treatment has been associated with worse survival outcomes in non-small-cell lung cancer (NSCLC). However, little is known about the impact of delay in time to diagnosis. We aimed to evaluate the impact of time from radiographic suspicion to histologic diagnosis on survival outcomes using the US SEER-Medicare population database. We identified patients from the SEER-Medicare data set diagnosed with any stage NSCLC between January 1, 2011, and December 31, 2015, who received stage-appropriate treatment and had a computed tomography scan within 1 year of diagnosis. Time to confirmation was determined as the interval between most recent computed tomography imaging and date of histologic diagnosis. Our primary outcome was overall survival (OS). In total, 10,824 eligible patients were identified. The median time to confirmation was 20 (range 0-363) days. Using multivariate Cox regression models, longer time to confirmation was associated with improved OS in all comers driven by stage IV patients after adjustment for age, sex, diagnosis year, histology, and comorbidity index. In a separate landmark analysis excluding patients deceased within 6 months of diagnosis, the association between time to diagnosis and survival was no longer evident. Time to confirmation of NSCLC was inversely associated with OS in this US SEER population study. This association was lost when patients deceased within 6 months of diagnosis were excluded, suggesting that retrospective registry-claims databases may not be the optimal data source to study time to diagnosis as a quality metric because of the unaccounted confounding effects of tumor behavior. Prospective evaluations of clinically enriched data sources may better serve this purpose.

The Relative Survival Impact of Guideline-Concordant Clinical Staging and Stage-Appropriate Treatment of Potentially Curable Non-Small Cell Lung Cancer

Lung cancer management guidelines strive to improve outcomes. Theoretically, thorough staging promotes optimal treatment selection. We examined the association between guideline-concordant invasive mediastinal nodal staging, guideline-concordant treatment, and non-small cell lung cancer survival. What is the current practice of invasive mediastinal nodal staging for patients with lung cancer in a structured multidisciplinary care environment? Is guideline-concordant staging associated with guideline-concordant treatment? How do they relate to survival? We evaluated patients with nonmetastatic non-small cell lung cancer diagnosed from 2014 through 2019 in the Multidisciplinary Thoracic Oncology Program of the Baptist Cancer Center, Memphis, Tennessee. We examined patterns of mediastinal nodal staging and stage-stratified treatment, grouping patients into cohorts with guideline-concordant staging alone, guideline-concordant treatment alone, both, or neither. We evaluated overall survival with Kaplan-Meier curves and Cox proportional hazards models. Of 882 patients, 456 (52%) received any invasive mediastinal staging. Seventy-four percent received guideline-concordant staging; guideline-discordant staging decreased from 34%in 2014 to 18%in 2019 (P< .0001). Recipients of guideline-concordant staging were more likely to receive guideline-concordant treatment (83%vs66%; P< .0001). Sixty-one percent received both guideline-concordant invasive mediastinal staging and guideline-concordant treatment; 13%received guideline-concordant staging alone; 17%received guideline-concordant treatment alone; and 9%received neither. Survival was greatest in patients who received both (adjusted hazard ratio [aHR], 0.41; 95%CI, 0.26-0.63), followed by those who received guideline-concordant treatment alone (aHR, 0.60; 95%CI, 0.36-0.99), and those who received guideline-concordant staging alone (aHR, 0.64; 95%CI, 0.37-1.09) compared with neither (P< .0001, log-rank test). Levels of guideline-concordant staging were high, were rising, and were associated with guideline-concordant treatment selection in this multidisciplinary care cohort. Guideline-concordant staging and guideline-concordant treatment were complementary in their association with improved survival, supporting the connection between these two processes and lung cancer outcomes.

