JAMA news releases are made available to the public after 3 pm US Central time on the first 4 Tuesdays of each month. The Archives Journals news releases are made available to the public after 3 pm Central time on Mondays. We also provide a list of previous news releases.
THIS WEEK'S CONTENT
JAMA NEWS RELEASES
(Embargoed for Release: 3 p.m. CT, Tuesday, October 4, 2005)
JAMA NEWS RELEASES
USE OF PULMONARY ARTERY CATHETERIZATION DOES NOT SHOW BENEFIT FOR SEVERE HEART FAILURE PATIENTS
STUDY DEMONSTRATES HOW GENE VARIANT MAY CONTRIBUTE TO CANCER DEVELOPMENT
STUDY IDENTIFIES RISK FACTORS FOR MULTIPLE MELANOMA SKIN CANCER
USE OF KIDNEY PAIRED DONATION FOR INCOMPATIBLE DONORS COULD EXPAND DONOR POOL
JAMA REPORT (VIDEO NEWS RELEASE SCRIPT)
VIDEO: Windows Media | Quicktime
RESEARCHERS IDENTIFY RISK FACTORS FOR MULTIPLE, SERIOUS MELANOMA SKIN CANCERS
INFORMATION CONTAINED IN THESE NEWS RELEASES IS PROTECTED BY COPYRIGHT. JOURNAL ATTRIBUTION IS REQUIRED.
TV Note: This week's JAMA video news release is on the features and risk factors for multiple melanoma skin cancer. The release will be fed Tuesday, October 4, from 9:00 - 9:30 a.m. ET on Intelsat America 6 (formerly Telstar 6), Transponder 11 (C-Band) and from 2:00 - 2:30 p.m. ET on Intelsat America 6, Transponder 11 (C-Band). For more information, call 312/464-JAMA (5262).
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Embargoed for Release: 3 p.m. CT, Tuesday, October 4, 2005
Media Advisory: To contact Lynne W. Stevenson, M.D., call Amy Smith at 617-534-1603. To contact the corresponding author of the 2nd article, Vic Hasselblad, Ph.D., call Richard Merritt at 919-660-1309.
To contact editorial co-author Jesse B. Hall, M.D., call John Easton at 773-702-6241.
USE OF PULMONARY ARTERY CATHETERIZATION DOES NOT SHOW BENEFIT FOR SEVERE HEART FAILURE PATIENTS
CHICAGO—Hospitalized patients with severe congestive heart failure did not experience a benefit from use of pulmonary artery catheterization, but had more adverse events, according to a study in the October 5 issue of JAMA.
Advances in medical therapy have improved outcomes for many ambulatory patients with heart failure and low ejection fraction (EF; a measure of how much blood the left ventricle of the heart pumps out with each contraction), according to background information in the article. However, each year an estimated 250,000 to 300,000 patients are hospitalized for heart failure with low EF, and the 1-year survival rate after hospitalization may be as low as 50 percent, even with recommended medical therapies. Recent studies have indicated that pulmonary artery catheters (PAC), a device used to monitor hemodynamic status and guide therapy, may increase the risk of death for hospitalized patients.
Lynne W. Stevenson, M.D., of Brigham and Women's Hospital, Boston, and colleagues with the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial, tested the hypothesis that for patients with severe heart failure, therapy guided by PAC monitoring and clinical assessment would lead to more days alive and fewer days hospitalized during 6 months compared with therapy guided by clinical assessment alone. The randomized controlled trial included 433 patients at 26 sites and was conducted from January 18, 2000, to November 17, 2003. Patients were assigned to receive clinical assessment and a PAC or clinical assessment alone. The primary goal in both groups was resolution of clinical congestion, with other targets based on levels of pulmonary artery and right atrial pressures.
The researchers found that therapy in both groups led to substantial reduction in symptoms, jugular venous pressure, and edema (swelling from fluid buildup). Use of the PAC did not significantly affect the primary end point of days alive and out of the hospital during the first 6 months (133 days vs. 135 days), death (43 patients [10 percent] vs. 38 patients [9 percent]), or the number of days hospitalized (8.7 vs. 8.3). In-hospital adverse events were more common among patients in the PAC group (47 [21.9 percent] vs. 25 [11.5 percent]). There were no deaths related to PAC use, and no difference for in-hospital plus 30-day mortality (10 [4.7 percent] vs. 11 [5.0 percent]). Exercise and quality of life end points improved in both groups with a trend toward greater improvement with the PAC, which reached significance for the time trade-off at all time points after randomization.
