Bilateral Renal Oncocytoma: Active Surveillance Versus Partial Nephrectomy.

Renal oncocytomas (ROs) are benign tumors comprising 16% of renal masses. Due to the overlapping phenotypes seen in RO and chromophobe renal cell carcinoma (RCC) and lack of specific clinical and laboratory characteristics of RO, physicians face a challenge when arriving at a definitive diagnosis of RO. ROs additionally appear indistinct from RCCs on CT scan, contributing further to the difficulty of arriving at a clear diagnosis of RO.  This is a case report of a 66-year-old man who presented with flank pain found to be related to bilateral ROs and underwent bilateral partial nephrectomies. ROs are benign small renal masses that often pose a diagnostic challenge since preoperative diagnosis can be difficult to achieve. Given advancements in technology, active surveillance with core renal biopsy is a promising approach to accurately diagnose and manage ROs conservatively. The application of these techniques has wide-reaching implications for patients and physicians by reducing the need for a potentially harmful surgery and creating a cost-effective way to manage a diagnosis.

Creating a longitudinal integrated clerkship with mutual benefits for an academic medical center and a community health system.

The longitudinal integrated clerkship is a model of clinical education driven by tenets of social cognitive theory, situated learning, and workplace learning theories, and built on a foundation of continuity between students, patients, clinicians, and a system of care. Principles and goals of this type of clerkship are aligned with primary care principles, including patient-centered care and systems-based practice. Academic medical centers can partner with community health systems around a longitudinal integrated clerkship to provide mutual benefits for both organizations, creating a sustainable model of clinical training that addresses medical education and community health needs. A successful one-year longitudinal integrated clerkship was created in partnership between an academic medical center and an integrated community health system. Compared with traditional clerkship students, students in this clerkship had better scores on Clinical Performance Examinations, internal medicine examinations, and high perceptions of direct observation of clinical skills.Advantages for the academic medical center include mitigating the resources required to run a longitudinal integrated clerkship while providing primary care training and addressing core competencies such as systems-based practice, practice-based learning, and interprofessional care. Advantages for the community health system include faculty development, academic appointments, professional satisfaction, and recruitment.Success factors include continued support and investment from both organizations' leadership, high-quality faculty development, incentives for community-based physician educators, and emphasis on the mutually beneficial relationship for both organizations. Development of a longitudinal integrated clerkship in a community health system can serve as a model for developing and expanding these clerkship options for academic medical centers.

Influence of patient coaching on analgesic treatment adjustment: secondary analysis of a randomized controlled trial.

CONTEXT: For patients with cancer-related pain and their physicians, routine oncology visits are an opportunity to adjust the analgesic regimen and secure better pain control. However, treatment intensification occurs haphazardly in practice. OBJECTIVES: To estimate the effect of patient-centered tailored education and coaching (TEC) on the likelihood of analgesic treatment adjustment during oncology visits, and in turn, the influence of treatment adjustment on subsequent cancer pain control, we studied patients enrolled in a randomized trial of TEC. METHODS: Just before a scheduled oncology visit, 258 patients with at least moderate baseline pain received TEC or control; just after the same visit, they reported on whether the physician recommended a new pain medicine or a change in dose of an existing medicine. Pain severity and pain-related impairment were measured two, six, and 12 weeks later. RESULTS: Patients assigned to TEC were more likely than controls to report a change in the analgesic treatment regimen (60% vs. 36%, P<0.01); significant effects persisted after adjustment for baseline pain, study site, and physician (adjusted odds ratio 2.61, 95% confidence interval 1.55, 4.40, P<0.01). In a mixed-effects repeated measures regression, analgesic change (but not TEC itself) was associated with a sustained decrease in pain severity (P<0.05). CONCLUSION: TEC increases the likelihood of self-reported, physician-directed adjustments in analgesic prescribing, and treatment intensification is associated with better cancer pain outcomes.

Cancer Health Empowerment for Living without Pain (Ca-HELP): effects of a tailored education and coaching intervention on pain and impairment.

We aimed to determine the effectiveness of a lay-administered tailored education and coaching (TEC) intervention (aimed at reducing pain misconceptions and enhancing self-efficacy for communicating with physicians) on cancer pain severity, pain-related impairment, and quality of life. Cancer patients with baseline "worst pain" of ≥4 on a 0-10 scale or at least moderate functional impairment due to pain were randomly assigned to TEC or enhanced usual care (EUC) during a telephone interview conducted in advance of a planned oncology office visit (265 patients randomized to TEC or EUC; 258 completed at least one follow-up). Patients completed questionnaires before and after the visit and were interviewed by telephone at 2, 6, and 12 weeks. Mixed effects regressions were used to evaluate the intervention adjusting for patient, practice, and site characteristics. Compared to EUC, TEC was associated with increased pain communication self-efficacy after the intervention (P<.001); both groups showed significant (P<.0001), similar, reductions in pain misconceptions. At 2 weeks, assignment to TEC was associated with improvement in pain-related impairment (-0.25 points on a 5-point scale, 95% confidence interval -0.43 to -0.06, P=.01) but not in pain severity (-0.21 points on an 11-point scale, -0.60 to 0.17, P=.27). The improvement in pain-related impairment was not sustained at 6 and 12 weeks. There were no significant intervention by subgroup interactions (P>.10). We conclude that TEC, compared with EUC, resulted in improved pain communication self-efficacy and temporary improvement in pain-related impairment, but no improvement in pain severity.

Cancer Health Empowerment for Living without Pain (Ca-HELP): study design and rationale for a tailored education and coaching intervention to enhance care of cancer-related pain.

BACKGROUND: Cancer-related pain is common and under-treated. This article describes a study designed to test the effectiveness of a theory-driven, patient-centered coaching intervention to improve cancer pain processes and outcomes. METHODS/DESIGN: The Cancer Health Empowerment for Living without Pain (Ca-HELP) Study is an American Cancer Society sponsored randomized trial conducted in Sacramento, California. A total of 265 cancer patients with at least moderate pain severity (Worst Pain Numerical Analog Score > or =4 out of 10) or pain-related impairment (Likert score > or = 3 out of 5) were randomly assigned to receive tailored education and coaching (TEC) or educationally-enhanced usual care (EUC); 258 received at least one follow-up assessment. The TEC intervention is based on social-cognitive theory and consists of 6 components (assess, correct, teach, prepare, rehearse, portray). Both interventions were delivered over approximately 30 minutes just prior to a scheduled oncology visit. The majority of visits (56%) were audio-recorded for later communication coding. Follow-up data including outcomes related to pain severity and impairment, self-efficacy for pain control and for patient-physician communication, functional status and well-being, and anxiety were collected at 2, 6, and 12 weeks. DISCUSSION: Building on social cognitive theory and pilot work, this study aims to test the hypothesis that a brief, tailored patient activation intervention will promote better cancer pain care and outcomes. Analyses will focus on the effects of the experimental intervention on pain severity and impairment (primary outcomes); self-efficacy and quality of life (secondary outcomes); and relationships among processes and outcomes of cancer pain care. If this model of coaching by lay health educators proves successful, it could potentially be implemented widely at modest cost. TRIAL REGISTRATION: [Clinical Trials Identifier: NCT00283166].

Advance directives in oncology: are they useful?

This paper discusses advance directives from the point of view of advanced directives: living wills, enduring power of attorney and combined instruments. They are discussed from the point of view of patients, the health-care teams and the public. It stresses the need for adequate information before such an instrument can be binding and suggests that enunciating goals is the most important task.