The emerging relevance of heterogeneity of treatment effect in clinical care: a study using stage IV prostate cancer as a model.

AIM: Heterogeneity of treatment effect (HTE) occurs when patient factors modify a treatment's effect on health outcomes due to interactions between these factors and the treatment. This article reviews evidence regarding HTE in stage IV prostate cancer (S4PC). METHOD: A systematic literature review was conducted in the MEDLINE and PubMed databases. Inclusion criteria required that articles examine the treatment-related impact of HTE factors on survival, adverse events or health-related quality of life in S4PC patients. The quality of evidence was graded good, fair or poor based on Agency for Healthcare Research and Quality guidelines. RESULTS: The search identified 2659 articles, of which 92 met the inclusion/exclusion criteria. HTE in S4PC was studied for biologic factors including age, race, clinical signs/symptoms, measures of S4PC disease severity, genetic factors, laboratory data, prior treatment, concurrent medications and comorbidities. Nonbiologic factors that were studied included social, geographic and dietary factors. Age and race seldom showed any correlation with S4PC outcomes. CONCLUSION: Diverse biologic and nonbiologic factors contribute to HTE in S4PC. This review in S4PC also provides an approach for examining HTE for other medical conditions. Ultimately, such knowledge can help oncologists prescribe more personalized medicine, help patients make more informed treatment choices, and inform policy-making and treatment coverage decisions.

Testicular germ cell tumors: biology and clinical update.

PURPOSE OF REVIEW: This overview discusses several important developments in testicular germ cell tumors in the past year. RECENT FINDINGS: Genomic studies continue to investigate gene expression as possible markers for disease relapse and chemotherapy resistance. Optimal treatment strategies for early-stage seminomas are evolving toward surveillance versus chemotherapy and away from radiation, and the role of retroperitoneal lymph node dissection in disseminated nonseminomatous cancers in complete remission is becoming less certain. SUMMARY: Treatment and surveillance paradigms continue to be defined and refined for both early and late-stage disease as research in these areas continues and the data from multiple large studies mature.

Update on testicular germ cell tumors.

PURPOSE OF REVIEW: This overview discusses several important developments in testicular germ cell tumors in the last year. RECENT FINDINGS: Genomic studies are examining gene expression as possible markers for disease relapse and chemotherapy resistance. Optimal treatment strategies for early-stage nonseminomatous tumors continue to evolve, and advanced disease states continue to be challenging entities in terms of optimizing therapy and outcome. Long-term survivorship issues are also being evaluated in this patient population. SUMMARY: Significant challenges remain for treatment of certain categories of testicular germ cell tumors. Treatment and surveillance paradigms continue to be defined and refined as research in these areas continues.

Maryland's first inpatient chest pain short stay unit as an alternative to emergency room-based observation unit.

INTRODUCTION: Approximately 8 million people in the United States visit emergency rooms (ERs) annually for chest pain but only about 1.2 million were ultimately diagnosed with acute myocardial infarction. Of concern, up to 4% to 5% of patients with acute myocardial infarction are those inappropriately discharged from the ER. ER-based observation units (EROU) were developed to enable safe, expedited, and effective management of these patients with negative initial workup. In the state of Maryland, the unique reimbursement system serves as a disincentive to operate EROU. The inpatient chest pain short stay unit (CPSSU) at St. Agnes hospital is the first in Maryland dedicated to evaluating patients with chest pain. We study the performance of CPSSU as compared with that of EROU. METHODS: The project is a prospective observational study that involved consecutive patients presenting to St. Agnes ER with the primary complaint of chest pain between June 1, 2005 and November 30, 2005. After negative initial electrocardiograms and cardiac enzymes, the patients were further evaluated using a standard CPSSU protocol in ER or CPSSU. Primary outcome variables were myocardial infarction or death. RESULTS: A total of 332 patients were enrolled among which 202 were worked up in ER and 130 in CPSSU. There were no deaths and only 1 patient with significant coronary artery disease, representing 0.3% of study population was missed. Thirteen patients (3.9%) were detected with significant coronary artery disease. Severe 3 vessel disease was found in 4 (1.2%) patients. Median cost (and revenue) of evaluation in ER and CPSSU was $978.323 ($1203.533) and $1543.287 ($2947.85), respectively. CONCLUSION: Inpatient CPSSU initiative is an effective alternative to EROU for evaluating chest pain patients with negative initial workup. Furthermore, this is achieved with net profit gain of $1744.37 over that of EROU evaluation.