Stage-appropriate treatment of keratoconus

Der Keratokonus (KK) ist eine progrediente kegelförmige Hornhautvorwölbung, die eine parazentrale Verdünnung an der Kegelspitze verursacht und typischerweise beidseitig asymmetrisch auftritt. Nach einer sorgfältigen Anamnese und Einstufung des Schweregrades steht heute eine gezielte stadiengerechte Therapie zur Verfügung. Ist der Brillenvisus nicht mehr ausreichend, werden von einem Spezialisten formstabile sauerstoffdurchlässige Kontaktlinsen (KL) angepasst. Bei Progression und für den Patienten im Alltag nutzbarem Visus empfiehlt sich das Riboflavin-UVA-Crosslinking (CXL), bei herabgesetztem Visus und klarer zentraler Hornhaut sind bei KL-Intoleranz intrastromale Ringsegmente (ICRS) indiziert. Ist das Stadium weiter fortgeschritten, empfiehlt sich die tiefe anteriore lamelläre (DALK) oder perforierende Keratoplastik (PKP). Bei einem akuten Keratokonus ist die PKP kontraindiziert, allerdings verkürzen tiefstromale Nähte zur Readaptation des Descemet-Risses mit Gasfüllung der Vorderkammer den Verlauf erheblich. Fast keine andere Augenerkrankung ist heutzutage einer frühen apparativen Diagnose und stadiengerechten Therapie so gut zugänglich wie der KK.

Racial Disparities in Lung Cancer Diagnosis and Treatment: A Single Center, Retrospective Study in Central Indiana

Background/Objective: &#x0D; Lung cancer is the second most common cancer and the leading cause of death from cancer in the United States. However, there is a disparity in incidence and mortality between African Americans and Caucasians. This study aims to analyze factors that could describe this difference, such as treatment, socioeconomic, or behavioral differences using information from an Indiana University Simon Cancer Center (IUSCC) lung cancer registry. We hypothesized that African Americans will have a higher lung cancer stage at diagnosis and mortality, associated with less timely, stage-appropriate treatment. &#x0D; Methods: &#x0D; Using data collected from patients diagnosed with lung cancer at IUSCC from 2000-2016, we compared racial differences in diagnoses and subsequent management. Patients were categorized by race and clinical stage at diagnosis. Further categorization by sex, vital status, age at diagnosis, time from diagnosis to treatment and death, tobacco use, surgery, chemotherapy, insurance coverage, and histology was performed. We determined the rates of surgery or chemotherapy by stage at diagnosis. Statistical analyses are by student t-test or 2-way ANOVA. &#x0D; Results: &#x0D; African Americans were younger than Caucasians at lung cancer diagnosis (average 63.4 vs. 61.2 years p-value &lt; 0.001). African American race was associated with a longer time from diagnosis to treatment (36.4 vs. 32.1 days, p=0.023) and shorter time from diagnosis to death (475.1 vs. 623.7 days, p=0.001). The data suggests that African Americans have a later stage at diagnosis, are more likely to be uninsured and less likely to be covered by private insurance. The data suggests African Americans have a lower rate of surgery (Stages 1-3) and chemotherapy (Stages 3B and 4). &#x0D; Conclusion and Potential Impact: &#x0D; This data suggests racial differences in lung cancer diagnosis, treatment and outcomes. Future analyses will focus on multiple comparisons to determine possible impacts of socioeconomic and environmental factors on these outcomes at IUSCC and other university-affiliated health care systems.

Current diagnostic imaging and treatment planning for laryngeal cancer

Laryngeal cancer is the third most common malignancy in the head and neck region. Endoscopic laryngoscopy with assessment of vocal fold function, microlaryngoscopy with biopsy and computed tomography (CT)/magnetic resonance imaging (MRI) remain the cornerstones of diagnostic workup. Thus, in the context of therapy planning, consideration of individual functional and socioeconomic aspects is of major importance. Due to the short acquisition time and the possibility to perform functional maneuvers, CT is the tool of choice. MRI allows better soft tissue differentiation, but is more susceptible to movement artifacts and is complicated by disease-specific symptoms. The choice of examination method therefore depends on the patient's physical resilience. Depending on the study, the information on the sensitivity of CT with regard to the question of cartilage infiltration varies between 62 and 87% with aspecificity between 75 and 98%. For MRI, sensitivity between 64 and 95% and specificity between 56 and 88% are stated. The synthesis of the findings from endoscopy, biopsy and imaging is prerequisite for initiation of stage-appropriate treatment. For image interpretation, knowledge of the anatomical landmarks is essential. However, the assessment of posttherapeutic changes also poses achallenge for the radiologist. Regular interdisciplinary dialogue between radiologists, otorhinolaryngologists and radiotherapists in the context of primary diagnostics, therapy planning and aftercare is essential.

