Bruce Jancin

CHICAGO – Using N-terminal prohormone brain natriuretic peptide levels to guide therapy in patients with systolic heart failure proved superior to standard of care management in terms of cardiovascular event rates, quality of life, and echocardiographic parameters in the randomized prospective PROTECT trial.

"If duplicated in larger cohorts, treatment guided by NT-proBNP may represent a new paradigm for heart failure care," Dr. James L. Januzzi Jr. said at the annual scientific sessions of the American Heart Association.

PROTECT (the ProBNP Outpatient Tailored Chronic Heart Failure Therapy study) was a single-center unblinded trial of 151 patients with systolic heart failure and a mean left ventricular ejection fraction of 27%. They were randomized to standard guideline-driven management on the basis of heart failure signs and symptoms or to the same approach with the added goal of reducing NT-proBNP levels to 1,000 pg/mL or less, a threshold previously shown to predict risk in heart failure patients.

Participants were scheduled for quarterly clinic visits, with extra ones as needed to achieve therapeutic goals, said Dr. Januzzi, director of the cardiac intensive care unit at Massachusetts General Hospital, Boston.

The study was halted early for ethical reasons after 10 months. At that point a total of 100 cardiovascular events – worsening heart failure, heart failure hospitalization, acute coronary syndrome, ventricular arrhythmias, cerebral ischemia, or cardiovascular death – had occurred in the standard-treatment group, compared with 58 events in patients on NT-proBNP–guided therapy. The major difference between the two study arms was the sharply lower likelihood of worsening heart failure or heart failure hospitalization in the NT-proBNP–guided arm.

Importantly, the reduction in cardiovascular events was similar in patients over age 75 and in those who were younger.

The secondary outcome of quality of life, assessed using the Minnesota Living with Heart Failure Questionnaire, also showed significantly greater improvement in the guided-treatment arm. In all, 61% of subjects in the NT-proBNP–guided arm achieved at least a 10-point improvement over baseline, considered clinically meaningful, compared with 39% on standard management.

The guided-treatment group also did significantly better in terms of secondary echocardiographic end points, with larger improvements in left ventricular ejection fraction and in ventricular remodeling as reflected by changes in LV end-systolic and end-diastolic volume index, the cardiologist continued.

NT-proBNP–guided therapy proved safe and was well tolerated, with no significant increase in adverse events.

Patients in the guided-treatment arm had a median of six clinic visits, compared with five with standard management. The median baseline NT-proBNP level in the guided-therapy arm was 2,344 pg/mL. It fell to 1,125 pg/mL, with 44% of subjects in the guided-therapy arm attaining an NT-proBNP of 1,000 pg/mL or less.

Up-titration of heart failure medications was common in both study arms, but was significantly greater in the NT-proBNP group. A total of 63% of patients in the guided-therapy arm were placed on an aldosterone blocker, compared with 45% of controls.

Session cochair Dr. Gregg C. Fonarow said in an interview that he views PROTECT as a successful proof-of-concept study. But before biomarker-guided treatment of heart failure becomes part of guideline-recommended, routine outpatient care, it will be necessary to see if the Massachusetts General Hospital experience can be extended to other settings, including primary care practices, where many patients with heart failure receive their treatment. This will require a large multicenter trial with a diverse group of clinicians; randomization by site; and hard clinical end points, including mortality. A proposal for such a study has been presented to the National Heart, Lung, and Blood Institute for funding consideration.

"It’s a large and expensive trial, but the impact is potentially profound," said Dr. Fonarow, professor of medicine and director of the Ahmanson-UCLA Cardiomyopathy Center, Los Angeles. "Given the costs of heart failure and the tremendous number of outpatient visits for this disease, if we truly had a well-validated guide using biomarkers, that would be a phenomenal advance."

The PROTECT trial was sponsored in part by Roche Diagnostics. Dr. Januzzi declared he serves as a consultant to and speaker for the company.

CHICAGO – Using N-terminal prohormone brain natriuretic peptide levels to guide therapy in patients with systolic heart failure proved superior to standard of care management in terms of cardiovascular event rates, quality of life, and echocardiographic parameters in the randomized prospective PROTECT trial.

"If duplicated in larger cohorts, treatment guided by NT-proBNP may represent a new paradigm for heart failure care," Dr. James L. Januzzi Jr. said at the annual scientific sessions of the American Heart Association.

PROTECT (the ProBNP Outpatient Tailored Chronic Heart Failure Therapy study) was a single-center unblinded trial of 151 patients with systolic heart failure and a mean left ventricular ejection fraction of 27%. They were randomized to standard guideline-driven management on the basis of heart failure signs and symptoms or to the same approach with the added goal of reducing NT-proBNP levels to 1,000 pg/mL or less, a threshold previously shown to predict risk in heart failure patients.

