Recent Publications by CFE Educators

Patient preferences pertaining to surgical options for thyroid cancer management are not well studied. Our aim was to conduct a discrete choice experiment (DCE) to characterize participants' views on the relative importance of various risks and benefits associated with lobectomy versus total thyroidectomy for low-risk thyroid cancer. Adult participants with low-risk thyroid cancer or a thyroid nodule requiring surgery were asked to choose between experimentally designed surgical options with varying levels of risk of nerve damage (1%, 9%, 14%), hypocalcemia (0%, 3%, 8%), risk of needing a second surgery (0%, 40%), cancer recurrence (1%, 3%, 5%), and need for daily thyroid hormone supplementation (yes, no). Their choices were analyzed using random-parameters logit regression. One hundred fifty participants completed an online DCE survey. Median age was 58 years; 82% were female. Twenty-four participants (16%) had a diagnosis of thyroid cancer at the time of completing the survey, and 126 (84%) had a thyroid nodule necessitating surgery. On average, 35% of participants' choices were explained by differences in the risk of cancer recurrence; 28% by the chance of needing a second surgery; 19% by the risk of nerve damage; and 9% by differences in risks of hypocalcemia and the need for thyroid hormone supplementation. When accounting for differences in postoperative risks, the average patient favored lobectomy over total thyroidectomy as long as the chance of needing a second (i.e., completion) surgery after initial lobectomy remained below 30%. Participants would accept a 4.1% risk of cancer recurrence if the risk of a second surgery could be reduced from 40% to 10%. While patients with thyroid cancer may have clear preferences for extent of surgery, common themes moderating preferences for surgical interventions were identified in the DCE. Adequate preoperative evaluation to decrease the chance of a second surgery and providing patients with a good understanding of risks and benefits associated with extent of surgery can lead to better treatment decision-making.

Everyone of reproductive potential, no matter sex or gender, may have contraceptive needs. However, with no professional society guidelines and scant data on contraceptive use for transgender and gender-diverse (TGD) populations, clinicians' abilities to counsel patients on use, safety, side effects, and efficacy is severely limited. We know very little about how estrogen- and progestin-containing contraceptive methods interact with gender-affirming testosterone therapy. Consequently, providers must extrapolate from data on use of hormonal contraceptive methods in presumed cisgender women and rely on clinical expertise. Based on available literature and expert opinion, there are important considerations for each method that can help guide contraceptive counseling with TGD patients. Specific considerations include differential experience of side-effects in TGD patients, barriers to access, and potential misconceptions regarding menstruation and reproductive capacity. When counseling a TGD person about their contraception options, providers should engage in shared decision-making, acknowledging the spectrum of identities and experiences within these communities. In order to support gender-affirming patient-centered care, providers should also create a space that is welcoming, use language that promotes inclusivity, and perform physical exams that consider the potential physical and emotional discomforts specific to these patients. Given the lack of population-specific data and guidelines, we encourage providers to integrate what is known about contraceptive use in cisgender women with the unique needs of TGD persons to apply a shared decision-making contraceptive counseling approach with members of these communities.

PURPOSE

Palliative care is recommended for patients with metastatic cancer, but there has been limited research about embedded palliative care for specific patient populations. We describe the impact of a pilot program that provided routine, early, integrated palliative care to patients with metastatic colorectal cancer.

METHODS

Mixed methods pre-post intervention cohort study at an academic cancer center. Thirty control then 30 intervention patients with metastatic colorectal cancer were surveyed at baseline and 1, 3, 6, 9, and 12 months thereafter about symptoms, quality-of-life, and likelihood of cure. We compared survey responses, trends over time, rates of advance care planning, and healthcare utilization between groups. Patients, family caregivers, and clinicians were interviewed.

RESULTS

Patients in the intervention group were followed for an average of 6.5 months and had an average of 3.5 palliative care visits. At baseline, symptoms were mild (average 1.85/10) and 78.2% of patients reported good/excellent quality-of-life. Half (50.9%) believed they were likely to be cured of cancer. Over time, symptoms and quality-of-life metrics remained similar between groups, however intervention patients were more realistic about their likelihood of cure (p = 0.008). Intervention patients were more likely to have a surrogate documented (83.3% vs. 26.7%, p  0.0001), an advance directive completed (63.3% vs. 13.3%, p  0.0001), and non-full code status (43.3% vs. 16.7%, p  0.03). All patients and family caregivers would recommend the program to others with cancer.

CONCLUSIONS

We describe the impact of an embedded palliative care program for patients with metastatic colorectal cancer, which improved prognostic awareness and rates of advance care planning.

BACKGROUND

The association between male pattern baldness and prostate cancer has been inconsistent. We prospectively investigated the association between baldness at age 45 and prostate cancer risk in the Health Professionals Follow-up Study (HPFS), focusing on clinical and molecular markers.

