Impact of Clinical Pharmacy Surveillance on Pharmacy Services: A Quality Improvement Project.

GOAL: The purpose of this quality improvement project was to retrospectively evaluate pharmacist time to clinical surveillance alert intervention before and after implementing a pharmacy-directed alert priority category across a large for-profit United States health system with well-established clinical pharmacy surveillance software integrated into the clinical pharmacy workflow. The findings contributed to a financial evaluation of pharmacist productivity compared with drug spend for pharmacy-directed interventions that included intravenous (IV)-to-oral-conversion and renal dosing opportunities. METHODS: A retrospective quality improvement pre-/postanalysis of deidentified, prepopulated clinical surveillance alert data for the preimplementation period of January 1, 2021, through September 30, 2021, was compared with that for the postimplementation period of November 1, 2021, to January 31, 2022, for 169 hospitals. Clinical pharmacist workflow was mapped pre- and postimplementation. The average time to alert intervention was calculated using the mean time in minutes between the alert firing within the software and when the pharmacist reviewed the alert, grouped by hospital, alert status, and priority category. Medications converted from IV to oral were assessed using the clinical surveillance software IV-to-oral calculator. Postimplementation renal dose cost savings were modeled using pharmacist-completed alerts by rule name that indicated a possible dose decrease based on the patient's renal function and current medication. PRINCIPAL FINDINGS: Time to alert intervention for all completed pharmacist interventions was reduced for high-priority alerts by 32.6 min (p < .001) and routine-priority alerts by 65.1 min (p = .147). Alerts that moved to the pharmacy-directed alert priority category resulted in a reduced time to alert intervention of 38.7 min (p = .003). Normalized average wholesale price (AWP) cost savings from IV-to-oral conversion within 3 days of conversion eligibility were $1,693,600 in the preimplementation period and $1,867,400 in the postimplementation period, a $173,700 increase in cost savings. A total of 7,972 completed postimplementation renal dose adjustments resulted in a modeled AWP normalized cost savings of $1,076,700. PRACTICAL APPLICATIONS: Results indicated that optimizing clinical surveillance software alerts was effective and increased pharmacist productivity. Specifically, creating a pharmacy-directed alert category that pharmacists were able to complete by hospital policy or protocol improved workflow efficiency and increased IV-to-oral medication conversion cost savings. Further study is needed to validate the renal dose-modeled cost savings and address the financial benefits of quality measures to prevent acute kidney injury.

Operationalizing a Medication Safety Gap Assessment for a Large Health System.

Background: Medication errors continue to be a leading cause of medical errors. In the United States alone, 7000 to 9000 people die annually due to a medication error, and many more are harmed. Since 2014, the Institute for Safe Medication Practices (ISMP) has advocated for several best practices in acute care facilities derived from reports of patient harm. Methods: The medication safety best practices chosen for this assessment were based on the 2020 ISMP Targeted Medication Safety Best Practices (TMSBP) and health system-identified opportunities. Each month, for 9 months, select best practices were covered with associated tools to assess the current state, document the gap, and close identified gaps. Results: Overall, 121 acute care facilities participated in most safety best practice assessments. Of the best practices assessed, there were 8 practices that more than 20 hospitals documented as not implemented and 9 practices where more than 80 hospitals had fully implemented them. Conclusion: Full implementation of medication safety best practices is a resource-intensive process that requires strong change management leadership at a local level. As noted by the redundancy in published ISMP TMSBP, there is an opportunity to continue improving safety in acute care facilities across the United States.

Elevating Exposure of Pharmacy Services and Medication Management.

Description Medications are the mainstay of treatment for many disorders and diseases. Our guest editorial board is proud to highlight the complexity of medication management and the talented pharmacists dedicated to safety and effectiveness. This special issue of the HCA Healthcare Journal of Medicine is dedicated specifically to pharmacy services across the healthcare spectrum, featuring pharmacist medication management research and education aimed at enhancing the safety of patients and colleagues.

Reducing Unnecessary Acid Suppression Use in Hospitalized Patients: A Description of Targeted Strategies Implemented Across a Large Health System.