Participants were scheduled for quarterly clinic visits, with extra ones as needed to achieve therapeutic goals, said Dr. Januzzi, director of the cardiac intensive care unit at Massachusetts General Hospital, Boston.

The study was halted early for ethical reasons after 10 months. At that point a total of 100 cardiovascular events – worsening heart failure, heart failure hospitalization, acute coronary syndrome, ventricular arrhythmias, cerebral ischemia, or cardiovascular death – had occurred in the standard-treatment group, compared with 58 events in patients on NT-proBNP–guided therapy. The major difference between the two study arms was the sharply lower likelihood of worsening heart failure or heart failure hospitalization in the NT-proBNP–guided arm.

Importantly, the reduction in cardiovascular events was similar in patients over age 75 and in those who were younger.

The secondary outcome of quality of life, assessed using the Minnesota Living with Heart Failure Questionnaire, also showed significantly greater improvement in the guided-treatment arm. In all, 61% of subjects in the NT-proBNP–guided arm achieved at least a 10-point improvement over baseline, considered clinically meaningful, compared with 39% on standard management.

The guided-treatment group also did significantly better in terms of secondary echocardiographic end points, with larger improvements in left ventricular ejection fraction and in ventricular remodeling as reflected by changes in LV end-systolic and end-diastolic volume index, the cardiologist continued.

NT-proBNP–guided therapy proved safe and was well tolerated, with no significant increase in adverse events.

Patients in the guided-treatment arm had a median of six clinic visits, compared with five with standard management. The median baseline NT-proBNP level in the guided-therapy arm was 2,344 pg/mL. It fell to 1,125 pg/mL, with 44% of subjects in the guided-therapy arm attaining an NT-proBNP of 1,000 pg/mL or less.

Up-titration of heart failure medications was common in both study arms, but was significantly greater in the NT-proBNP group. A total of 63% of patients in the guided-therapy arm were placed on an aldosterone blocker, compared with 45% of controls.

Session cochair Dr. Gregg C. Fonarow said in an interview that he views PROTECT as a successful proof-of-concept study. But before biomarker-guided treatment of heart failure becomes part of guideline-recommended, routine outpatient care, it will be necessary to see if the Massachusetts General Hospital experience can be extended to other settings, including primary care practices, where many patients with heart failure receive their treatment. This will require a large multicenter trial with a diverse group of clinicians; randomization by site; and hard clinical end points, including mortality. A proposal for such a study has been presented to the National Heart, Lung, and Blood Institute for funding consideration.

"It’s a large and expensive trial, but the impact is potentially profound," said Dr. Fonarow, professor of medicine and director of the Ahmanson-UCLA Cardiomyopathy Center, Los Angeles. "Given the costs of heart failure and the tremendous number of outpatient visits for this disease, if we truly had a well-validated guide using biomarkers, that would be a phenomenal advance."

The PROTECT trial was sponsored in part by Roche Diagnostics. Dr. Januzzi declared he serves as a consultant to and speaker for the company.

CHICAGO – Using N-terminal prohormone brain natriuretic peptide levels to guide therapy in patients with systolic heart failure proved superior to standard of care management in terms of cardiovascular event rates, quality of life, and echocardiographic parameters in the randomized prospective PROTECT trial.

"If duplicated in larger cohorts, treatment guided by NT-proBNP may represent a new paradigm for heart failure care," Dr. James L. Januzzi Jr. said at the annual scientific sessions of the American Heart Association.

PROTECT (the ProBNP Outpatient Tailored Chronic Heart Failure Therapy study) was a single-center unblinded trial of 151 patients with systolic heart failure and a mean left ventricular ejection fraction of 27%. They were randomized to standard guideline-driven management on the basis of heart failure signs and symptoms or to the same approach with the added goal of reducing NT-proBNP levels to 1,000 pg/mL or less, a threshold previously shown to predict risk in heart failure patients.

Participants were scheduled for quarterly clinic visits, with extra ones as needed to achieve therapeutic goals, said Dr. Januzzi, director of the cardiac intensive care unit at Massachusetts General Hospital, Boston.

The study was halted early for ethical reasons after 10 months. At that point a total of 100 cardiovascular events – worsening heart failure, heart failure hospitalization, acute coronary syndrome, ventricular arrhythmias, cerebral ischemia, or cardiovascular death – had occurred in the standard-treatment group, compared with 58 events in patients on NT-proBNP–guided therapy. The major difference between the two study arms was the sharply lower likelihood of worsening heart failure or heart failure hospitalization in the NT-proBNP–guided arm.

