Surgery News - April 2008 - (Page 3)

APRIL 2008 • SURGERY NEWS NEWS Improved Melanoma Outcomes Congressmen Aiming Linked to Guideline Compliance For 18-Month Fee Fix B Y P AT R I C E W E N D L I N G Else vier Global Medical Ne ws C H I C A G O — Adherence to national cancer treatment guidelines was associated with decreased local and regional recurrence, improved disease-free and overall survival, and decreased treatment-associated morbidity in a study of 327 consecutive clinically node-negative melanoma patients. A review of cancer registry data at Rush North Shore Medical Center in Skokie, Ill., revealed that 72% of patients were treated in compliance with National Comprehensive Cancer Network (NCCN) recommendations for margins of excision, Dr. Jennifer Erickson Foster and colleagues reported at a symposium sponsored by the Society of Surgical Oncology. Appropriate lymph node staging and treatment was received by 271 patients or 83%. Interestingly, when treatment was performed by a surgical oncologist, margin compliance was 95% and lymph node compliance 92%, said Dr. Foster, the lead investigator. A recommended completion lymph node dissection was performed for a positive sentinel lymph node in 78% of patients. Patients treated in a noncompliant fashion with regard to margins had a threefold increase in postoperative complications in comparison with those treated in a compliant fashion. Similarly, patients treated in a lymph node–noncompliant fashion were 2.4 times more likely to have a postoperative complication. Both findings were statistically significant, said Dr. Erickson Foster, who reported no conflicts of interest for the investigators. Noncompliance with NCCN guidelines for mar- gins of excision was associated with increased locoregional (26% vs. 6%) and distant recurrence (8% vs. 6%), as compared with compliant cases. Locoregional disease alone as the first site of relapse was seen in 33% of lymph node–noncompliant cases vs. 6% of lymph node–compliant cases. Five-year disease-free survival was higher among margin-compliant cases, compared with marginnoncompliant cases (86% vs. 68%), as was 5-year overall survival (93% vs. 83%). Similar increases in disease-free (85% vs. 54%) and overall (95% vs. 66%) survival were observed with compliance to lymph node staging and treatment recommendations. The mean follow-up was 51 months (minimum 18 months) and mean age 66 years; 53% of the patients were women, and 32% of melanomas were located on the trunk. Postoperative complications were reported in 55 patients (17%). “These findings suggest that compliance with NCCN guidelines improves outcomes in clinically node-negative melanoma patients,” senior author Dr. Tina J. Hieken, a surgeon at Rush Medical College, in Chicago, said in an interview. Audience member Dr. Daniel G. Coit, who cochaired the NCCN guideline committee for melanoma, stressed that noncompliance with recommendations should not be equated with poor medical care. “Guidelines are a point of departure,” said Dr. Coit of Memorial Sloan-Kettering Cancer Center in New York. “They are not how we must do it, and we need to be very careful about how we define that, because there are other people who don’t know that and will be looking at these kinds of presentations very carefully, and they’re going to come to the wrong conclusion.” B Y A L I C I A A U LT Else vier Global Medical Ne ws WA S H I N G T O N — Several members of Congress who spoke at a conference sponsored by the American Academy of Otolaryngology–Head and Neck Surgery said they were hopeful that their colleagues would enact legislation quickly to increase physician fees for at least 18 months. The current legislation, due to expire in June, was a slap in the face to physicians, said Rep. Mike Burgess (R-Tex.). “What an insult,” said Rep. Burgess, an ob.gyn. who introduced a bill in March to reset the sustainable growth rate formula baseline to the year of 2007 and to eliminate it in 2010. The bill, H.R. 5545, would also improve incentives for e-prescribing and for participation in the Physicians Quality Reporting Initiative. At press time, the bill had no cosponsors. It had been referred to the House Ways and Means Committee and the House Energy and Commerce Committee. Rep. Bart Gordon (R-Tenn.), a senior member of the Energy and Commerce Health Subcommittee, said he was hopeful that corrective legislation would be passed, including a fee increase through 2009. The Ways and Means Health Subcommittee chairman, Rep. Pete Stark (D-Calif.), seemed less sanguine about quick action this year. But he said that the Senate has promised to have a bill by April. The most likely scenario is a reimbursement fix that follows the Medicare Payment Advisory Commission’s recommendation of a 1%-2% increase over the next few years, said Rep. Stark. The next 4-6 years will be incredibly exciting for the health reform movement, he said. Rep. Tom Price (R-Ga.), a physician and Fellow of the American College of Surgeons, shares this opinion. He introduced a bill in midFebruary (H.R. 5445) to increase physician fees by 1% for the remainder of 2008, and 1.8% for 2009. That bill was referred to the