Clinician Perspectives on Factors Affecting Shared Decision Making about Lung Cancer Screening

Background/Objective. In 2015, the Centers for Medicare and Medicaid Services (CMS) announced coverage for annual lung cancer screening (LCS) with low dose computed tomography (LDCT) for individuals who are 55 to 77 years of age, have \u3e 30 pack years of smoking history, and undergo shared decision making (SDM) prior to screening. Most referrals for LCS are initiated in primary care. Currently, little is known about how primary care physicians view SDM and barriers in practice to SDM about LCS. This study aimed to gather information to help fill these knowledge gaps. Methods. I worked with senior leadership in the Department of Medicine to identify a set of internal medicine physicians at Thomas Jefferson University (TJU) and contacted them via email requesting their participation in an interview about SDM in LCS. I developed an interview guide that included questions about the following: understanding of SDM, perceptions about SDM in LCS, and receptivity to use of an online decision support intervention (DSI). I completed in-person, audio recorded interviews, which were transcribed for analysis. I then analyzed the interview transcripts using NVivo qualitative analysis software. Results. Nine physicians were interviewed from a pool of twenty-three physicians over a period of three weeks. With regards to understanding of SDM, physicians were in agreement that SDM is a joint decision based on a discussion about the risks and benefits of an intervention that considers patient values and medical status. Physician perceptions of SDM in LCS was influenced by patient comorbidities, LCS controversies and complexity, and limited office time. Receptivity to using an online DSI was generally positive and particularly favored its patient education component and easing of physician workload. Conclusions. Observations from this study highlight a common general understanding of SDM, yet mixed approaches to SDM in LCS. Strong support also exists for a DSI that educates patients about LCS and saves physicians time. Future steps include interviewing a set of family medicine physicians to investigate potential differences in viewpoints compared to internal medicine physicians

Postoperative hyperphosphatemia significantly associates with adverse survival in colorectal cancer patients

BACKGROUND: Hyperphosphatemia has been implicated in the development and treatment of various cancers. However, whether it can be used as a direct prognostic marker of colorectal cancer (CRC) has remained unexplored. Given new insights into the importance of hyperphosphatemia in CRC, we sought to evaluate the association of hyperphosphatemia with the clinical outcomes of this disease. METHODS: In a retrospective analysis of a well-characterized clinic-based cohort with 1,241 CRC patients, we assessed the association of postoperative hyperphosphatemia with patient overall survival. RESULTS: Postoperative hyperphosphatemia measured within the first month after surgery was significantly associated with CRC survival. Compared to patients with a normal phosphate level, those with hyperphosphatemia exhibited a significant unfavorable overall survival with a hazard ratio (HR) of 1.84 (95% confidence interval [CI] 1.49–2.29, P=2.6×10(−8), (log-rank P=1.2×10(−7)). Stratified analyses indicated the association was more pronounced in patients with colon (HR=2.00, 95% CI 1.57–2.56, P=3.17×10(−8)) but not rectal cancer (HR=0.96, 95% CI 0.58–1.59, P=0.889) (P interaction=0.023), as well as in those not receiving chemotherapy (HR=2.15, 95% CI 1.59–2.90, P=6.2×10(−7)) but not in those receiving chemotherapy (HR=1.30, 95% CI 0.92–1.82, P=0.136) (P interaction=0.012). Flexible parametric survival model demonstrated that the increased risk for death conferred by postoperative hyperphosphatemia persisted over 150 months after surgery. CONCLUSION: Our data indicated that postoperative hyperphosphatemia might be used as a prognostic marker of CRC patients after surgery. Since phosphate level is routinely tested in clinics, it may be incorporated into clinical models to predict CRC survival

Cell-free circulating mitochondrial DNA content and risk of hepatocellular carcinoma in patients with chronic HBV infection.

Recent studies have demonstrated a potential link between circulating cell-free mitochondrial DNA (mtDNA) content and cancers. However, there is no study evaluating the association between circulating mtDNA as a non-invasive marker of hepatocellular carcinoma (HCC) risk. We conducted a nested case-control study to determine circulating mtDNA content in serum samples from 116 HBV-related HCC cases and 232 frequency-matched cancer-free HBV controls, and evaluate the retrospective association between mtDNA content and HCC risk using logistic regression and their temporal relationship using a mixed effects model. HCC cases had significantly lower circulating mtDNA content than controls (1.06 versus 2.47, P = 1.7 × 10(-5)). Compared to HBV patients with higher mtDNA content, those with lower mtDNA content had a significantly increased risk of HCC with an odds ratio (OR) of 2.19 (95% confidence interval [CI] 1.28-3.72, P = 0.004). Quartile analyses revealed a significant dose-dependent effect (Ptrend = 0.001) for this association. In a pilot longitudinal sub-cohort of 14 matched cases-control pairs, we observed a trend of dramatically decreased mtDNA content in cases and slightly decreased mtDNA content in controls, with a significant interaction of case-control status with time (Pinteraction = 0.049). Our findings suggest that circulating mtDNA is a potential novel non-invasive biomarker of HCC risk in HBV patients

Integration of circulating tumor cell and neutrophil-lymphocyte ratio to identify high-risk metastatic castration-resistant prostate cancer patients.

BACKGROUND: The neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and circulating tumor cells (CTCs) have been associated with survival in castration-resistant prostate cancer (CRPC). However, no study has examined the prognostic value of NLR and PLR in the context of CTCs. METHODS: Baseline CTCs from mCRPC patients were enumerated using the CellSearch System. Baseline NLR and PLR values were calculated using the data from routine complete blood counts. The associations of CTC, NLR, and PLR values, individually and jointly, with progression-free survival (PFS) and overall survival (OS), were evaluated using Kaplan-Meier analysis, as well as univariate and multivariate Cox models. RESULTS: CTCs were detected in 37 (58.7%) of 63 mCRPC patients, and among them, 16 (25.4%) had ≥5 CTCs. The presence of CTCs was significantly associated with a 4.02-fold increased risk for progression and a 3.72-fold increased risk of death during a median follow-up of 17.6 months. OS was shorter among patients with high levels of NLR or PLR than those with low levels (log-rank P = 0.023 and 0.077). Neither NLR nor PLR was individually associated with PFS. Among the 37 patients with detectable CTCs, those with a high NLR had significantly shorter OS (log-rank P = 0.024); however, among the 26 patients without CTCs, the OS difference between high- and low-NLR groups was not statistically significant. Compared to the patients with CTCs and low NLR, those with CTCs and high levels of NLR had a 3.79-fold risk of death (P = 0.036). This association remained significant after adjusting for covariates (P = 0.031). Combination analyses of CTC and PLR did not yield significant results. CONCLUSION: Among patients with detectable CTCs, the use of NLR could further classify patients into different risk groups, suggesting a complementary role for NLR in CTC-based prognostic stratification in mCRPC

Changing Patient and Physician Behavior: Moving Toward Informed and Shared Decision-Making

Dr. Myers provides an overview on decision aids used to facilitate informed decision making in cancer care. The case of prostate cancer screening is used to illustrate the impact of mediated decision support in the context of the physician-patient encounter. Dr. Myers also discusses the potential impact of mediated decision support and obstacles to implementing the decision counseling program