National practice patterns of completion lymph node dissection for sentinel node-positive melanoma.

BACKGROUND AND OBJECTIVES: Close observation may be an appropriate alternative to completion lymph node dissection (CLND) for selected patient populations, especially those with minimal tumor burden in the sentinel lymph node (SLN). In this study, we examined the practice patterns of CLND utilization. METHODS: Using the National Cancer Database, we examined CLND utilization in SLN-positive patients diagnosed with clinically node-negative Stage III melanoma from 2012 to 2015. Hierarchical logistic regression models were constructed to assess the factors associated with observation after positive SLN biopsy (SLNB). RESULTS: Of the 131 171 patients identified, 55 688 (42.5%) underwent SLNB and 7200 (12.9%) had an SLN with a metastatic disease. CLND was performed in 57.0% of the patients with a positive SLNB. Patients were more likely to forgo CLND if the primary tumor was located on the lower extremity (odds ratio [OR], 1.65, 95% confidence interval [CI], 1.40-1.94), were older (P < 0.001), had multiple comorbidities (OR, 1.61, 95% CI, 1.19-2.20), or were diagnosed with melanoma in 2015 (OR, 1.33, 95% CI, 1.13-1.56 vs 2012). CONCLUSIONS: CLND utilization varied based on patient factors and decreased over time. As evidence supports close observation in selected patient populations with low SLN tumor burden, monitoring is needed to ensure that CLND is performed in the appropriate patient populations. However, this will require improvements in the data collected by cancer registries.

American Cancer Society perspectives on environmental factors and cancer.

Cancer prevention is central to the mission of the American Cancer Society (ACS). The ACS's prevention activities take many forms, but are primarily focused on modifiable risk factors that have been demonstrated to have the largest impact on cancer risk in the general population (with particular emphasis on tobacco use because of its large impact on cancer), and well-proven policy and program interventions. The ACS addresses nutrition, physical inactivity and obesity, alcohol consumption, excessive sun exposure, prevention of certain chronic infections, and selected other environmental factors through a variety of venues, including consensus guidelines (eg, nutrition and physical activity, human papillomavirus vaccination) and developing educational materials for health care providers and the general public. In contrast to the broad definition of environmental factors used by the ACS and most other public health agencies, some members of the general public associate the term "environmental" only with toxic air and water pollutants and other, predominantly manmade, hazards that people encounter, often involuntarily, in their daily life. This article will provide an overview of the ACS's approach to the prevention of cancer associated with such toxic pollutants in the context of its mission and priorities with respect to cancer prevention.

A novel technique to measure in vivo uterine suspensory ligament stiffness.

OBJECTIVE: The purpose of this study was to describe a new computer-controlled research apparatus for measuring in vivo uterine ligament force-displacement behavior and stiffness and to present pilot data for women with and without prolapse. STUDY DESIGN: Seventeen women with varying uterine support underwent testing in the operating room (OR) after anesthetic induction. A tripod-mounted computer-controlled linear servoactuator was used to quantify force-displacement behavior of the cervix and supporting ligaments. The servoactuator applied a caudally directed force to a tenaculum at 4 mm/sec velocity until the traction force reached 17.8 N (4 lbs). Cervix location on Pelvic Organ Prolapse Quantification system (POP-Q) in the clinic, in the OR, at rest, and with minimal force (<1.1 N); maximum force (17.8 N) was recorded. Ligament "stiffness" between minimum and maximum force was calculated. RESULTS: The mean ± SD subject age was 54.5 ± 12.7 years; parity was 2.9 ± 1.1; body mass index was 29.0 ± 4.3 kg/m(2), and POP-Q point C was -3.1 ± 3.9 cm. POP-Q point C was correlated most strongly with cervix location at maximum force (r = +0.68; P = .003) and at rest (r = +0.62; P = .009). Associations between cervix location at minimum force (r = +0.46; P = .059) and ligament stiffness (r = -0.44; P = .079) were not statistically significant. Cervix location in the OR with minimal traction lay below the lowest point found on POP-Q for 13 women. CONCLUSION: POP-Q point C was correlated strongly with cervix location at rest and at maximum traction force; however, only 19% of the variation in POP-Q point C location was explained by ligament stiffness. The cervix location in the OR at minimal traction lay below POP-Q point C value in three-fourths of the women.

Concerns and frustrations about the public reporting of device-related healthcare-associated infections: Perspectives of hospital leaders and staff.