Accuracy of lung cancer staging in the multidisciplinary team setting.

Accurate staging of lung cancer is of utmost importance in determining the stage-appropriate treatment and prognosis. Imaging tests which include contrast-enhanced computed tomography (CT) examination of the chest to include the liver and adrenal glands and 18-fluoro-2 deoxyglucose positron emission tomography (PET)/CT scan facilitate the initial tumor node metastasis (TNM) staging of the disease and provide guidance on the optimal biopsy site and biopsy method. The diagnostic and staging approach should be tailored to the individual patient according to risk, benefit, patient preferences, and available expertise. Diagnosis and staging should preferably be accomplished with a single procedure or the least number of invasive procedures if more than one is needed. Ideally, centers managing lung cancer patients should have a multidisciplinary thoracic oncology board prescribing personalized evidence-based management tailored to each individual patient. Multidisciplinary team (MDT) meetings provide a platform for key experts from various disciplines to contribute specific advice on the management of each individual patient. As assessment of mediastinal lymph node involvement is an important component of lung cancer staging, optimal mediastinal staging can be achieved with a variety of techniques that can be discussed and performed by the various specialists in the MDT. Despite a relative paucity of quality evidence that MDT contributes to improvements in lung cancer survival outcomes, this approach has evolved to become the standard of care in many centers around the world. Thoracic MDT has resulted in more focused and timely investigations for histopathologic diagnosis and disease staging which translate into earlier treatment initiation. Moreover, there is increasing evidence that MDT care facilitates and allows access to investigations that lead to improved accuracy of tumor and nodal staging. However, there is still a paucity of evidence on the accuracy of lung cancer staging in the MDT setting.

Association of Mental Health Treatment With Outcomes for US Veterans Diagnosed With Non–Small Cell Lung Cancer

Preexisting mental health disorders (MHDs) are associated with increased mortality in people diagnosed with cancer, yet few data exist on the efficacy of interventions to mitigate this disparity. To evaluate the association of participation in mental health treatment programs (MHTPs), housing support programs, or employment support programs with stage at cancer diagnosis, receipt of stage-appropriate treatment, and mortality among patients with a preexisting MHD. This retrospective, population-based cohort study included 55 315 veterans in the Veterans Affairs Central Cancer Registry (VACCR) who had newly diagnosed non-small cell lung cancer (NSCLC) from September 30, 2000, to December 31, 2011. Data were analyzed from January 15, 2017, to March 17, 2020. Mental health disorders, including schizophrenia, bipolar disorder, depressive disorder, posttraumatic stress disorder, and substance use disorder. Stage at cancer diagnosis, receipt of stage-appropriate cancer treatment, all-cause mortality, and lung cancer-specific mortality. Of 55 315 veterans with a new diagnosis of NSCLC included in the analysis (98.1% men; mean [SD] age, 68.1 [9.8] years), 18 229 had a preexisting MHD, among whom participation in MHTPs was associated with a lower likelihood of being diagnosed in a late stage (odds ratio [OR], 0.62; 95% CI, 0.58-0.66; P < .001), a higher likelihood of receiving stage-appropriate treatment (OR, 1.55; 95% CI, 1.26-1.89; P < .001), lower all-cause mortality (adjusted hazard ratio [AHR], 0.74; 95% CI, 0.72-0.77; P < .001), and lower lung cancer-specific mortality (AHR, 0.77; 95% CI, 0.74-0.80; P < .001). Likewise, participation in housing and employment support programs was associated with similar improvements in all outcomes described above. In veterans with preexisting MHDs diagnosed with NSCLC, participation in MHTPs and housing and employment support programs was associated with improved lung cancer-related outcomes. This study might be the first to demonstrate significant improvement in cancer mortality for patients with MHDs who participate in MHTPs, housing support programs, or employment support programs. This work supports substantial literature that investment in mental health and social needs can improve health outcomes and highlights the importance of further research to identify, evaluate, and implement interventions to improve outcomes for patients with MHDs who are diagnosed with cancer.