"Based on ESCAPE, there is no indication for routine use of PACs to adjust therapy during hospitalization for decompensation of long-term heart failure. It seems probable that there are some patients and some therapies that yield improved outcome with PAC monitoring and others with counterbalancing deleterious effects," the authors write. "For patients in whom signs and symptoms of congestion do not resolve with initial therapy, consideration of PAC monitoring at experienced sites appears reasonable if the information may guide further choices of therapy.
"The ESCAPE trial defined the most compromised patient population to be studied in an National Heart Lung Blood Institute heart failure trial with medical therapy, with 19 percent (83 patients) mortality at 6 months. No diagnostic test by itself will improve outcomes. New strategies should be developed to test both the interventions and the targets to which they should be tailored. Although most trials in a high-event population have focused on reducing mortality, patients with advanced heart failure express willingness to trade survival time for better health during the time remaining. How patients value their daily lives should help guide both the design and evaluation of new therapies," the authors conclude.
(JAMA. 2005;294:1625-1633. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: This research was supported by a contract from the National Heart, Lung, and Blood Institute to Duke University Medical Center.
USE OF PULMONARY ARTERY CATHETER IN CRITICALLY ILL PATIENTS HAS NEUTRAL EFFECT
A meta-analysis of previous studies indicates that use of a pulmonary artery catheter in critically ill patients neither increases risk of death or hospital stay or adds benefit, according to another article in this issue of JAMA.
The PAC is used to diagnose various diseases and physiological states, monitor the progress of critically ill patients, and guide the selection and adjustment of medical therapy, according to background information in the article. The PAC is often considered a cornerstone of critical care and a hallmark of the intensive care unit (ICU). Approximately 1 million PACs are used annually in the United States. However, despite widespread use of these devices, there is conflicting data about their effectiveness, and whether they increase risk of illness and death. Since the mid-1980s, randomized clinical trials (RCTs) have been conducted to evaluate the efficacy of the PAC. However, none of these trials have been persuasive individually, because they are limited by small sample sizes in heterogeneous populations.
Despite the overwhelmingly negative outcomes of the literature, clinicians continue to use the PAC in ICUs based on personal experience and the belief that careful monitoring will improve decision making and clinical outcomes.
Monica R. Shah, M.D., M.H.S., of Columbia University Medical Center, New York, and colleagues performed a meta-analysis of recently published clinical trials testing the safety and efficacy of the PAC. The researchers located the RCTs, in which patients were randomly assigned to PAC or no PAC, from several databases. Eligible studies included patients who were undergoing surgery, in the ICU, admitted with advanced heart failure, or diagnosed with acute respiratory distress syndrome and/or sepsis; and studies that reported death and the number of days hospitalized or the number of days in the ICU as outcome measures. The researchers found 13 RCTs that included 5,051 patients.
"Our meta-analysis of 13 RCTs evaluating the safety and efficacy of the PAC demonstrates that use of the catheter neither improves outcomes in critically ill patients nor increases mortality or days in hospital. This provides a broader confirmation of the recent results of the ESCAPE trial, which showed that the routine use of the PAC in patients with advanced heart failure did not reduce or increase death or days in hospital," the authors write.
"During the past 60 years, the PAC has evolved from a simple diagnostic tool to a device that is used for monitoring and determining goal-directed therapy. Our meta-analysis shows that despite the widespread acceptance of the PAC, use of this device across a variety of clinical circumstances in critically ill patients does not improve survival or decrease the number of days hospitalized. ... These results suggest that the PAC should not be used for the routine treatment of patients in the ICU, patients with decompensated heart failure, or patients undergoing surgery until or unless effective therapies can be found that improve outcomes when coupled with this diagnostic tool," the authors conclude.
(JAMA. 2005;294:1664-1670. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: This meta-analysis was funded by the Duke Clinical Research Institute.