Background: Ensuring the appropriate use of proton pump inhibitors (PPIs) and histamine type 2-receptor antagonists (H2RAs) is an important hospital patient safety and quality initiative because therapy may be inappropriately continued during transitions of care. In this article, we aim to describe the impact of targeted quality improvement strategies to reduce unnecessary acid suppression use in hospitalized patients across a large health system. Methods: Beginning January 1, 2018, focused quality improvement strategies to prevent unnecessary initiation and continuation of proton pump inhibitors (PPIs) and histamine type 2-receptor antagonists (H2RAs) were implemented throughout a large health system. Targeted strategies were initially tested as part of the PPI deprescribing Institute for Healthcare Improvement (IHI) International Innovators Network initiative and were expanded to include H2RAs for hospitalized patients. Strategies to decrease PPIs and H2RAs during hospitalization included standardization of stress ulcer prophylaxis care pathways, evidence-based order set modifications, technology-driven support, and clinical pharmacy metric performance to goal. PPI/H2RA days of therapy (DOT) per 1000 patient days were measured from the first quarter (1Q) of 2017 to the fourth quarter (4Q) of 2021 to determine if implemented strategies resulted in improvement. Results: After quality improvement strategies were implemented, the number of PPI/H2RA DOT was reduced by 7.9 days per 1000 patient days each quarter over 4 years. The average PPI/H2RA DOT per 1000 patient days decreased from 592 (1Q 2017) to 439 (4Q 2021). In the fourth quarter of 2018, 45 hospitals (28%) achieved a 10% reduction in combined PPI/H2RA DOT per 1000 patient days, and 121 hospitals (97%) attained the goal of greater than 25% of eligible patients deprescribed PPI/H2RA for ICU patients in the fourth quarter of 2019. In the fourth quarter of 2020, 97 hospitals (87%) met the metric of 40% or more of eligible patients deprescribed from PPI/H2RA in or after an ICU stay, and 85 hospitals (87%) reached 50% or more of eligible patients deprescribed PPI/H2RA in or after an ICU stay in 4Q2021. Conclusion: Targeted quality improvement strategies decreased unnecessary PPI and H2RA use for a large health system over 4 years. Continually evaluating measured results along with establishing a new clinical pharmacy metric goal each year to encourage further improvement contributed to deprescribing success.

Implementation of Clinical Pharmacy Surveillance Technology and a Pharmacy Practice Model Re-Design Across a Multi-State Health System.

Background: Outcomes-directed pharmacy models are necessary to further comprehensive, patient-centric clinical care. This report describes the implementation of clinical surveillance technology and the development of clinical pharmacy metrics to measure outcomes that support return on investment. The overall goal of clinical surveillance technology implementation in this quality improvement project was to extend the pharmacists' reach and to improve patient safety and clinical outcomes with greater operational efficiencies. Methods: In 2013, a clinical pharmacy surveillance tool was piloted and expanded over the next 2 years to 154 hospitals across the health system. Over the next 6 years, the number of hospitals utilizing the technology, the number of drug therapy modifications, the time to pharmacist intervention, clinical pharmacy metric results, and return on investment were tracked. Results: From 2015 to 2021, the number of hospitals with clinical surveillance technology implemented grew to 177 hospitals. During this same time, the number of frontline clinical pharmacist drug therapy modifications more than doubled, and the time for pharmacists to respond to alerts decreased from 13.9 to 2.6 hours. Since 2015, the percentage of patients on vancomycin de-escalated by 3 days of therapy has increased by 12% and the percentage of patients with a UTI treated with fluoroquinolone decreased by 25%. Hard and soft dollar savings resulted in an annual return on investment of 1:12.9. Conclusion: After implementing the redesigned pharmacy services model, pharmacists were more efficient and patient outcomes improved.

Breast Cancer Statistics, 2022.

