The impact of telemedicine in cancer care

e20508

Background: The Technology Exchange for Cancer Health Network is a collaborative, multi-state effort using Telemedicine and integrated electronic health records to provide rural cancer care management. Methods: The purpose of the study was to compare quality, safety, and cost outcomes for patients receiving rural Telehealth care versus “routine” urban care. Patients with a cancer diagnosis requiring treatment for at least 1 year were eligible for the study. Telehealth patients saw their oncologist in person at rural sites for initial care and via telemedicine for about half of subsequent visits, allowing clinicians in-person clinical assessments while still taking advantage of time savings associated with telemedicine. Results: 217 patients (134 rural, 83 urban) were enrolled from 05/25/05 to 09/30/08. Patient satisfaction was high; 95 % of patients indicated their telemedicine visit was as good as or better than an in-person visit. Telemedicine patients also reported significant time and travel cost savings. Cost analysis comparing cost savings (physician travel time) with telemedicine costs (equipment, high speed lines) indicated that cost-benefit is driven by distance to rural facility and number of physician trips avoided. Telemedicine must save at least 5 hours of physician travel time per month to break even. Telemedicine was also associated with improvements in access to care. Using patient self-reported health care visit data (verified with local providers), we identified a significant decline in disparities between urban and rural patients (see Table ). Conclusions: Telemedicine offers a promising method for increasing access to oncology care that is convenient for and well-accepted by patients at reasonable costs. Our results also suggest that telemedicine facilitates access to more than just oncology care. The regular follow-up care provided through telemedicine visits may identify unmet need that might otherwise go untreated, yielding improvements in patient outcomes.

[Table: see text]

No significant financial relationships to disclose.

Cellular characterisation of magnetic resonance imaging bone oedema in rheumatoid arthritis; implications for pathogenesis of erosive disease

Objectives:

Magnetic resonance imaging (MRI) bone oedema is an important predictor of bone erosion in rheumatoid arthritis (RA). This study aimed to determine the cellular components of MRI bone oedema, and clarify the relationship between bone erosion and MRI bone oedema.

Methods:

Twenty-eight bones from 11 patients with RA undergoing orthopaedic surgery were analysed by quantitative and semi-quantitative immunohistochemistry. Pre-operative contrast-enhanced MRI scans were analysed for bone oedema.

Results:

The density of osteoclasts was higher in those samples with MRI bone oedema than those without MRI bone oedema (p = 0.01). Other cells identified within bone marrow included macrophages and plasma cells, and these were more numerous in samples with MRI bone oedema (p = 0.02 and 0.05 respectively). B cells were present in lower numbers, but B cell aggregates were identified in some samples with MRI bone oedema. There was a trend to increased RANKL expression in samples with MRI bone oedema (p = 0.09). Expression of RANKL correlated with the number of osteoclasts (r = 0.592, p = 0.004).

Conclusions:

The increased number of osteoclasts and RANKL expression in samples with MRI bone oedema supports the hypothesis that bone erosion in RA occurs through activation of local bone resorption mechanisms within subchondral bone as well as through synovial invasion into bone.

Technology exchange for cancer health network

19598

Background: The Technology Exchange for Cancer Health Network (TECH-Net) is a collaborative, multi-state effort to implement a systematic care program to improve cancer management in the rural communities of west Tennessee, north Mississippi and east Arkansas. This Health Information Technology (HIT) project uses a two-pronged approach to total clinical decision support: (1) provide access to oncology, hematology, and other specialists through the dedicated telehealth network of the University of Tennessee's Health Science Center in conjunction with the University of Tennessee Cancer Institute; and (2) rely on a distributed electronic health record (EHR) with integrated decision support systems for online management of cancer protocols, electronic orders, and medication management. Methods: Patients with a cancer diagnosis requiring treatment for at least one year are eligible to participate. The ultimate goal for this project is to enroll 250 patients (125 rural, 125 urban) and compare quality, safety, and cost outcomes for patients receiving rural Telehealth care versus “routine” urban care. Telehealth patients see their oncologist in person at the rural sites for initial care, and see their physician via telemedicine for approximately one-half of their subsequent visits. This approach allows the clinician to make in-person clinical assessments on a regular basis while still taking advantage of the time savings associated with telemedicine. Results: 163 patients have been enrolled in the study (127 rural, 36 urban) over 18 months. Patient satisfaction has been high - 95 % of patients indicated their telemedicine visit was as good as or better than an in-person office visit. Cost analysis comparing cost savings (physician travel time) with telemedicine costs (equipment, high speed lines) indicates that the cost-benefit depends critically on distance to the rural facility and number of physician trips avoided. Initial cost data indicate that telemedicine must save at least 5 hours of physician travel time per month to break even. Conclusions: Telemedicine offers a feasible method for increasing access to oncology care in rural areas that is well-accepted by both patients and clinicians.