Ways and Means Committee and to the Energy and Commerce Committee. At press time, the bill had 2 dozen or so cosponsors. Some Say Findings Fail ‘Sniff Test’ Dissection • from page 1 lines recommend that a CLND should be performed for sentinel lymph node–positive melanoma, and that the CLND and SLNB should generally be performed in separate operations to allow for detailed histologic examination. An optimal lymph node evaluation count was recently included in the guidelines, suggesting that 15 or more nodes be examined for cervical and axillary dissections and 10 or more be examined for inguinal dissections. Of the 1,470 patients who underwent a dissection, Dr. Bilimoria and his coinvestigators found 453 or 31% had fewer than 10 nodes examined. Patients were less likely to have 10 or more nodes evaluated if they had lowerextremity melanoma or were treated at low-volume and community hospitals. Significantly more nodes were harvested at NCCN/NCI centers than at community hospitals (16 vs. 13) and at the highestversus the lowest-volume hospitals (17 vs. 13). The mean age of the patients was 59 years. Many audience members were incredulous and insisted the data on which the findings were based did not pass the “sniff test.” “I think [these are] very important data that we need to be able to tap into, but [they show us] still the frailties of the database,” said Dr. Rosa Cuenca, an ACS Fellow and director of the Breast Wellness Center at the Titus Regional Medical Center in Mount Pleasant, Tex. “I have a real hard time believing these numbers represent an accurate picture,” said Dr. Vernon Sondak, an ACS Fellow and chief of the division of cutaneous oncology at the H. Lee Moffitt Cancer Center, in Tampa, Fla. In particular, Dr. Sondak took umbrage with the finding that only 42% of patients (615/1,470) underwent CLND as a separate surgery after their SLNB. In his experience, 1% or less of SLNB procedures are converted to a simultaneous CLND operation, Dr. Sondak said. An impromptu show of hands by the audience revealed that hardly any physicians in the audience regularly used routine frozen sections during SLNB, which would be needed to perform a simultaneous CLND. Dr. Bilimoria responded that it is possible, but unlikely, that the data were incorrect because the investigators were able to exclude patients who had clinically positive nodes, where the procedure coding was unambiguous, and when it was unlikely that patients were referred to other hospitals that are not Commission on Cancer approved to complete their procedure. He also noted that the findings are in sync with those published in the landmark paper by McGlynn et al. showing that only 55% of Americans received rec- ommended care across 30 acute and chronic conditions (N. Engl. J. Med. 2003;348:2635-45). A second study showed a declining rate of CLND utilization among melanoma patients, from 76% in 1998 to 66% in 2001 ( J. Clin. Oncol. 2005;23:6054-62). “Some of the gap may also be due to changing attitudes toward the need for a CLND, which will become clearer with the completion of the MSLT II [Multicenter Selective Lymphadenectomy Trial II],” Dr. Bilimoria said in an interview. “Moreover, some surgeons and patients may elect to forgo CLND when microscopic or IHC [immunohistochemical]only sentinel node metastases are found, as opposed to when a larger tumor burden is discovered in the sentinel node.” Dr. Harald Hoekstra, of the University of Groningen (the Netherlands), was “shocked” by the data because in his homeland of the Netherlands, 99% of patients with a positive sentinel node achieve a CLND—the current standard of care. “How is it possible that 50% of the patients were not treated in the United States with this series according to guidelines?” he asked. “The figures are wrong or the doctors are not treating patients according to what is called evidence-based medicine.” One of the strongest indicators that the data were correct, Dr. Bilimoria said, was that a similar analysis in breast cancer patients revealed that 90% of these patients underwent CLND. As for why the breast data seem concordant while the melanoma data are so shocking, part of the answer may lie in the assumption that these patients were treated by surgical oncologists, when in fact many may have been seen by plastic surgeons or dermatologists, who have a different view of the disease, suggested Dr. Paula Termuhlen, an ACS Fellow at Wright State University, in Dayton, Ohio. Surgeon-specific information was not available in the database, but will be starting next year, said Dr. Bilimoria, who disclosed no conflicts of interest. Dr. Daniel G. Coit, an ACS Fellow with Memorial Sloan-Kettering Cancer Center in New York who cochaired the NCCN melanoma guidelines committee, called for the data to be audited before it is formally publis

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Surgery News - April 2008 Contents Comorbidities Sway Bariatric Outcomes Database Finds Gap in Dissection For Melanoma Future Surgeon Shortage Predicted Dexterity Demo Best for Bile? Health Policy Scan Plan

Surgery News - April 2008

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