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October 13, 2009JAMA news releases are made available to the public after 3 pm US Central time on the first 4 Tuesdays of each month. The Archives of 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 CONTENTS
JAMA NEWS RELEASES — Theme Issue on Surgical Care
(Embargoed for Early Release: 10 a.m. CT Tuesday, October 13, 2009)
JAMA REPORT (VIDEO SCRIPT)
INFORMATION CONTAINED IN THESE NEWS RELEASES IS PROTECTED BY COPYRIGHT. JOURNAL ATTRIBUTION IS REQUIRED. JOURNALISTS CAN NOW ACCESS EMBARGOED JAMA/ARCHIVES STUDIES ON-LINE. Go to www.jamamedia.org for more information and to apply for access. TV Note: This week's JAMA Report video is on the role of patients and their surgeons in determining the use of mastectomy for treatment of breast cancer. The report will be fed Tuesday, October 13, from 9:00 - 9:15 a.m. ET and 2:00 - 2:15 p.m. ET, on Galaxy 28 (C-Band), Transponder 15, downlink frequency: 4000 vertical, audio 6.2/6.8. For more information, call 312/464-JAMA. The JAMA Report video is also now available on Pathfire every Tuesday, in VNF Provider A. Please look for the JAMA Report tab. Please Note: The FOR THE MEDIA website now has a search feature to enable media to find previous JAMA/Archives news releases on specific medical topics. This search feature link is located on the home page at www.jamamedia.org EMBARGOED FOR RELEASE UNTIL 10 A.M. (CT), Tuesday, October 13, 2009
Minimally Invasive Radical Prostatectomy Shows Some Advantages, But Also Higher Rate of Certain Complications
CHICAGO—New research indicates that the use of minimally invasive procedures (including the use of robotic assistance) for radical prostatectomy, which have increased significantly in recent years, may shorten hospital stays and decrease respiratory and surgical complications, but may also result in an increased rate of certain complications, including incontinence and erectile dysfunction, according to a study in the October 14 issue of JAMA, a theme issue on surgical care. Jim C. Hu, M.D., M.P.H., of Brigham and Women's Hospital, Boston, presented the findings of the study at a JAMA media briefing in Chicago. Minimally invasive radical prostatectomy (MIRP), in particular with the use of robotic assistance, has increased from 1 percent to 40 percent of all radical prostatectomies from 2001 to 2006, according to background information in the article. But this rapid increase has occurred despite limited data on outcomes and greater costs compared with open retropubic radical prostatectomy (RRP; surgery in which an incision is made in the lower abdomen to remove the prostate, which is located in the pelvis behind the pubic bone). "Moreover, the widespread direct-to-consumer advertising and marketed benefits of robotic-assisted MIRP in the United States may promote publication bias against studies that detail challenges and suboptimal outcomes early in the MIRP learning curve. Until comparative effectiveness of robotic-assisted MIRP can be demonstrated, open RRP, with a 20-year lead time for dissemination of surgical technique relative to MIRP, remains the gold standard surgical therapy for localized prostate cancer," the authors write. Dr. Hu and colleagues assessed the outcomes for men with prostate cancer who underwent MIRP (n = 1,938) vs. RRP (n = 6,899), using U.S. Surveillance, Epidemiology, and End Results Medicare linked data. During the study period, the use of MIRP increased almost 5-fold, from 9.2 percent in 2003 to 43.2 percent in 2006-2007. After analyses, the researchers found that men undergoing MIRP vs. RRP experienced shorter hospital length of stay (median [midpoint], 2.0 vs. 3.0 days), were less likely to receive transfusions (2.7 percent vs. 20.8 percent), and were at lower risk of postoperative respiratory complications (4.3 percent vs. 6.6 percent) and miscellaneous surgical complications (4.3 percent vs. 5.6 percent). "However, men undergoing MIRP vs. RRP experienced more genitourinary complications [involving the genital and urinary organs or their functions; 4.7 percent vs. 2.1 percent) and were more often diagnosed as having incontinence and erectile dysfunction. The need for additional cancer therapies was similar by surgical approach," the authors write. The researchers also found that greater receipt of MIRP vs. RRP was associated with living in areas of higher socioeconomic status based on education and income, and that this may be the result of a "highly successful robotic-assisted MIRP marketing campaign disseminated via the Internet, radio, and print media channels likely to be frequented by men of higher socioeconomic status."
"In light of the mixed outcomes associated with MIRP, our finding that men of higher socioeconomic status opted for a high-technology alternative despite insufficient data demonstrating superiority over an established gold standard may be a reflection of a society and health care system enamored with new technology that increased direct and indirect health care costs but had yet to uniformly realize marketed or potential benefits during early adoption," the authors conclude.