No significant financial relationships to disclose.

Comparison of kinematics in skilled and unskilled arms of the same recreational baseball players

We examined mechanisms of coordination that enable skilled recreational baseball players to make fast overarm throws with their skilled arm and which are absent or rudimentary in their unskilled arm. Arm segment angular kinematics in three dimensions at 1000 Hz were recorded with the search-coil technique from the arms of eight individuals who on one occasion threw with their skilled right arm and on another with their unskilled left arm. Compared with their unskilled arm, the skilled arm had: a larger angular deceleration of the upper arm in space in the forward horizontal direction; a larger shoulder internal rotation velocity at ball release (unskilled arms had a negative velocity); a period of elbow extension deceleration before ball release; and an increase in wrist velocity with an increase in ball speed. It is suggested that some of these differences in arm kinematics occur because of differences between the skilled and unskilled arms in their ability to control interaction torques (the passive torque at one joint due to motion at adjacent joints). It is proposed that one reason unskilled individuals cannot throw fast is that, unlike their skilled counterparts, they have not developed the coordination mechanisms to effectively exploit interaction torques.

Outbreak of extended spectrum beta-lactamase producing E. coli in a nursing home in Ireland, May 2006

In May 2006, a consultant microbiologist noted two isolates of extended spectrum beta-lactamase (ESBL)-producing Escherichia coli associated with urinary tract infections in a single week in two residents in a nursing home in Ireland

Patients involved in clinical research are more concerned about intrinsic and traditional research (“publish or perish”) conflicts of interests (COI) than potential financial conflicts: Results of interviews with advanced cancer patients enrolling in phase I trials

6008

Background: Concerns exist about the potential for financial COI to bias the design, conduct, analysis, and reporting of clinical trials. However, information is lacking about the perceptions of these COI among actual research subjects—both in general and relative to more intrinsic and traditional research COI. Methods: Using a standardized survey, cancer patients (pts) were asked closed-ended and semi-qualitative questions regarding their concerns about extrinsic, e.g., financial, and intrinsic, e.g. career advancement, COI. Results: To date, 120 pts either enrolled, or being evaluated for participation, in phase I trials have been approached for an interview with 96 completing the interview (80% response rate). Median age of respondents is 61 y (33–82); 55% male; 83% Ca, 10% AA, 2% AsA or HA; 38% college educated. 91%, 100%, and 94% thought that the involved investigators (MDs), drug companies, and hospitals benefited from a clinical trial respectively. The benefits cited for MDs was improvement in knowledge/ability to treat pts. The benefits cited for the hospital and drug company were described as prestige and financial. 38% would be concerned if an MD involved in a clinical trial receives financial benefit from the research, e.g., being a paid consultant or owning stock in company involved in a trial, and 43% thought that they should be informed of these potential benefits. 64% thought they should be concerned if an MD receives career advancement benefits from trial participation, and 69% thought they should be informed of this benefit. 45% thought that investigators might feel institutional pressure to enroll pts. Qualitative data revealed that pts’ lack of concern about financial COI related to their assumption that MDs already receive financial benefits-believing this to be acceptable-with some even encouraging it. Conclusions: Cancer pts were more concerned about intrinsic and traditional research COI than potential financial COI. As well, many assume that MDs receive financial benefits from research. These results may be helpful when considering COI management policies.

No significant financial relationships to disclose.

Neuropilin-1 expression in adenocarcinoma and squamous cell carcinoma of the lung is differentially regulated by hypoxia

17152

Background: Neuropilin-1 (NRP-1) is an isoform-specific receptor for VEGF165 and semaphorin3A, initially discovered on migrating neurons. NRP-1 expression has been reported on a number of tumour cell lines in the absence of the other VEGF receptors, where it mediates survival signals. In this study we examined the regulation of NRP-1 by hypoxia, its effect on survival in a panel of lung cancer cell lines and its potential as a biomarker in retrospective human lung tumours. Methods: A549, SK-MES1, H460 and H647 cells were grown in serum depleted media (0.5%) in normoxic or hypoxic (0.1% O2) conditions and screened for NRP-1 expression by western and immunocytochemistry analysis. Cell survival and apoptosis was determined using BrdU and Annexin-V/PI staining respectively following treatment with an antibody to the extracellular NRP-1 domain. A panel of 100 retrospective resected lung tumours and matched normal samples were stained for NRP-1 expression by immunhistochemistry. Results: A549, SKMES-1 and H647 cell lines all expressed NRP-1 and displayed reduced survival following treatment with NRP-1 antibody (1ug/ml) compared to controls (A549 46%, SKMES-1 61%, H647 53%). H460 did not express NRP-1 and no survival inhibition was seen in the cell line (104%). Reduced survival was accompanied by increased apoptosis in all NRP-1 positive cell lines. Hypoxia strongly increased NRP-1 expression in the A549 adenocarcinoma (AC) cell line, while NRP-1 was decreased in SKMES-1 squamous cell carcinoma (SCC) following hypoxia. Neutralisation of NRP-1 had a greater effect in A549 cells under hypoxia (37%), with a lesser effect in SKMES-1 cells (82%). Western analysis of matched frozen normal and lung cancer biopsies showed NRP-1 overexpression in AC and decreased expression in SCC relative to normal. High NRP-1 expression was confirmed in AC and large cell carcinoma by immunohistochemistry, relative to normal. However, SCCs had a lower level of NRP-1 staining, supporting the results by western analysis and following hypoxia in vitro. Conclusions: These results implicate NRP-1 as an important survival pathway in lung cancer. Hypoxia differentially regulated NRP-1 mediated survival implicating this pathway as a potential therapeutic strategy in AC.