Survival impact of multidisciplinary thoracic oncology care in a regional healthcare system.

2004 Background: Much-advocated, the value and impact of multidisciplinary care and planning (MDC) needs greater evidence. We compared non-small cell lung cancer (NSCLC) patient characteristics, treatment patterns and survival in a large community healthcare system spanning 3 US states with some of the highest lung cancer incidence and mortality rates. Methods: We identified MDC patients in the Tumor Registry NSCLC data from 2011-2017. Because the MDC program was located in metropolitan Memphis, we separated non-MDC patients by location of care resulting in 3 cohorts: MDC, non-MDC metropolitan care and non-MDC regional care. Using National Comprehensive Cancer Network guidelines, we categorized treatment by stage as ‘preferred’, ‘appropriate’ (allowable under certain circumstances). We compared demographic and clinical characteristics across cohorts using chi-squared tests and compared survival using Cox regression with Bonferroni adjustment. We repeated survival analysis with propensity matched cohorts. Results: Of 6259 patients, 14% received MDC, 56% metro care and 30% regional care; MDC had the highest rates of African Americans (34% v 28% v 22%), stage I-IIIB (63 v 40 v 50), urban residents (81 v 78 v 20), stage-preferred treatment rates (66 v 57 v 48), stage-appropriate treatment rates (78 v 70 v 63;), and lowest non-treatment rates (6 v 21 v 28). All p&lt;0.001. Compared to MDC, the hazard for death was higher in metro (1.4, 95% confidence interval 1.3-1.6) and regional (1.7, 1.5-1.9); hazards were higher in regional care v metro (1.2, 1.1-1.3); all p&lt;0.001 after adjustment. Results were similar for MDC comparisons after propensity matching with and without adjusting for preferred treatment. No differences in regional and metro cohorts. Conclusions: In this large community-based healthcare system, receipt of MDC for NSCLC was associated with significantly higher rates of guideline-concordant care and survival, providing strong evidence for recommending rigorous implementation of MDC. [Table: see text]

Syphilis: Understanding Traditional and Reverse Screening Algorithms

Interpreting syphilis screening tests can be a challenge for health care providers. Clinical laboratories primarily use the reverse algorithm to screen for syphilis; however, the Centers for Disease Control and Prevention recommend the traditional algorithm. Both algorithms require the interpretation of 2 different serologic assays for screening and confirmation. Serologic testing used in both algorithms is reviewed for nurse practitioners to correctly interpret test results to establish a timely diagnosis and provide stage-appropriate treatment.

Association of Receipt of Positron Emission Tomography–Computed Tomography With Non–Small Cell Lung Cancer Mortality in the Veterans Affairs Health Care System