EDITORIAL: SEARCHING FOR EVIDENCE TO SUPPORT PULMONARY ARTERY CATHETER USE IN CRITICALLY ILL PATIENTS
In an accompanying editorial, Jesse B. Hall, M.D., of the University of Chicago, comments on the articles in this week's JAMA on PAC.
"What is the evidence for the broader issue of PAC use in the ICU and perioperative setting? The data collected to date certainly do not support routine use of the catheter in any patient group, and the currently available information could be viewed as justifying 'pulling the pulmonary artery catheter' from routine use, a suggestion made almost 10 years ago. One important additional trial is nearing completion and evaluates the use of PAC in patients with adult respiratory distress syndrome."
"Should there be a positive result attributable to PAC in this trial, a specific niche for this technology may remain in critical care. If the results of this soon-to-be-completed trial show no benefit of PAC monitoring, it is likely that the available data will indicate that it is time to remove the catheter from widespread use, or at the very least relegate this former common monitoring tool to salvage therapy of an extremely small and select number of patients. The need to question the routine use of this monitoring modality was quite real and the results of the last 5 years of study most valuable. Once again the community of critical care physicians has been edified by the approach of 'Don't just do something, stand there! And then think about it. ...'" Dr. Hall concludes.
(JAMA. 2005;294:1693-1694. Available pre-embargo to the media at www.jamamedia.org)
For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.
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Embargoed for Release: 3 p.m. CT, Tuesday, October 4, 2005
Media Advisory: To contact Boris Pasche, M.D., Ph.D., call Elizabeth Crown at 312-503-8928.
STUDY DEMONSTRATES HOW GENE VARIANT MAY CONTRIBUTE TO CANCER DEVELOPMENT
CHICAGO—A relatively common cancer susceptibility gene appears to be frequently acquired in metastatic lesions from colorectal cancer, and give cancer cells a growth advantage, according to a study in the October 5 issue of JAMA.
Transforming growth factor beta (TGF-beta) is a potent naturally occurring inhibitor of cell growth, according to background information in the article. It exerts its action by binding to type I (TGFBR1) and type II (TGFBR2) receptors located on the cell membrane. Increased cell growth due to decreased TGF-beta growth inhibition may contribute to cancer development. TGFBR1*6A is a common polymorphism (variation) of TGFBR1. Previous studies have shown that TGFBR1*6A is one of the first candidate tumor susceptibility alleles (DNA codings of the same gene) that is found in a large proportion of the general population (13.7 percent) and significantly increases cancer risk by approximately 24 percent. How TGFBR1*6A contributes to cancer development is largely unknown.
Boris Pasche, M.D., Ph.D., of Northwestern University Feinberg School of Medicine, Chicago, and colleagues conducted a study that included 531 patients with a diagnosis of head and neck cancer, colorectal cancer, or breast cancer recruited from 3 centers in the United States and from 1 center in Spain from June 1, 1994, through June 30, 2004. Multiple genetic testing of the cancer cells was conducted.
The researchers found that TGFBR1 mutated into TGFBR1*6A, i.e. was somatically acquired, in 13 of 44 (29.5 percent) colorectal cancer metastases, in 4 of 157 (2.5 percent) of colorectal tumors, in 4 of 226 (1.8 percent) head and neck primary tumors, and in none of the 104 patients with breast cancer.
While TGF-beta inhibits the growth of normal cells, cancer cells secrete larger amounts of TGF-beta than their normal counterparts. The researchers showed that, in the presence of TGF-beta, the growth of cancer cells that carry the TGFBR1*6A gene is 55 percent greater than cancer cells that do not carry this gene, indicating that TGFBR1*6A give cancer cells a selective advantage. This, together with the findings that TGFBR1*6A is acquired by tumors, may explain why half of all liver metastases from colorectal cancer carried the TGFBR1*6A gene while it is only found in 14 percent of the general population.
"...individuals who carry the *6A allele, either in the germline or somatically acquired by the tumor, may have a greater likelihood of developing metastases than individuals who do not carry this allele. *6A may therefore serve as a useful biomarker in cancer." The authors add that TGFBR1*6A may bestow cancer cells with a growth advantage in the presence of TGF-beta.