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org. EMBARGOED FOR RELEASE UNTIL 10 A.M. (CT), Tuesday, October 13, 2009
Study Suggests Mastectomy Not Being Overused For Breast Cancer Treatment
CHICAGO—With there being a concern that mastectomy is excessively used as a treatment for breast cancer, a survey of nearly 2,000 women indicates that breast-conserving surgery was attempted as the initial therapy for about 75 percent of those surveyed, according to a study in the October 14 issue of JAMA, a theme issue on surgical care. Monica Morrow, M.D., of Memorial Sloan-Kettering Cancer Center, New York, presented the findings of the study at a JAMA media briefing in Chicago. "Concerns about excessive use of mastectomy for patients with breast cancer have been raised for more than 2 decades. Rates of breast-conserving surgery (BCS) have been used by some as a quality measure. Despite a marked increase in BCS, concerns persist that women with breast cancer are being overtreated with mastectomy," according to background information in the article. Dr. Morrow and colleagues conducted a study to determine the reasons women undergo initial mastectomy for treatment of breast cancer and the frequency of mastectomy after BCS is attempted. The study consisted of a survey of women age 20 to 79 years with intraductal or stage I and II breast cancer diagnosed between June 2005 and February 2007 and reported to the National Cancer Institute's Surveillance, Epidemiology, and End Results registries for the metropolitan areas of Los Angeles and Detroit. The final survey sample included 1,984 female patients (502 Latinas, 529 blacks, and 953 non-Hispanic white or other). The researchers found that of the patient population, 75.4 percent had BCS as an initial surgical therapy; 23 percent had initial mastectomy; 13.4 percent received initial mastectomy based on surgeon recommendation; 8.8 percent received initial mastectomy when the first surgeon did not recommend one procedure over another or recommended BCS; and 8.8 percent received mastectomy after unsuccessful attempts at BCS. Of the 1,984 patients, 19.1 percent sought a second opinion about surgical options prior to treatment. "This was more common for women with a higher education level and for those advised to undergo mastectomy (33.4 percent) vs. those advised to have BCS (15.6 percent) or those who did not receive a recommendation for one procedure over another (21.2 percent)," the authors write. They also found that 11.9 percent of patients who received an initial BCS recommendation received a second opinion for mastectomy; 12.1 percent of the patients who consulted a second surgeon received a discordant opinion. Among the 1,459 women for whom BCS was attempted, additional surgery was required in 37.9 percent of patients. Mastectomy was most common in patients with stage II cancer. "The results of this study suggest that most surgeons in 2 large, diverse urban regions appropriately recommended local therapy options for patients with breast cancer. The majority of women who received a surgeon recommendation for initial mastectomy reported a clinical contraindication to breast conservation," the authors write. "Our results also suggest that patient preferences may play an important role in shaping the pattern of surgical treatment for breast cancer. One-third of patients appear to choose mastectomy as initial treatment when not given a specific recommendation for BCS or mastectomy by their surgeon, accounting for about one-quarter of total mastectomy use. Patients may prefer mastectomy for peace of mind or to avoid radiation."
"In conclusion, findings of this survey of women with breast cancer demonstrate that the etiology [cause] of current mastectomy rates is multifactorial, but that BCS is recommended by surgeons and attempted in a majority of patients," the researchers write. "Our findings suggest that a combined approach of education for patients and health care professionals targeting specific areas may improve decision making."