This article is the American Cancer Society's update on female breast cancer statistics in the United States, including population-based data on incidence, mortality, survival, and mammography screening. Breast cancer incidence rates have risen in most of the past four decades; during the most recent data years (2010-2019), the rate increased by 0.5% annually, largely driven by localized-stage and hormone receptor-positive disease. In contrast, breast cancer mortality rates have declined steadily since their peak in 1989, albeit at a slower pace in recent years (1.3% annually from 2011 to 2020) than in the previous decade (1.9% annually from 2002 to 2011). In total, the death rate dropped by 43% during 1989-2020, translating to 460,000 fewer breast cancer deaths during that time. The death rate declined similarly for women of all racial/ethnic groups except American Indians/Alaska Natives, among whom the rates were stable. However, despite a lower incidence rate in Black versus White women (127.8 vs. 133.7 per 100,000), the racial disparity in breast cancer mortality remained unwavering, with the death rate 40% higher in Black women overall (27.6 vs. 19.7 deaths per 100,000 in 2016-2020) and two-fold higher among adult women younger than 50 years (12.1 vs. 6.5 deaths per 100,000). Black women have the lowest 5-year relative survival of any racial/ethnic group for every molecular subtype and stage of disease (except stage I), with the largest Black-White gaps in absolute terms for hormone receptor-positive/human epidermal growth factor receptor 2-negative disease (88% vs. 96%), hormone receptor-negative/human epidermal growth factor receptor 2-positive disease (78% vs. 86%), and stage III disease (64% vs. 77%). Progress against breast cancer mortality could be accelerated by mitigating racial disparities through increased access to high-quality screening and treatment via nationwide Medicaid expansion and partnerships between community stakeholders, advocacy organizations, and health systems.

Cancer treatment and survivorship statistics, 2022.

The number of cancer survivors continues to increase in the United States due to the growth and aging of the population as well as advances in early detection and treatment. To assist the public health community in better serving these individuals, the American Cancer Society and the National Cancer Institute collaborate triennially to estimate cancer prevalence in the United States using incidence and survival data from the Surveillance, Epidemiology, and End Results cancer registries, vital statistics from the Centers for Disease Control and Prevention's National Center for Health Statistics, and population projections from the US Census Bureau. Current treatment patterns based on information in the National Cancer Database are presented for the most prevalent cancer types by race, and cancer-related and treatment-related side-effects are also briefly described. More than 18 million Americans (8.3 million males and 9.7 million females) with a history of cancer were alive on January 1, 2022. The 3 most prevalent cancers are prostate (3,523,230), melanoma of the skin (760,640), and colon and rectum (726,450) among males and breast (4,055,770), uterine corpus (891,560), and thyroid (823,800) among females. More than one-half (53%) of survivors were diagnosed within the past 10 years, and two-thirds (67%) were aged 65 years or older. One of the largest racial disparities in treatment is for rectal cancer, for which 41% of Black patients with stage I disease receive proctectomy or proctocolectomy compared to 66% of White patients. Surgical receipt is also substantially lower among Black patients with non-small cell lung cancer, 49% for stages I-II and 16% for stage III versus 55% and 22% for White patients, respectively. These treatment disparities are exacerbated by the fact that Black patients continue to be less likely to be diagnosed with stage I disease than White patients for most cancers, with some of the largest disparities for female breast (53% vs 68%) and endometrial (59% vs 73%). Although there are a growing number of tools that can assist patients, caregivers, and clinicians in navigating the various phases of cancer survivorship, further evidence-based strategies and equitable access to available resources are needed to mitigate disparities for communities of color and optimize care for people with a history of cancer. CA Cancer J Clin. 2022;72:409-436.

Utilizing Pharmacists to Optimize Medication Management Strategies During the COVID-19 Pandemic.

As the COVID-19 pandemic swept through the United States, our heath-system mobilized clinical pharmacy services to address critical clinical medication management needs. Reinforcing recommended medication management strategies for clinical pharmacists was key to successful implementation. Best practice strategies include converting patients from intravenous (IV) to oral medication, transitioning to IV push medication administration, evaluating standard medication administration timing, reviewing metered dose inhaler (MDI) and nebulizer utilization, using alternatives for medications in short supply, reviewing coronavirus disease COVID-19 treatment recommendations, reviewing COVID-19 patient care on interdisciplinary rounds, de-prescribing and de-escalating to eliminate unnecessary medications, and assessing for appropriate venous thromboembolism prophylaxis. These strategies served to help protect medication supply, reduce number of staff entries into patient rooms to conserve personal protective equipment, limit nursing time in patient rooms to reduce COVID-19 exposure risk, and to conserve compounding supplies. Here we present example medication management guidance as used by a large healthcare system during the COVID-19 pandemic.