Positron emission tomography-computed tomography (PET-CT) has been increasingly used in the management of lung cancer, but its association with survival has not been convincingly documented. To examine the association of the use of PET-CT with non-small cell lung cancer (NSCLC) mortality in the US Department of Veterans Affairs (VA) health care system from 2000 to 2013. This cohort study included 64 103 veterans receiving care in the VA health care system who were diagnosed with incident NSCLC between September 2000 and December 2013. Data analysis took place in October 2018. Use of PET-CT before and/or after diagnosis. All-cause and NSCLC-specific 5-year mortality; secondary outcome was receipt of stage-appropriate treatment. A total of 64 103 veterans with the diagnosis of NSCLC were evaluated; 62 838 (98.0%) were men, and 50 584 (78.9%) were white individuals. Among these, 51 844 (80.9%) had a PET-CT performed: 25 735 (40.1%) in the 12 months before diagnosis and 41 242 (64.3%) in the 5 years after diagnosis. Increased PET-CT use (597 of 978 veterans [59.2%] in 2000 vs 3649 of 3915 [93.2%] in 2013) and decreased NSCLC-specific 5-year mortality (879 of 978 veterans [89.9%] in 2000 vs 3226 of 3915 veterans [82.4%] in 2013) were found over time. Increased use of stage-appropriate therapy was also seen over time, from 346 of 978 veterans (35.4%) in 2000 to 2062 of 3915 (52.7%) in 2013 (P < .001). Increased PET-CT use was associated with higher-complexity level VA facilities (26 127 veterans [82.3%] at level 1a vs 1289 [75.2%] at level 3 facilities; P < .001) and facilities with on-site PET-CT compared with facilities without on-site PET-CT (33 081 [82.2%] vs 17 443 [80.3%]; P < .001). Use of PET-CT before diagnosis was associated with increased likelihood of stage-appropriate treatment for all stages of NSCLC (eg, veterans with stage 1 disease: 4837 of 7870 veterans [61.5%] who received PET-CT underwent surgical resection vs 4042 of 7938 veterans [50.9%] who did not receive PET-CT; P < .001) and decreased mortality in a risk-adjusted model among all participants and among veterans undergoing stage-appropriate treatment (all-cause mortality: hazard ratio [HR], 0.78; 95% CI, 0.77-0.79; NSCLC-specific mortality: HR, 0.78; 95% CI, 0.76-0.80). Facilities with on-site PET-CT and higher-complexity level facilities were associated with a mortality benefit, with 16% decreased mortality at level 1a vs level 3 facilities (HR, 0.84; 95% CI, 0.80-0.89) and a 3% decrease in all-cause mortality in facilities with on-site PET-CT (HR, 0.97; 95% CI, 0.96-0.99). In this study, the use of PET-CT among veterans with NSCLC significantly increased from 2000 to 2013, coinciding with decreased 5-year mortality and an increase in stage-appropriate treatment. Variation in use of PET-CT was found, with the highest use at higher-complexity level facilities and those with PET-CT on-site. These facilities were associated with reduced all-cause and NSCLC-specific mortality.

Disparities in lung cancer outcomes for veterans with comorbid mental disorders.

6577 Background: Emerging evidence suggests that cancer patients with comorbid mental disorders have worse outcomes. Lung cancer is the leading cause of cancer-related death in the United States, yet the impact of specific mental disorders on outcomes for patients diagnosed with lung cancer is not well known. Methods: Stage at diagnosis and receipt of stage-appropriate treatment were assessed for 55,315 Veterans with non-small cell lung cancer (NSCLC) in the Veterans Affairs (VA) Central Cancer Registry from 2000 to 2011. Patients were stratified by the presence of specific comorbid mental disorders. Multivariate analysis evaluated the association between mental disorders and survival, as well as the impact of VA treatment programs on survival. Results: Patients with schizophrenia had lower rates of localized disease at diagnosis compared to those without mental disorders. Schizophrenia and dementia were associated with significantly lower rates of stage-appropriate treatment for localized, locoregional, and metastatic disease. Conversely, patients with depression or PTSD were more frequently diagnosed with early-stage disease and significantly more likely to receive stage-appropriate treatment across all stages. After adjusting for baseline differences, stage, and rates of stage-appropriate treatment, hazard of death was higher for patients with schizophrenia (hazard ratio [HR] 1.10; 95% CI, 1.03-1.16; P &lt; .005) and dementia (HR 1.11; 95% CI, 1.06-1.18; P &lt; .0005). Participation in VA-based programs to address mental illness, substance use, and homelessness was associated with a significant reduction in all-cause mortality (HR 0.71; 95% CI, 0.68-0.75; P &lt; .0001) and lung-cancer specific mortality (HR 0.73; 95% CI, 0.69-0.77; P &lt; .0001). Conclusions: Schizophrenia and dementia are strong negative predictors of survival among Veterans diagnosed with NSCLC. VA-based mental health treatment programs are associated with reductions in all-cause and lung cancer-related mortality, highlighting the importance of funding and promoting mental health and supportive programs.