METHODS

Baldness was self-reported on the 1992 questionnaire using the modified Norwood-Hamilton scale prior to diagnosis. We estimated HRs between baldness and prostate cancer risk among 36,760 men, with follow-up through 2014. We also investigated whether baldness was associated with prostate cancer defined by tumor protein expression of androgen receptor and the presence of the TMPRSS2:ERG fusion.

RESULTS

During 22 years, 5,157 prostate cancer cases were identified. Fifty-six percent of the men had either frontal or vertex baldness. No significant associations were found between baldness and prostate cancer risk. Among men younger than 60 years, there was a statistically significant association between frontal and severe vertex baldness and overall prostate cancer (HR: 1.74; 95% confidence interval: 1.23-2.48). Baldness was not significantly associated with expression of molecular subtypes defined by AR and TMPRSS2:ERG IHC of prostate tumors.

CONCLUSIONS

This study showed no association between baldness at age 45 and prostate cancer risk, overall or for clinical or molecular markers. The association between baldness and overall prostate cancer among younger men is intriguing, but caution is warranted when interpreting this finding.

IMPACT

The null findings from this large cohort study, together with previous literature's inconclusive findings across baldness patterns, suggest that baldness is not a consistent biomarker for prostate cancer risk or progression.

OBJECTIVE

Brain arteriovenous malformations (AVMs) consist of dysplastic blood vessels with direct arteriovenous shunts that can hemorrhage spontaneously. In children, a higher lifetime hemorrhage risk must be balanced with treatment-related morbidity. The authors describe a collaborative, multimodal strategy resulting in effective and safe treatment of pediatric AVMs.

METHODS

A retrospective analysis of a prospectively maintained database was performed in children with treated and nontreated pediatric AVMs at the University of California, San Francisco, from 1998 to 2017. Inclusion criteria were age ≤ 18 years at time of diagnosis and an AVM confirmed by a catheter angiogram.

RESULTS

The authors evaluated 189 pediatric patients with AVMs over the study period, including 119 ruptured (63%) and 70 unruptured (37%) AVMs. The mean age at diagnosis was 11.6 ± 4.3 years. With respect to Spetzler-Martin (SM) grade, there were 38 (20.1%) grade I, 40 (21.2%) grade II, 62 (32.8%) grade III, 40 (21.2%) grade IV, and 9 (4.8%) grade V lesions. Six patients were managed conservatively, and 183 patients underwent treatment, including 120 resections, 82 stereotactic radiosurgery (SRS), and 37 endovascular embolizations. Forty-four of 49 (89.8%) high-grade AVMs (SM grade IV or V) were treated. Multiple treatment modalities were used in 29.5% of low-grade and 27.3% of high-grade AVMs. Complete angiographic obliteration was obtained in 73.4% of low-grade lesions (SM grade I-III) and in 45.2% of high-grade lesions. A periprocedural stroke occurred in a single patient (0.5%), and there was 1 treatment-related death. The mean clinical follow-up for the cohort was 4.1 ± 4.6 years, and 96.6% and 84.3% of patients neurologically improved or remained unchanged in the ruptured and unruptured AVM groups following treatment, respectively. There were 16 bleeding events following initiation of AVM treatment (annual rate: 0.02 events per person-year).

CONCLUSIONS

Coordinated multidisciplinary evaluation and individualized planning can result in safe and effective treatment of children with AVMs. In particular, it is possible to treat the majority of high-grade AVMs with an acceptable safety profile. Judicious use of multimodality therapy should be limited to appropriately selected patients after thorough team-based discussions to avoid additive morbidity. Future multicenter studies are required to better design predictive models to aid with patient selection for multimodal pediatric care, especially with high-grade AVMs.

PURPOSE

Alterations in the urinary microbiome have been associated with urological diseases. The microbiome of patients with urethral stricture disease (USD) remains unknown. Our objective is to examine the microbiome of USD with a focus on inflammatory USD caused by lichen sclerosus (LS).

METHODS

We collected mid-stream urine samples from men with LS-USD (cases; n = 22) and non-LS USD (controls; n = 76). DNA extraction, PCR amplification of the V4 hypervariable region of the 16S rRNA gene, and sequencing was done on the samples. Operational taxonomic units (OTUs) were defined using a > 97% sequence similarity threshold. Alpha diversity measurements of diversity, including microbiome richness (number of different OTUs) and evenness (distribution of OTUs) were calculated and compared. Microbiome beta diversity (difference between microbial communities) relationships with cases and controls were also assessed.

RESULTS

Fifty specimens (13 cases and 37 controls) produced a 16S rRNA amplicon. Mean sample richness was 25.9 vs. 16.8 (p = 0.076) for LS-USD vs. non-LS USD, respectively. LS-USD had a unique profile of bacteria by taxonomic order including Bacillales, Bacteroidales and Pasteurellales enriched urine. The beta variation of observed bacterial communities was best explained by the richness.

CONCLUSIONS

Men with LS-USD may have a unique microbiologic richness, specifically inclusive of Bacillales, Bacteroidales and Pasteurellales enriched urine compared to those with non-LS USD. Further work will be required to elucidate the clinical relevance of these variations in the urinary microbiome.