Importantly, the reduction in cardiovascular events was similar in patients over age 75 and in those who were younger.

The secondary outcome of quality of life, assessed using the Minnesota Living with Heart Failure Questionnaire, also showed significantly greater improvement in the guided-treatment arm. In all, 61% of subjects in the NT-proBNP–guided arm achieved at least a 10-point improvement over baseline, considered clinically meaningful, compared with 39% on standard management.

The guided-treatment group also did significantly better in terms of secondary echocardiographic end points, with larger improvements in left ventricular ejection fraction and in ventricular remodeling as reflected by changes in LV end-systolic and end-diastolic volume index, the cardiologist continued.

NT-proBNP–guided therapy proved safe and was well tolerated, with no significant increase in adverse events.

Patients in the guided-treatment arm had a median of six clinic visits, compared with five with standard management. The median baseline NT-proBNP level in the guided-therapy arm was 2,344 pg/mL. It fell to 1,125 pg/mL, with 44% of subjects in the guided-therapy arm attaining an NT-proBNP of 1,000 pg/mL or less.

Up-titration of heart failure medications was common in both study arms, but was significantly greater in the NT-proBNP group. A total of 63% of patients in the guided-therapy arm were placed on an aldosterone blocker, compared with 45% of controls.

Session cochair Dr. Gregg C. Fonarow said in an interview that he views PROTECT as a successful proof-of-concept study. But before biomarker-guided treatment of heart failure becomes part of guideline-recommended, routine outpatient care, it will be necessary to see if the Massachusetts General Hospital experience can be extended to other settings, including primary care practices, where many patients with heart failure receive their treatment. This will require a large multicenter trial with a diverse group of clinicians; randomization by site; and hard clinical end points, including mortality. A proposal for such a study has been presented to the National Heart, Lung, and Blood Institute for funding consideration.

"It’s a large and expensive trial, but the impact is potentially profound," said Dr. Fonarow, professor of medicine and director of the Ahmanson-UCLA Cardiomyopathy Center, Los Angeles. "Given the costs of heart failure and the tremendous number of outpatient visits for this disease, if we truly had a well-validated guide using biomarkers, that would be a phenomenal advance."

The PROTECT trial was sponsored in part by Roche Diagnostics. Dr. Januzzi declared he serves as a consultant to and speaker for the company.

DENVER – The Ayurvedic medical practice known as shirodhara showed promise as a nonpharmacologic treatment for insomnia in a small pilot study.

Shirodhara is a relaxing procedure that entails dripping warm herbalized oil from a special pot onto the forehead of a supine patient. In Hindu culture, the forehead is the site of the third eye. The term shirodhara comes from the Sanscrit words shir (head) and dhara (flow).

The pilot study involved nine patients who underwent shirodhara for insomnia for 40 minutes daily on 5 consecutive days. Brahmi oil, which is sesame oil processed with waterhyssop (Bacopa monnieri) and other herbs, was used in the study, Dr. S. Prasad Vinjamury explained at the annual meeting of the American Public Health Association.

Mean symptomatic improvement as reflected in Insomnia Severity Index scores was 31% on day 5 compared with baseline. Three patients showed a modest 4%-8% improvement, while the other six experienced more substantial 26%-70% reductions in Insomnia Severity Index scores, said Dr. Vinjamury of the Southern California University of Health Sciences, an institution for complementary and alternative medicine located in Whittier, Calif.

One week following the fifth and final shirodhara treatment session, three patients showed further improvement. The rest either maintained the gains seen at the end of therapy or reverted to baseline.

Patients reported no treatment side effects. That’s a big plus for shirodhara as a potential therapy for insomnia, given that it has been estimated that 1.6 million Americans resort to complementary and alternative medicine for insomnia because they wish to avoid medication side effects, tolerance, and dependence, he observed.

In India, shirodhara is a popular therapy for a wide variety of medical ailments, including insomnia. In the United States, some health spas offer it as part of a relaxing massage package. This pilot study in insomnia was intended as proof of concept, paving the way for properly designed randomized, controlled trials in U.S. patients, according to Dr. Vinjamury.

He declared having no relevant financial interests.

DENVER – The Ayurvedic medical practice known as shirodhara showed promise as a nonpharmacologic treatment for insomnia in a small pilot study.

Shirodhara is a relaxing procedure that entails dripping warm herbalized oil from a special pot onto the forehead of a supine patient. In Hindu culture, the forehead is the site of the third eye. The term shirodhara comes from the Sanscrit words shir (head) and dhara (flow).