No significant financial relationships to disclose.

Clinical and pathological correlations in male breast cancer (MBC): Intratumoral aromatase expression (ITA) via tissue microarray (TMA)

10553

Background: Most cases of MBC are hormone-receptor (HR) positive and there is anecdotal evidence of disease response to aromatase inhibitors in the metastatic setting. Study objectives were to (i) assess clinical-pathologic characteristics in a cohort of MBC, (ii) evaluate intratumoral aromatase expression and (iii) assess its’ prognostic impact. Methods: A retrospective chart review was conducted for all cases of MBC seen at the Nova Scotia Cancer Centre between 1985–2005. Data abstracted included disease stage, tumor grade, HR status (ER/PR), HER2-neu and ITA expression as well as dates of disease recurrence and death. Tumor blocks were incorporated into 3 TMA’s with control specimens (gynecomastia, benign breast tissue, liver). Four 1.0 mm cores were taken of each tumor. Immunohistochemistry (IHC) was performed with the following antibodies; 6F11 ER primary Ab (Ventana, USA), 1A6 PR primary Ab (Ventana, USA), TAB250 monoclonal mouse anti-HER2 (Zymed, USA), DAKO 0185 rabbit anti-human c-erbB2 (DAKO, Canada), mouse anti-human p450 aromatase Ab (Cedarlane, Canada). ITA staining intensity and distribution was compared to benign hepatic tissue and if > or = to liver was called ’strong’ while < liver was called ’weak’. The log-rank test was used for survival comparisons. Kaplan-Meyer curves were used to estimate 5year disease-free (DFS) and overall (OS) survival probabilities. Results: 54 cases were identified with median age at diagnosis of 64 (31–85 yrs). Median tumor size was 2.6 cms (0.9–8cms) and 22 (41%) had nodal metastases. 45 cases had tissue available for IHC. Of these, 40 (89%) were ER and 33 (73%) were PR positive. HER2-neu was overexpressed in 4/42 (9.5%) and 12/45 (27%) had strong ITA expression. 5 yr DFS was 71% and OS was 64%. In univariate analysis strong (vs weak) ITA expression was associated with improved 5 yr OS (92% vs 49%, p = 0.038) but not DFS (82% vs 76%, p = 0.44) rates. Conclusion: The suggestion of improved OS but not DFS for those tumors with strong ITA expression may imply that these were more responsive to hormonal therapy in the metastatic setting or had a more indolent pace of progression. It is suggested that further investigation of ITA and response to hormonal therapy in MBC is warranted.

No significant financial relationships to disclose.

Internet use is associated with utilization of genetic counseling for BRCA 1/2 mutations in women with a family history of breast or ovarian cancer

10654

Background: Women obtain breast cancer risk information from a variety of sources including mass media, the internet and personal and professional sources. Little is know about how internet use for health information influences choices about breast cancer risk evaluation and decision making. Methods: Case control study of 408 women with a family history of breast or ovarian cancer, of whom 217 underwent genetic counseling for BRCA 1/2 testing (cases) and 191 women who did not (controls). Participants received primary care within a large health system in greater Philadelphia, PA. Results: Women with a family history of breast or ovarian cancer who reported frequent use of the internet for health information (>1–2 times a month) were significantly more likely to undergo genetic counseling for BRCA 1/2 testing than women that rarely used the internet to obtain health information (<2 times a year) (odds ratio 2.6; 95% CI 1.7–4.0). This association persisted after adjustment for age, race, education and Gail risk (adjusted odds ratio 2.1; 95% CI 1.05–4.2) Conclusions: Frequent use of the internet for health care information is associated with higher use of genetic counseling for BRCA 1/2 mutations in women with a family history of breast or ovarian cancer. The association can not be explained by differences in education, cancer risk, age or race. A possible hypothesis for this association is that internet use exposes women to more information about genetic testing, BRCA testing opportunities and the experiences of other women who have utilized BRCA counseling services.

No significant financial relationships to disclose.