BACKGROUND: Public reporting of healthcare-associated infections (HAIs) aims to incentivize improvement in infection prevention. The motivation and mechanisms of public reporting have raised concerns about the reliability of this data, but little is known about the specific concerns of hospital leaders and staff. This study sought to better understand perspectives of individuals in these roles regarding the identification and public reporting of HAIs. METHODS: We conducted interviews with 471 participants including hospitals leaders (eg, administrative and clinical leaders) and hospital staff (eg, physicians and nurses) between 2017 and 2019 across 18 US hospitals. A semistructured interview guide was used to explore perspectives about the use of HAI data within the context of management strategies used to support infection prevention. RESULTS: Interviewees described concerns about public reporting of HAI data, including a lack of trust in the data and inadvertent consequences of its public reporting, as well as specific frustrations related to the identification and accountability for publicly-reported HAIs. CONCLUSION: Concerns and frustrations related to public reporting of HAI data highlight the need for improved guidelines, transparency, and incentives. Efforts to build trust in publicly-reported HAI data can help ensure this information is used effectively to improve infection prevention practices.

Comprehensive analysis of common genetic variation in 61 genes related to steroid hormone and insulin-like growth factor-I metabolism and breast cancer risk in the NCI breast and prostate cancer cohort consortium.

There is extensive evidence that increases in blood and tissue concentrations of steroid hormones and of insulin-like growth factor I (IGF-I) are associated with breast cancer risk. However, studies of common variation in genes involved in steroid hormone and IGF-I metabolism have yet to provide convincing evidence that such variants predict breast cancer risk. The Breast and Prostate Cancer Cohort Consortium (BPC3) is a collaboration of large US and European cohorts. We genotyped 1416 tagging single nucleotide polymorphisms (SNPs) in 37 steroid hormone metabolism genes and 24 IGF-I pathway genes in 6292 cases of breast cancer and 8135 controls, mostly Caucasian, postmenopausal women from the BPC3. We also imputed 3921 additional SNPs in the regions of interest. None of the SNPs tested was significantly associated with breast cancer risk, after correction for multiple comparisons. The results remained null when cases and controls were stratified by age at diagnosis/recruitment, advanced or nonadvanced disease, body mass index, with or without in situ cases; or restricted to Caucasians. Among 770 estrogen receptor-negative cases, an SNP located 3' of growth hormone receptor (GHR) was marginally associated with increased risk after correction for multiple testing (P(trend) = 1.5 × 10(-4)). We found no significant overall associations between breast cancer and common germline variation in 61 genes involved in steroid hormone and IGF-I metabolism in this large, comprehensive study. Although previous studies have shown that variations in these genes can influence endogenous hormone levels, the magnitude of the effect of single SNPs does not appear to be sufficient to alter breast cancer risk.

Cigarette smoking and the risk of incident and fatal melanoma in a large prospective cohort study.

OBJECTIVE: Previous studies suggest that smoking may be inversely associated with risk of melanoma. We attempted to replicate this finding using data from the Cancer Prevention Study II (CPS-II) and CPS-II Nutrition cohort, two large prospective cohort studies of cancer mortality and incidence, respectively, with long-term follow-up. METHODS: Cox proportional hazards regression analysis was used to examine the association between smoking status and risk of melanoma mortality and incidence among Caucasians in these cohorts. Analyses were adjusted by age, occupation, latitude and educational status. RESULTS: The incidence rate of melanoma was lower in current than never smokers in both men [hazard ratio (HR): 0.70, 95% confidence interval (CI): (0.48-1.02)] and women [0.50 (0.30-0.83)]; incidence was not lower in former than in never smokers for either sex. The death rate from melanoma was lower in male current than never smokers [0.77 (0.62-0.94)], and in male and female former smokers [0.86 (0.73-1.01)] and [0.83 (0.65-1.06)], respectively. No trends in incidence or mortality were observed in male or female current smokers with years of smoking or cigarettes per day. CONCLUSIONS: This study provides limited support for the hypothesis that smoking reduces melanoma risk. The inconsistent results by smoking status and lack of clear dose-response relationships weaken the evidence for causality.

The global burden of cancer: priorities for prevention.