"Since 13.7 percent of the general population and 17.1 percent of patients with a diagnosis of cancer carry at least 1 copy of the *6A allele, our findings may have substantial public health importance. The high frequency of *6A carriers in the general population and the moderately increased risk of breast, colon, and ovarian cancer that it confers implies that the dominant effects of *6A have an incomplete penetrance. Additional studies are needed to determine which environmental and genetic factors may modify the penetrance of *6A in these tumor types," the researchers write.
"The results highlight a new facet of TGF-beta signaling in cancer and suggest that TGFBR1*6A may represent a potential therapeutic target in cancer."
(JAMA. 2005;294:1634-1646. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: For funding/support information, please see the JAMA article.
For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.
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Embargoed for Release: 3 p.m. CT, Tuesday, October 4, 2005
Media Advisory: To contact corresponding author Daniel G. Coit, M.D., call Maria Connizzo at 212-639-3956.
STUDY IDENTIFIES RISK FACTORS FOR MULTIPLE MELANOMA SKIN CANCER
CHICAGO—Patients with a family history of multiple melanoma skin cancer are at increased risk of multiple primary melanomas, according to a study in the October 5 issue of JAMA.
In 2005, there will be an estimated 62,000 new cases of invasive melanoma and an estimated 7,600 deaths due to melanoma in the United States, according to background information in the article. Melanoma is the fifth leading cancer in men and the sixth leading cancer in women in the United States. The incidence of melanoma continues to rise at about 3 percent per year in the United States, with an estimated lifetime risk for an individual of 1.4 percent. This increasing incidence puts a larger portion of the population at risk not only for one primary melanoma but also for subsequent primary melanomas.
Cristina R. Ferrone, M.D., and colleagues from Memorial Sloan-Kettering Cancer Center, New York, conducted a study to identify the incidence and characteristics of patients at risk of developing multiple primary melanomas (MPM). The study included 4,484 patients diagnosed with a first primary melanoma between January 1, 1996, and December 31, 2002.
The researchers found that 385 patients (8.6 percent) had 2 or more primary melanomas, with an average of 2.3 melanomas per MPM patient. Seventy-eight percent had 2 primary melanomas. For 74 percent of patients, the initial melanoma was the thickest tumor. Fifty-nine percent presented with their second primary tumor within 1 year. Twenty-one percent of MPM patients had a positive family history of melanoma compared with only 12 percent of patients with a single primary melanoma (SPM). Thirty-eight percent of MPM patients had dysplastic nevi (DN; atypical moles) compared with 18 percent of SPM patients.
The estimated cumulative 5-year risk of a second primary tumor for the entire cohort was 11.4 percent, with almost half of that risk occurring within the first year. For patients with a positive family history or dysplastic nevi, the estimated 5-year risk of MPM was significantly higher at 19.1 percent and 23.7 percent, respectively. The most striking increase in incidence for the MPM population was seen for development of a third primary melanoma from the time of second primary melanoma, which was 15.6 percent at 1 year and 30.9 percent at 5 years.
"Patients with a positive family history or a history of DN are at significantly greater risk of developing MPM and should be enrolled in more intensive dermatologic surveillance programs. This high-risk subset of patients should also be further characterized genetically to further elucidate the biology and etiology of melanoma," the authors conclude.
(JAMA. 2005;294:1647-1654. Available pre-embargo to the media at www.jamamedia.org)
For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.
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Embargoed for Release: 3 p.m. CT, Tuesday, October 4, 2005
Media Advisory: To contact Robert A. Montgomery, M.D., D.Phil., call Eric Vohr at 410-955-8665.
To contact editorial co-author Arthur J. Matas, M.D., call Molly Portz at 612-625-2640.
USE OF KIDNEY PAIRED DONATION FOR INCOMPATIBLE DONORS COULD EXPAND DONOR POOL
CHICAGO—A preliminary study suggests that kidney paired donation transplantation, in which incompatible donor/recipient pairs exchange kidneys so that each recipient receives a compatible kidney, had graft survival rates equivalent to compatible live donor transplants, according to a study in the October 5 issue of JAMA.