Excellent outcomes in bilateral testicular germ cell tumors over four decades.

523 Background: Bilateral testicular germ cell tumours (BTC) form a small minority of testicular cancer and detailed management data are sparse. Methods: Bilateral testicular cancer (BTC) patients managed at a single cancer centre were retrospectively analyzed. Synchronous BTC was defined as uni+contralateral presentation within 3 months. Patient characteristics, treatment and outcomes were collected. Kaplan-Meier method was used to calculate the overall survival (OS) and relapse-free survival (RFS). Results: Between Jan 1971 to Jun 2018, 118 pts were included. Nine patients (7.6%) had cryptorchidism. Twenty-two patients (18.6%) had synchronous BTC at median age of 30(21-54) years, 11 presented with concordant histology (10-seminoma). Median follow-up time was 96(1-220) months. Two of 14 patients (14%) with stage I disease on surveillance had retroperitoneal nodal recurrence, other 3 (21%) had testicular recurrence after partial orchiectomy alone. No recurrence occurred for 8 stage II/III patients (36%) who received stage-appropriate treatment. All patients were alive without disease at last follow-up. For metachronous BTC, the median age was 27(16-68) and 37(19-78) years for first and second diagnosis, respectively. The median time interval was 88 (8-352) months, with shorter interval when second primary was non-seminoma, median 69 vs. 92 months. Concordant histology was present in 58 (38-seminoma) patients and discordant in 38 patients. There were 66, 23, 7 and 84, 9, 3 patients with stage I, II, III disease for first and second testicular cancer (TC), respectively. For all stage I disease, 69% of non-seminoma (n = 33) and 79% of seminoma (n = 81) were on surveillance, of whom the crude relapse rate was 15%. The median follow-up time after second diagnosis was 87 months. In all, 35 patients (30%) with recurrence except 1 were successfully salvaged. The 10-year OS and RFS for whole cohort was 99% and 69.8%, respectively. Conclusions: In our series, seminoma was the more common pathology, and management based on pathology and stage yielded excellent outcomes regardless of prior therapy. Metachronous BTC may occur at extremely long time intervals such that longer follow-up is needed to capture the majority of contralateral primary TC.

The Treatment of Primary Arthritis of the Finger and Thumb Joint.

Primary finger and thumb joint arthritis is common, with a markedly rising prevalence from age 50 onward. As the population as a whole ages, the need for effective, stage-appropriate treatment of this condition is increasing. This review is based on pertinent publications retrieved by a selective search in the PubMed and Cochrane Library databases. Pain on movement and morning stiffness are commonly reported symptoms. Thorough physical examination and plain x-rays are mandatory. In the early stages of primary finger and thumb joint arthritis, a conservative, multimodal treatment approach involving the use of splints, physiotherapy, and non-steroidal anti-inflammatory drugs can be helpful. The intraarticular injection of hyaluronic acid or cortisone seems to relieve pain in the short term, but its long-term efficacy in primary finger and thumb joint arthritis is questionable. Arthrodesis (joint fusion) is a reliable surgical treatment option for arthritis of the metacarpophalangeal and interphalangeal joints of the thumb. For mobility-preserving surgery of the metacarpophalangeal joints of the second through fifth fingers, silicone implant arthroplasty remains the gold standard. Symptomatic, advanced arthritis of the distal interphalangeal joint is most effectively treated with arthrodesis. The efficacy of conservative treatment has been documented in high-quality clinical trials, while that of surgical treatment has not. The various surgical methods have yielded benefits in routine clinical use, but these remain to be assessed in randomized and controlled trials.