Despite decreases in the cancer death rates in high-resource countries, such as the USA, the number of cancer cases and deaths is projected to more than double worldwide over the next 20-40 years. Cancer is now the third leading cause of death, with >12 million new cases and 7.6 million cancer deaths estimated to have occurred globally in 2007. By 2030, it is projected that there will be approximately 26 million new cancer cases and 17 million cancer deaths per year. The projected increase will be driven largely by growth and aging of populations and will be largest in low- and medium-resource countries. Under current trends, increased longevity in developing countries will nearly triple the number of people who survive to age 65 by 2050. This demographic shift is compounded by the entrenchment of modifiable risk factors such as smoking and obesity in many low-and medium-resource countries and by the slower decline in cancers related to chronic infections (especially stomach, liver and uterine cervix) in economically developing than in industrialized countries. This paper identifies several preventive measures that offer the most feasible approach to mitigate the anticipated global increase in cancer in countries that can least afford it. Foremost among these are the need to strengthen efforts in international tobacco control and to increase the availability of vaccines against hepatitis B and human papilloma virus in countries where they are most needed.

An Examination of the Barriers to and Facilitators of Implementing Nurse-Driven Protocols to Remove Indwelling Urinary Catheters in Acute Care Hospitals.

BACKGROUND: Urinary catheter nurse-driven protocols (UCNDPs) for removal of indwelling urinary catheters (IUCs) can potentially prevent catheter-associated urinary tract infections (CAUTIs). However, they are used inconsistently. The objective of this study was to examine the barriers to and facilitators of implementation of UCNDPs in acute care hospitals. METHODS: Between September 2017 and January 2019, researchers interviewed 449 frontline staff (nurses, physicians), managers, and executives from 17 US hospitals to better understand their experiences implementing, using, and overseeing use of UCNDPs. Our semistructured interview guide included questions about management practices and policies regarding enactment of a UCNDP. RESULTS: Although the features of UCNDPs differed across hospitals, the analysis revealed that hospitals experienced common issues related to implementing and consistently using UCNDPs as a result of three major barriers: (1) nurse deference to physicians, (2) physician push-back, and (3) miscommunication about IUC removal. Interviewees also described several important facilitators to help overcome these barriers: (1) training care team members to use the UCNDP, (2) discussing IUC necessity and UCNDP use during rounds, (3) reminding care team members to follow UCNDPs, and (4) developing buy-in for UCNDP use across the hospital. CONCLUSION: Although UCNDPs are fundamental in efforts to reduce and prevent CAUTIs, hospitals can proactively support their implementation and use by developing the skills that care team members need to enact UCNDPs when patients meet the clinical indications for removal, and increasing awareness about the value and importance of such protocols for reducing CAUTIs and improving patient safety.

Disparities in the diagnostic evaluation of microhematuriaand implications for the detection of urologic malignancy.

INTRODUCTION: Disparities in survival for bladder and kidney cancer among the genders and patients with varying insurance coverage have been identified. Microhematuria (MH), a potential early clinical sign of genitourinary malignancy, should prompt a standardized diagnostic evaluation. However, many patients do not complete a full evaluation and may be at risk of a missed or delayed identification of genitourinary pathology. METHODS: Patients 35 and older with a new diagnosis of MH between 2007 and 2015 were retrospectively identified at a large health system. Our primary outcome of interest was completion of cystoscopy and imaging. Regression modeling was used to assess associations between gender and insurance status with completion of a MH evaluation, adjusted for clinical factors, urinalysis data, and patient demographics. RESULTS: Of 15,161 patients with MH, only 1,273 patients (8.4%) completed upper tract imaging and a cystoscopy; 899 (5.9%) within 1 year. Median time to imaging was 75days and 68.5days for cystoscopy. Of those with an incomplete evaluation, 23.7% underwent cystoscopy and 76.3% underwent imaging. Male gender, private insurance, and increased MH severity on UA were associated with a complete evaluation. More patients who completed an evaluation were diagnosed with bladder (4.8% vs. 0.3%) and kidney cancer (3.1% vs. 0.4%) when compared to those who did not. CONCLUSION: Few patients complete a timely evaluation of MH. Women and underinsured patients are disproportionately less likely to complete a work-up for microhematuria and this may have downstream implications for diagnosis.

Recent trends in Black-White disparities in cancer mortality.

Despite decreases in overall cancer death rates across all racial and ethnic groups since the early 1990s, racial disparities in cancer mortality persist. We examined temporal trends in Black-White disparities in cancer mortality from all sites combined, smoking-related cancers (lung and a group including oral cavity, pharynx, larynx, esophagus, pancreas, bladder, and kidney), and sites affected, or potentially affected by screening and treatment (breast, prostate, colon/rectum). Death rates, rate differences, and rate ratios comparing Blacks to Whites from 1975 through 2004 were based on mortality data from the National Center for Health Statistics. The Black-White disparity in overall cancer death rates narrowed from the early 1990s through 2004, especially in men. This reduction was driven predominantly by more rapid decreases in mortality from tobacco-related cancers in Black men than White men. In contrast, racial disparities in mortality from cancers potentially affected by screening and treatment increased over most of the interval since 1975. Coordinated efforts to improve early detection and treatment for all segments of the population are essential to eliminate racial disparities in cancer mortality.