Assessment of Oral Anticoagulant Adverse Drug Events Before and After Implementation of a Real-Time Clinical Surveillance Tool.

OBJECTIVE: The aim of the study was to determine the effect on occurrence of oral anticoagulant adverse drug events (ADEs) after implementation of a real-time clinical surveillance tool in a large health system. METHODS: Records of patients receiving an oral anticoagulant during a 6-month period before and after implementation of a real-time clinical surveillance tool were reviewed for 31 hospitals within a nationwide health system. The real-time clinical surveillance tool analyzed clinical data from the electronic medical record and alerted the pharmacist of potential opportunities for patient clinical intervention. Oral anticoagulant administration data, International Classification of Diseases, Ninth Edition code documentation of ADEs caused by oral anticoagulants, and alert notification data from the real-time clinical surveillance tool were evaluated. RESULTS: A total of 56,761 patients were included in the study. The oral anticoagulant ADE ratio decreased from 0.69% during the period before implementation of the real-time clinical surveillance tool to 0.41% during the period after implementation (P < 0.001). Most alert notifications and greatest impact on ADE ratio occurred in patients administered a single oral anticoagulant during hospitalization. CONCLUSIONS: Implementation of a real-time clinical surveillance tool prompting pharmacist intervention reduced the oral anticoagulant ADE ratio for the health system.

Characteristics Contributing to a Pharmacy Services Excellence Model in a Large Health System.

Objective: To identify characteristics that contribute to and promote a pharmacy services center of excellence model in a large health system. Methods: In 2019, a survey was conducted of 161 acute care pharmacy departments of health system-affiliated hospitals. Information captured included pharmacy practice models, pharmacist resource allocation, training of pharmacy residents, postgraduate training and pharmacist certifications. Results were combined with clinical pharmacy metric performance and centralized electronic data to identify features of top performing pharmacy departments. Results: Survey results were received from 141 of 161 affiliated hospitals (88%). Hospitals with 100 to 299 beds comprised 54% (n = 16 of 30) of the hospitals "at goal" and 66% (n = 26 of 40) of hospitals with "opportunity". Hospitals with top performing pharmacy services had greater participation in interdisciplinary rounds, reporting "always" participating in Adult Critical Care (67% versus 43%) and Medical/Surgical (30% vs. 8%) rounds. Hospitals that trained pharmacy residents had a greater number of clinical pharmacy metrics at goal (5.89 ± 1.59 versus 4.16 ± 1.86, p < 0.001), employed more board-certified pharmacists (2.32 ± 1.49 versus 1.57 ± 1.62, p = 0.019), more postgraduate year 1 (PGY1) trained pharmacists (2.06 ± 1.33 versus 1.19 ± 1.19, p < 0.001) and more PGY2 trained pharmacists (0.58 ± 0.64 versus 0.19 ± 0.44, p = 0.002). When including several key hospital characteristics into a single model, hospitals that trained pharmacy residents were significantly associated with achieving "at goal" status (p = 0.011). Conclusion: Defining characteristics of a pharmacy services center of excellence model included "at goal" clinical pharmacy metrics performance, clinical pharmacist time dedicated to patient care activities, accredited pharmacy residency training programs, presence of pharmacists with advanced training or board certification and optimal operations and scheduling.

Pharmacy-Led Medication Reconciliation Program Reduces Adverse Drug Events and Improves Satisfaction in a Community Hospital.