The number of patients waiting for a kidney transplant continues to increase at an alarming pace and any significant gains in closing the gap between organ supply and demand are likely to come from the increased use of live donors, according to background information in the article. The two most significant barriers to greater use of live donors are blood type incompatibility and human leukocyte antigens (HLA) antigen sensitization. Based on blood group frequencies in the United States, there is a 36 percent probability that any two individuals will be blood type incompatible, eliminating up to one-third of the potential live donor pool. In about 30 percent of the patients on the deceased donor waiting list, HLA antigen sensitization is present due to exposure to foreign tissue in the form of previous transplants, pregnancies, or blood transfusions.
An alternative strategy is kidney paired donation (KPD) transplantations. In KPD transplants, incompatible donor/recipient pairs exchange kidneys so that each recipient receives a compatible organ. The KPD transplant program represents a cost savings compared with desensitization, which is significantly less costly than if an individual continues to undergo dialysis. While logistically challenging, a broader implementation of KPD on a regional or national scale could provide compatible organs for a substantial number of the estimated 6,000 patients on the waiting list who currently have incompatible donors.
Robert A. Montgomery, M.D., D.Phil., of Johns Hopkins University School of Medicine, Baltimore, and colleagues conducted a study to determine the feasibility and effectiveness of KPD for the management of patients with incompatible donors. Paired donations were matched and transplanted from a pool of blood type or crossmatch incompatible donors and recipients with end-stage renal disease (6 conventional and 4 unconventional KPD transplants) between June 2001 and November 2004.
A total of 22 patients received transplants through 10 paired donations including 2 triple exchanges. At a median follow-up of 13 months, the patient survival rate was 100 percent and the graft survival rate was 95.5 percent. Twenty-one of the 22 patients have functioning grafts with a median 6-month serum creatinine level of 1.2 mg/dL. There were no instances of antibody-mediated rejection despite the inclusion of 5 patients who were highly sensitized to HLA antigens due to previous exposure to foreign tissue. Four patients developed acute cellular rejection (18 percent).
The complexity and potential benefits of an unconventional KPD transplant are demonstrated by the triple exchange. Based on blood type and HLA antigen antibody reactivity, the probability of finding a suitable donor in the deceased donor pool for each of the 3 recipients was 0.029, 0.033 and 0.008.
"This study demonstrates that KPD transplants can be performed with outcomes similar to compatible living donor kidney transplants. The cost savings and decrease in waiting time that could be realized by a wider application of this concept are substantial. Because the likelihood of finding a suitable match is dependent on the size of the pool, a national list could enable many more transplants. We estimate that about half of the incompatible pairs could receive transplants using a national KPD transplant scheme with blood type compatible, negative crossmatch kidneys, including as many as 14 percent of the highly sensitized patients," the authors write.
"Patients unable to be matched by KPD could undergo desensitization with their intended donor. Those who were not deemed acceptable for desensitization due to high titer or immunologic risk could participate in a less restricted KPD search in which a more favorable, but not completely compatible, donor could be identified. This single center experience demonstrates that KPD is feasible, successful, and if applied to larger donor pools capable of expanding access to renal transplantation," the researchers conclude.
(JAMA. 2005;294:1655-1663. Available pre-embargo to the media at www.jamamedia.org)
EDITORIAL: THE IMPORTANCE OF INNOVATIVE EFFORTS TO INCREASE ORGAN DONATION
In an accompanying editorial, Arthur J. Matas, M.D., and David E. R. Sutherland, M.D., Ph.D., of the University of Minnesota, Minneapolis, examine the findings by Montgomery et al.
"The individual organ recipients who undergo a successful transplantation have greatly improved expectations compared with those individuals who continue to undergo dialysis. Removing candidates from the transplant waiting list shortens the waiting time for the remainder of patients. One of the limitations of paired exchange is the small number of eligible donor/recipient pairs at each center, making finding a matched pair difficult. Regional or national matching programs would make finding pairs more probable, but including the highly sensitized blood type O candidates would require extensive laboratory testing."
"However, there are several important cautions. While transplant physicians see the tremendous benefit that organ recipients derive from a successful transplant, organ transplantation raises numerous ethical issues involving protection of the donor, informed consent, and equity in organ allocation. To date, only a limited number of long-term outcome and quality-of-life follow-up studies have been performed concerning conventional donors. Paired exchange leads to additional concerns. For example, what if one kidney fails early but the other functions well? Those involved in such programs must pay careful attention to the informed consent process and should be conducting formal follow-up studies of donors."