Dipstick Urinalysis as a Test for Microhematuria and Occult Bladder Cancer.

Introduction: There is a lack of evidence supporting the routine use of laboratory tests to detect bladder cancer. Identifying a cost-effective and widely available diagnostic aid may improve bladder cancer outcomes. We sought to evaluate the utility of dipstick urinalysis to detect microhematuria and diagnose bladder cancer in a large, diverse, contemporary cohort. Methods: All non-pregnant women and men 35 and older with a new diagnosis of microhematuria (≥3 RBC/hpf) were identified via a multi-center electronic medical record data warehouse query. Negative controls with no history of hematuria were randomly chosen and included to complete our cohort. Comparison between dipstick urinalysis and microscopic urinalysis on self-matched patients for the detection of microhematuria and diagnosis of bladder cancer was performed via Spearman's rank correlation coefficient, sensitivity/specificity testing, and ROC curve analysis. Results: A total of 46,842 patients were included. Spearman's rank order correlation (rho = 0.66) between degree of microhematuria on dipstick urinalysis and microscopic urinalysis indicated a strong positive relationship. The ROC curve for dipstick urinalysis to identify microhematuria had an AUC of 0.80 (95% CI 0.79-0.81). No difference (p = 0.83) in diagnostic accuracy between dipstick urinalysis (AUC 0.74, 95% CI 0.70-0.78) and microscopic urinalysis (AUC 0.73, 95% CI 0.69-0.78) as a test for bladder cancer was found. Conclusion: Dipstick urinalysis provides a highly specific test for microhematuria and similar accuracy to microscopic urinalysis when used as a diagnostic tool to detect bladder cancer.

National comparison of oncologic quality indicators between open and robotic-assisted radical cystectomy.

INTRODUCTION: Despite increased adoption of robotic-assisted radical cystectomy (RARC), no national data have validated its oncologic efficacy compared to the "standard" open radical cystectomy (ORC). Positive surgical margins (PSM) and lymph node (LN) yield during radical cystectomy (RC) have an established relationship with bladder cancer outcomes. Here, we propose these 2 as quality indicators for RC and assess their differences to compare the oncologic efficacy between RARC and ORC. METHODS: Using the National Cancer Data Base for the years 2010 to 2012, all patients who underwent ORC or RARC were analyzed. Baseline demographic and cancer stage information were compared as well as unadjusted rates of PSM and LN yield. Survival effect of each indicator was assessed. Using propensity score adjustment, rates of PSM and LN yield were compared between RARC and ORC. RESULTS: A total of 12,036 patients are included who underwent RC, 20% (2,397) of which were performed robotically. Percentage RARC of total RC increased from 16.2% to 23.3% over the 3 study years. Compared to ORC, patients who underwent RARC were no different in age but were more often men (78.4% vs. 73.6%, P<0.001), had less-advanced cancer stage, and were more likely to have received neoadjuvant chemotherapy (20.9% vs. 14.5%, P<0.001). Most RARC procedures were performed at academic medical centers (66.1%). Unadjusted rates of PSM were lower in the RARC group (10.8% vs. 13.2%, P = 0.002) whereas median LN yield was higher in RARC patients (16 [interquartile range 9, 25] vs. 11 [interquartile range 5, 19], P<0.001). After propensity score covariate adjustment, there was no significant difference in PSM rate between RARC and ORC (-1.12% difference, [95% CI:-2.8, 0.32%]. However, RARC was associated with a higher node yield (+3.32 LN, [95% CI: 2.61, 4.03]) than ORC (P<0.001). CONCLUSION: The RARC is becoming more prevalent. In a national cohort, RARC was performed more often on men, with lower stage cancer, who were more likely to receive neoadjuvant chemotherapy. Controlling for these factors, RARC had comparable PSM rates but slightly higher LN yield than ORC.

Risk of non-melanoma cancers in first-degree relatives of CDKN2A mutation carriers.