Background: Pharmacy-led medication reconciliation identifies and corrects medication errors that can potentially cause moderate to severe harm. This research sought to identify the impact of pharmacy-led medication reconciliation on patient outcomes and describe the changes in healthcare workers' perceptions of the program. Methods: A pharmacy-led admission medication reconciliation program pilot started in July 2019, and a discharge medication reconciliation proof of concept was tested in September 2020 at a 432-bed hospital. The following periods were compared: August 2018 to February 2019 (pre-program implementation) and August 2019 to February 2020 (post-program implementation). Endpoints included patient outcomes, workforce productivity and interdisciplinary healthcare team satisfaction through program surveys. Patient outcomes were assessed with chisquared tests. Survey responses were assessed using the Likert scale. Descriptive statistics were used for productivity outcomes and the number of discharge medication reconciliations completed. Results: Approximately 18,000 admissions were recorded for each period. The adverse drug event (ADE) rate decreased 49% (p < 0.001), and the complication rate decreased 29.7% (p = 0.001). During post-pilot implementation, 6,530 medication histories were completed, and 70,050 medications were reviewed. Of medication histories completed, 22.6% of patient allergies/adverse drug reactions were updated, 52.3% of medications were clarified, and 54.7% of preferred outpatient pharmacies were updated. Pharmacy services completed medication histories in 38.8% of inpatients. In the proof of concept, 168 discharge medication lists were drafted. Survey results showed statistically significant improvement in healthcare team satisfaction. Conclusion: A pharmacy-led medication reconciliation program involving designated pharmacists and pharmacy technicians has shown to decrease ADEs and complications while improving interdisciplinary healthcare team satisfaction.

Pharmacy Services Reboot Roadmap: Resiliency During the COVID-19 Pandemic.

Description Planning for resumption of patient care services during and following the impact of novel coronavirus disease-2019 (COVID-19) while controlling costs are essential for pharmacy services resiliency. Implementation of a pharmacy services reboot roadmap across a 179 hospital health-system is described. The roadmap encompassed eight key areas: pharmacy leadership, staffing and scheduling, clinical pharmacy services, medication safety, medication supply, regulatory and compliance, team support opportunities, and financial stewardship. A supporting checklist and volume-based staffing plan are included as examples to assist pharmacy leaders in planning optimal pharmacy services support as patient volumes increase, particularly in the emergency department, surgical services and critical care areas. Resiliency strategies are provided as tangible planning considerations to assess the current status of, and prepare for, future operational and clinical pharmacy practice needs to support optimal patient care.

Analysis of antibiotic use in a large network of emergency departments.

PURPOSE: To assess antibiotic selection, administration, and prescribing practices in emergency departments across a large hospital system using evidence-based practices and susceptibility patterns. METHODS: This retrospective data review was conducted using health system-level electronic data compiled from 145 emergency departments (EDs) across the United States. Data were examined for national generalizability, most common diagnoses of infectious origin seen in nonadmitted patients in the ED, most commonly administered antibiotics in the ED, and geographically defined areas' unique patterns of antibiotic resistance and susceptibility. RESULTS: More than 627,000 unique patient encounters and 780,000 antibiotic administrations were assessed for trends in patient demographics, antibiotics administered for a diagnosis of infectious origin, and corresponding susceptibility patterns. Results indicated that practices in the EDs of this health system aligned with evidence-based practices for streptococcal pharyngitis, otitis media, cellulitis, and uncomplicated urinary tract infections. CONCLUSION: These results provide a representative sample of the current state of practices within many EDs across the United States for nonadmitted patients. A similar data reconstruction can be completed by other health systems to assess their prescribing practices in the ED to improve and elevate care for patients visiting the emergency room and treated as outpatients.

Cancer treatment and survivorship statistics, 2019.