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org. EMBARGOED FOR RELEASE UNTIL 10 A.M. (CT), Tuesday, October 13, 2009
Less Invasive Procedure for Repair of Abdominal Aortic Aneurysm May Reduce Short-Term Risk of Death
CHICAGO—Patients who received the less-invasive endovascular repair of an abdominal aortic aneurysm had a lower risk of death in the first 30 days after the procedure compared to patients who an open repair, but both procedures had similar rates of death after two years, according to a study in the October 14 issue of JAMA, a theme issue on surgical care. Frank A. Lederle, M.D., of the Veterans Affairs Medical Center, Minneapolis, presented the findings of the study at a JAMA media briefing in Chicago. "Each year in the United States, 45,000 patients with unruptured abdominal aortic aneurysm (AAA) undergo elective repair, resulting in more than 1,400 perioperative [the first 30 days after surgery or inpatient status] deaths," according to background information in the article. Endovascular repair, performed through a catheter inserted into an artery, was developed to provide a less invasive method than the standard open procedure, which involves an abdominal incision. But "limited data are available to assess whether endovascular repair of AAA improves short-term outcomes compared with traditional open repair," the authors write. Dr. Lederle and colleagues are conducting a multicenter clinical trial to examine outcomes after elective endovascular and open repair of AAA. This is an ongoing 9-year trial, with this interim report including postoperative outcomes of up to 2 years for 881 patients (age 49 years or older). Patients were randomized to either endovascular (n = 444) or open (n = 437) repair of AAA. Average follow-up was 1.8 years. The researchers found that the rate of death after surgery was significantly higher for open repair at 30 days (0.2 percent vs. 2.3 percent), and at 30 days or during hospitalization (0.5 percent vs. 3.0 percent). But there was no significant difference in all-cause death at two years (7.0 percent vs. 9.8 percent), and death after the perioperative period was similar in the two groups (6.1 percent vs. 6.6 percent). Patients in the endovascular repair group had reduced procedure time, blood loss and duration of mechanical ventilation. "Hospital and ICU stays were shorter with endovascular repair and need for transfusion was decreased. No significant differences were observed in major morbidities, secondary procedures, or aneurysm-related hospitalizations," the authors write.
"Longer-term data are needed to fully assess the relative merits of the 2 procedures."
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org. EMBARGOED FOR RELEASE UNTIL 10 A.M. (CT), Tuesday, October 13, 2009
Working Overnights By Attending Physicians Not Associated With Significantly Increased Risk of Procedure Complications the Next Day
Although Less Sleep Linked With Higher Rate of Complications
CHICAGO—Attending surgeons and obstetricians/gynecologists who worked nighttime hours did not have a significantly greater rate of complications for procedures performed the next day, but having less than six hours of opportunity for sleep between procedures was associated with an increased rate of surgical complications, according to a study in the October 14 issue of JAMA, a theme issue on surgical care. Jeffrey M. Rothschild, M.D., M.P.H., of Brigham and Women's Hospital, Boston, presented the findings of the study at a JAMA media briefing in Chicago. There has been increasing public attention on the role of resident physicians' fatigue in the occurrence of medical errors. In 2003, work hour limits were implemented for resident physicians in the U.S. Work hours of attending physicians are not restricted. "Little is known about the frequency of elective surgical and obstetrical/gynecologic procedures by attending physicians who participate in emergency procedures the night before. Even less is known about the risks of complications during these postnighttime procedures," according to background information in the article. Dr. Rothschild and colleagues examined the relationship between nighttime work hours, sleep, and rates of complications in procedures performed the next day. The researchers analyzed data on procedures performed from January 1999 through June 2008 by attending physicians (86 surgeons and 134 obstetricians/gynecologists) who had been in the hospital performing another procedure involving adult patients for at least part of the preceding night (12 a.m.- 6 a.m., postnighttime procedures). A total of 919 surgical and 957 obstetrical postnighttime procedures were matched with 3,552 and 3,945 control procedures, respectively. Control procedures included those of the same type performed by the same physician on days without preceding overnight procedures. The researchers found that complications occurred in 101 postnighttime procedures (5.4 percent) and 365 control procedures (4.9 percent). There was no difference detected in types of complications between postnighttime and control procedures. The most common surgical complications were organ injuries and bleeding. "Among postnighttime cases, a higher rate of procedural complications occurred when there were 6 or fewer hours of sleep opportunity (6.2 percent) compared with postnighttime procedures in which there were more than 6 hours of sleep opportunity (3.4 percent); this was predominantly due to operating room (surgical) complications (8.5 percent vs. 3.1 percent, respectively). Postnighttime procedures performed when work duration exceeded 12 hours showed nonsignificantly higher complication rates compared with shifts of 12 hours or less (6.5 percent vs. 4.3 percent)," the researchers write. "These data suggest that attending physicians, like residents and nurses, may be at increased risk of making errors when sleep deprived or working extended shifts." "Our data suggest that the business as usual of a ‘limitless work week' for attending physicians is not optimal for patient care," they add. The authors offer several initiatives that could lessen the risks of unsafe levels of fatigue during procedures, including having large physician groups avoid scheduling elective procedures following overnight on-call responsibilities; implementing a culture of teamwork and critical redesign of schedules; and, when possible, having adequate backup personnel available to relieve fatigued physicians.
"For situations in which it is necessary for attending physicians to conduct life-saving procedures following overnight work, effective strategies to minimize the effects of fatigue should be adopted into practice," the authors conclude.
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org.
JAMA REPORTS
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RESEARCH SUGGESTS MASTECTOMIES NOT OVERUSED IN THE INITIAL TREATMENT OF BREAST CANCER
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