The purpose of this study was to quantify the risk of cancers other than melanoma among family members of CDKN2A mutation carriers using data from the Genes, Environment and Melanoma study. Relative risks (RRs) of all non-melanoma cancers among first-degree relatives (FDRs) of melanoma patients with CDKN2A mutations (n = 65) and FDRs of melanoma patients without mutations (n = 3537) were calculated as the ratio of estimated event rates (number of cancers/total person-years) in FDRs of carriers vs noncarriers with exact Clopper-Pearson-type tests and 95% confidence intervals (CIs). All statistical tests were two-sided. There were 56 (13.1%) non-melanoma cancers reported among 429 FDRs of mutation carriers and 2199 (9.4%) non-melanoma cancers in 23 452 FDRs of noncarriers. The FDRs of carriers had an increased risk of any cancer other than melanoma (56 cancers among 429 FDRs of carrier probands vs 2199 cancers among 23 452 FDRs of noncarrier probands; RR = 1.5, 95% CI = 1.2 to 2.0, P = .005), gastrointestinal cancer (20 cancers among 429 FDRs of carrier probands vs 506 cancers among 23 452 FDRs of noncarrier probands; RR = 2.4, 95% CI = 1.4 to 3.7, P = .001), and pancreatic cancer (five cancers among 429 FDRs of carrier probands vs 41 cancers among 23 452 FDRs of noncarrier probands; RR = 7.4, 95% CI = 2.3 to 18.7, P = .002). Wilms tumor was reported in two FDRs of carrier probands and three FDRs of noncarrier probands (RR = 40.4, 95% CI = 3.4 to 352.7, P = .005). The lifetime risk of any cancer other than melanoma among CDKN2A mutation carriers was estimated as 59.0% by age 85 years (95% CI = 39.0% to 75.4%) by the kin-cohort method, under the standard assumptions of Mendelian genetics on the genotype distribution of FDRs conditional on proband genotype.

Alcohol consumption not associated with lung cancer mortality in lifelong nonsmokers.

Although alcohol consumption is associated with increased lung cancer risk in some studies, this relationship is difficult to interpret because of potential confounding by smoking. We measured lung cancer death rates in relation to self-reported alcohol consumption among 223,216 adults who reported no history of regular smoking when enrolled in a large prospective mortality study begun by the American Cancer Society in 1982. Participants were at least 30 years of age when enrolled and, consequently, were considered unlikely to initiate smoking during follow-up. During 24 years of follow-up, we identified 1,058 deaths from lung cancer. Cox proportional hazards analyses were conducted, adjusting for age, education, occupation, and race. No association between lung cancer mortality and any level of alcohol consumption was seen in men or women. Even among those who consumed four or more alcoholic drinks per day, the risk did not differ from those who abstained from alcohol [hazard ratios 0.97 (95% confidence interval, 0.76-1.22) and 0.69 (0.41-1.16) for men and women, respectively]. Due to the large population of lifelong nonsmokers in our cohort and the long period of follow-up, these findings provide substantial evidence against the hypothesis that alcohol consumption independently increases lung cancer risk.

Occupational exposure to metribuzin and the incidence of cancer in the Agricultural Health Study.

PURPOSE: Little is known about the potential carcinogenicity of the triazinone herbicide metribuzin. We evaluated the association between metribuzin use and cancer risk in the Agricultural Health Study, a prospective cohort study of licensed pesticide applicators in Iowa and North Carolina. METHODS: Applicators (N=23,072) provided information on metribuzin use on a self-administered questionnaire at enrollment (1993-1997). Among metribuzin users (n=8,504), there were 554 incident cancer cases. We used multivariable Poisson regression to evaluate potential associations between metribuzin use and cancer incidence by using two quantitative exposure metrics, lifetime days and intensity-weighted lifetime days. RESULTS: Using intensity-weighted lifetime days, the rate ratio (RR) and 95% confidence interval (CI) for the highest exposed tertile for lymphohematopoietic malignancies were 2.09 (95% CI: 0.99-4.29), p trend=0.02 and 2.42 (95% CI: 0.82-7.19), p trend=0.08 for leukemia. For non-Hodgkin lymphoma, the RR was 2.64 (95% CI: 0.76-9.11), p trend=0.13 for lifetime days and 2.52 (95% CI: 0.66-9.59), p trend=0.13 for intensity-weighted lifetime days. Patterns of association were similar for both exposure metrics, but associations were generally weaker than for intensity-weighted days. CONCLUSIONS: The results from this study suggest a potential association between metribuzin use and certain lymphohematopoietic malignancies; however, having not been observed previously, caution should be used in interpretation.