The number of cancer survivors continues to increase in the United States because of the growth and aging of the population as well as advances in early detection and treatment. To assist the public health community in better serving these individuals, the American Cancer Society and the National Cancer Institute collaborate every 3 years to estimate cancer prevalence in the United States using incidence and survival data from the Surveillance, Epidemiology, and End Results cancer registries; vital statistics from the Centers for Disease Control and Prevention's National Center for Health Statistics; and population projections from the US Census Bureau. Current treatment patterns based on information in the National Cancer Data Base are presented for the most prevalent cancer types. Cancer-related and treatment-related short-term, long-term, and late health effects are also briefly described. More than 16.9 million Americans (8.1 million males and 8.8 million females) with a history of cancer were alive on January 1, 2019; this number is projected to reach more than 22.1 million by January 1, 2030 based on the growth and aging of the population alone. The 3 most prevalent cancers in 2019 are prostate (3,650,030), colon and rectum (776,120), and melanoma of the skin (684,470) among males, and breast (3,861,520), uterine corpus (807,860), and colon and rectum (768,650) among females. More than one-half (56%) of survivors were diagnosed within the past 10 years, and almost two-thirds (64%) are aged 65 years or older. People with a history of cancer have unique medical and psychosocial needs that require proactive assessment and management by follow-up care providers. Although there are growing numbers of tools that can assist patients, caregivers, and clinicians in navigating the various phases of cancer survivorship, further evidence-based resources are needed to optimize care.

Use of clinical decision support to identify i.v.-to-oral conversion opportunities and cost savings.

PURPOSE: The use of a clinical decision support (CDS) tool to determine patients' eligibility for oral medication therapy and the opportunity cost of i.v.-to-oral conversion practices in a large health system was evaluated. METHODS: This multicenter, retrospective, process improvement study comprised CDS data generated by 149 hospitals from May 1 through October 31, 2015. Data related to i.v.-to-oral conversions were identified and compiled for evaluation. For each patient with an opportunity for i.v.-to-oral therapy conversion, corresponding barcode-assisted medication administration data were evaluated to determine the number of doses that were administered within prespecified time periods. RESULTS: A total of 121,685 i.v.-to-oral conversion opportunities, corresponding to 71,342 unique patients and encompassing 31 different medications, were evaluated. The top 13 medications representing 94% of the total number of alerts and over 1.4 million doses were included for analysis. Current i.v.-to-oral conversion practices saved the hospitals 9% on medication costs. Upon further evaluation, additional cost savings of 29-78% for those 13 medications could be achieved with more timely conversion from i.v. to oral therapy. CONCLUSION: Hospital pharmacists' i.v.-to-oral conversion practices with the CDS tool resulted in medication cost savings of 9%, or $1.48 million, for 13 medications evaluated over a 6-month period.

The burden of rare cancers in the United States.

There are limited published data on the burden of rare cancers in the United States. By using data from the North American Association of Central Cancer Registries and the Surveillance, Epidemiology, and End Results program, the authors provide information on incidence rates, stage at diagnosis, and survival for more than 100 rare cancers (defined as an incidence of fewer than 6 cases per 100,000 individuals per year) in the United States. Overall, approximately 20% of patients with cancer in the United States are diagnosed with a rare cancer. Rare cancers make up a larger proportion of cancers diagnosed in Hispanic (24%) and Asian/Pacific Islander (22%) patients compared with non-Hispanic blacks (20%) and non-Hispanic whites (19%). More than two-thirds (71%) of cancers occurring in children and adolescents are rare cancers compared with less than 20% of cancers diagnosed in patients aged 65 years and older. Among solid tumors, 59% of rare cancers are diagnosed at regional or distant stages compared with 45% of common cancers. In part because of this stage distribution, 5-year relative survival is poorer for patients with a rare cancer compared with those diagnosed with a common cancer among both males (55% vs 75%) and females (60% vs 74%). However, 5-year relative survival is substantially higher for children and adolescents diagnosed with a rare cancer (82%) than for adults (46% for ages 65-79 years). Continued efforts are needed to develop interventions for prevention, early detection, and treatment to reduce the burden of rare cancers. Such discoveries can often advance knowledge for all cancers. CA Cancer J Clin 2017. © 2017 American Cancer Society. CA Cancer J Clin 2017;67:261-272. © 2017 American Cancer Society.

Cancer treatment and survivorship statistics, 2016.