"Kidney transplantation remains a success story, but its promise and future continue to be threatened by the ongoing lack of suitable organ donors. While new methods to overcome this problem are welcome, the transplant community must face up to the new ethical issues that surround every advance," the authors conclude.
(JAMA. 2005;294:1691-1693. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: The work for this article was supported by a grant from the National Institutes of Health. Dr. Matas has received research support and financial support (including for conferences, for speaking, and for serving as a consultant) from several companies involved in developing and marketing immunosuppressive drugs used in transplantation.
For More Information: Contact the JAMA/Archives Media Relations Department at 312/464-JAMA (5262) or email: mediarelations{at}jama-archives.org.
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JAMA REPORTS
VIDEO: Windows Media | Quicktime
RESEARCHERS IDENTIFY RISK FACTORS FOR MULTIPLE, SERIOUS MELANOMA SKIN CANCERS
VIDEO:
NAT SOT UP FULL FOR :04
Dr. Coit speaking to/examining Bernard Korman
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“That area there looks very good.”
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Dr. Coit examining Bernard’s face/head
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THERE USED TO BE A MELANOMA THERE, UNTIL 79-YEAR OLD BERNARD KORMAN HAD IT REMOVED. OVER THE LAST DECADE, HE’S HAD MELANOMAS REMOVED FROM HIS HEAD, ARM AND CHEST. AND EACH ONE WAS A PRIMARY MELANOMA.
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Super: Daniel Coit, M.D.
Memorial Sloan-Kettering Cancer Center
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“What I mean when I’m talking about a primary melanoma is a new tumor that develops in the skin, as opposed to a secondary or an area of spread of the melanoma."
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Still photos of melanoma lesions
Dr. Coit at computer looking at images of melanoma on screen
GFX/JAMA COVER
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THESE ARE PICTURES OF PRIMARY MELANOMAS. IMAGINE GETTING TREATED FOR ONE, AND THEN ANOTHER POPS UP. DR. DANIEL COIT AND HIS COLLEAGES AT MEMORIAL SLOAN-KETTERING CANCER CENTER WANTED TO KNOW WHO WAS MOST AT RISK FOR GETTING MORE THAN ONE. THEIR FINDINGS APPEAR IN JAMA, THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION.
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Daniel Coit, M.D.
Memorial Sloan-Kettering Cancer Center
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“A patient with one primary melanoma is at risk for developing a second primary melanoma.”
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Still image of melanoma
Still photo of dysplastic nevi
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THAT RISK IS ABOUT 11 PERCENT. BUT SOME PEOPLE ARE AT EVEN GREATER RISK FOR A SECOND PRIMARY MELANOMA. IF YOU HAVE A FAMILY HISTORY OF MELANOMA, OR IF YOU HAVE ONE OF THESE ODD-LOOKING LIGHT BROWN FRECKLES OR MOLES - CALLED DYSPLASTIC (dis-PLAST-ic) NEVI (NEE-vi) – YOUR RISK GOES UP TO ABOUT TWENTY PERCENT. AND THERE’S MORE:
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Daniel Coit, M.D.
Memorial Sloan-Kettering Cancer Center
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“If you have a second primary melanoma, you have up to a 30% chance of getting a third primary melanoma.”
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Dr. Coit with Bernard Korman sitting in office
Dr. Coit examining Bernard’s face/head
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DR. COIT SAYS PEOPLE IN THAT HIGH-RISK GROUP NEED TO GET CHECKED OFTEN BY A DERMATOLOGIST FOR THE REST OF THEIR LIVES. BERNARD KORMAN SAYS THE ATTENTION HE GOT AT HIS FREQUENT CHECK-UPS SAVED HIS LIFE.
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Bernard KormanHad multiple primary melanomas
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“And the fact that I’m approaching 80 I attribute to the fact that I did get that kind of attention.”
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Dr. Coit examining Bernard’s face/head
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THIS IS MAVIS PRALL WITH THE JAMA REPORT.