The number of cancer survivors continues to increase because of both advances in early detection and treatment and the aging and growth of the population. For the public health community to better serve these survivors, the American Cancer Society and the National Cancer Institute collaborate to estimate the number of current and future cancer survivors using data from the Surveillance, Epidemiology, and End Results cancer registries. In addition, current treatment patterns for the most prevalent cancer types are presented based on information in the National Cancer Data Base and treatment-related side effects are briefly described. More than 15.5 million Americans with a history of cancer were alive on January 1, 2016, and this number is projected to reach more than 20 million by January 1, 2026. The 3 most prevalent cancers are prostate (3,306,760), colon and rectum (724,690), and melanoma (614,460) among males and breast (3,560,570), uterine corpus (757,190), and colon and rectum (727,350) among females. More than one-half (56%) of survivors were diagnosed within the past 10 years, and almost one-half (47%) are aged 70 years or older. People with a history of cancer have unique medical and psychosocial needs that require proactive assessment and management by primary care providers. Although there are a growing number of tools that can assist patients, caregivers, and clinicians in navigating the various phases of cancer survivorship, further evidence-based resources are needed to optimize care. CA Cancer J Clin 2016;66:271-289. © 2016 American Cancer Society.

Breast cancer statistics, 2015: Convergence of incidence rates between black and white women.

In this article, the American Cancer Society provides an overview of female breast cancer statistics in the United States, including data on incidence, mortality, survival, and screening. Approximately 231,840 new cases of invasive breast cancer and 40,290 breast cancer deaths are expected to occur among US women in 2015. Breast cancer incidence rates increased among non-Hispanic black (black) and Asian/Pacific Islander women and were stable among non-Hispanic white (white), Hispanic, and American Indian/Alaska Native women from 2008 to 2012. Although white women have historically had higher incidence rates than black women, in 2012, the rates converged. Notably, during 2008 through 2012, incidence rates were significantly higher in black women compared with white women in 7 states, primarily located in the South. From 1989 to 2012, breast cancer death rates decreased by 36%, which translates to 249,000 breast cancer deaths averted in the United States over this period. This decrease in death rates was evident in all racial/ethnic groups except American Indians/Alaska Natives. However, the mortality disparity between black and white women nationwide has continued to widen; and, by 2012, death rates were 42% higher in black women than in white women. During 2003 through 2012, breast cancer death rates declined for white women in all 50 states; but, for black women, declines occurred in 27 of 30 states that had sufficient data to analyze trends. In 3 states (Mississippi, Oklahoma, and Wisconsin), breast cancer death rates in black women were stable during 2003 through 2012. Widening racial disparities in breast cancer mortality are likely to continue, at least in the short term, in view of the increasing trends in breast cancer incidence rates in black women.

Cancer statistics: Breast cancer in situ.

An estimated 60,290 new cases of breast carcinoma in situ are expected to be diagnosed in 2015, and approximately 1 in 33 women is likely to receive an in situ breast cancer diagnosis in her lifetime. Although in situ breast cancers are relatively common, their clinical significance and optimal treatment are topics of uncertainty and concern for both patients and clinicians. In this article, the American Cancer Society provides information about occurrence and treatment patterns for the 2 major subtypes of in situ breast cancer in the United States-ductal carcinoma in situ and lobular carcinoma in situ-using data from the North American Association of Central Cancer Registries and the 13 oldest Surveillance, Epidemiology, and End Results registries. The authors also present an overview of in situ breast cancer detection, treatment, risk factors, and prevention and discuss research needs and initiatives.

Medical marijuana for cancer.

Answer questions and earn CME/CNE Marijuana has been used for centuries, and interest in its medicinal properties has been increasing in recent years. Investigations into these medicinal properties has led to the development of cannabinoid pharmaceuticals such as dronabinol, nabilone, and nabiximols. Dronabinol is best studied in the treatment of nausea secondary to cancer chemotherapy and anorexia associated with weight loss in patients with acquired immune deficiency syndrome, and is approved by the US Food and Drug Administration for those indications. Nabilone has been best studied for the treatment of nausea secondary to cancer chemotherapy. There are also limited studies of these drugs for other conditions. Nabiximols is only available in the United States through clinical trials, but is used in Canada and the United Kingdom for the treatment of spasticity secondary to multiple sclerosis and pain. Studies of marijuana have concentrated on nausea, appetite, and pain. This article will review the literature regarding the medical use of marijuana and these cannabinoid pharmaceuticals (with emphasis on indications relevant to oncology), as well as available information regarding adverse effects of marijuana use.