The pilot study involved nine patients who underwent shirodhara for insomnia for 40 minutes daily on 5 consecutive days. Brahmi oil, which is sesame oil processed with waterhyssop (Bacopa monnieri) and other herbs, was used in the study, Dr. S. Prasad Vinjamury explained at the annual meeting of the American Public Health Association.

Mean symptomatic improvement as reflected in Insomnia Severity Index scores was 31% on day 5 compared with baseline. Three patients showed a modest 4%-8% improvement, while the other six experienced more substantial 26%-70% reductions in Insomnia Severity Index scores, said Dr. Vinjamury of the Southern California University of Health Sciences, an institution for complementary and alternative medicine located in Whittier, Calif.

One week following the fifth and final shirodhara treatment session, three patients showed further improvement. The rest either maintained the gains seen at the end of therapy or reverted to baseline.

Patients reported no treatment side effects. That’s a big plus for shirodhara as a potential therapy for insomnia, given that it has been estimated that 1.6 million Americans resort to complementary and alternative medicine for insomnia because they wish to avoid medication side effects, tolerance, and dependence, he observed.

In India, shirodhara is a popular therapy for a wide variety of medical ailments, including insomnia. In the United States, some health spas offer it as part of a relaxing massage package. This pilot study in insomnia was intended as proof of concept, paving the way for properly designed randomized, controlled trials in U.S. patients, according to Dr. Vinjamury.

He declared having no relevant financial interests.

DENVER – The Ayurvedic medical practice known as shirodhara showed promise as a nonpharmacologic treatment for insomnia in a small pilot study.

Shirodhara is a relaxing procedure that entails dripping warm herbalized oil from a special pot onto the forehead of a supine patient. In Hindu culture, the forehead is the site of the third eye. The term shirodhara comes from the Sanscrit words shir (head) and dhara (flow).

The pilot study involved nine patients who underwent shirodhara for insomnia for 40 minutes daily on 5 consecutive days. Brahmi oil, which is sesame oil processed with waterhyssop (Bacopa monnieri) and other herbs, was used in the study, Dr. S. Prasad Vinjamury explained at the annual meeting of the American Public Health Association.

Mean symptomatic improvement as reflected in Insomnia Severity Index scores was 31% on day 5 compared with baseline. Three patients showed a modest 4%-8% improvement, while the other six experienced more substantial 26%-70% reductions in Insomnia Severity Index scores, said Dr. Vinjamury of the Southern California University of Health Sciences, an institution for complementary and alternative medicine located in Whittier, Calif.

One week following the fifth and final shirodhara treatment session, three patients showed further improvement. The rest either maintained the gains seen at the end of therapy or reverted to baseline.

Patients reported no treatment side effects. That’s a big plus for shirodhara as a potential therapy for insomnia, given that it has been estimated that 1.6 million Americans resort to complementary and alternative medicine for insomnia because they wish to avoid medication side effects, tolerance, and dependence, he observed.

In India, shirodhara is a popular therapy for a wide variety of medical ailments, including insomnia. In the United States, some health spas offer it as part of a relaxing massage package. This pilot study in insomnia was intended as proof of concept, paving the way for properly designed randomized, controlled trials in U.S. patients, according to Dr. Vinjamury.

He declared having no relevant financial interests.

DENVER – More than 568,000 fractures occur annually in U.S. high school athletes who participate in nine major sports, according to a new 4-year study.

Fractures accounted for 10.1% of all high school athletic injuries as well as 27% of all injuries requiring surgery, second only to complete ligament sprains, 30% of which underwent surgical repair, Natalie McIlvain said at the annual meeting of the American Public Health Association.

Foul play as determined by referee, coach, or athletic trainer played a role in 9.3% of all fractures, according to Ms. McIlvain of the center for injury research and policy at Nationwide Children’s Hospital in Columbus, Ohio.

She presented a study in which certified athletic trainers, who were on-site at a nationally representative sample of 100 U.S. high schools, recorded (in an Internet-based data collection tool) all the injuries that were incurred during practice and competition in 2005-2009. The researchers thereby captured the details of 18,316 fractures, which extrapolated to 568,177 fractures occurring annually.

Overall, 16.1% of fractures required surgery. The outliers were boys’ baseball, in which 26% of all fractures required surgery, and girls’ volleyball, in which surgery was needed in only 6% of fractures.

Fractures occurred at an overall rate of 2.48 per 10,000 athletic exposures (defined as one practice or competitive event). The rate was 4.97 fractures per 10,000 AEs during the heat of competition, a rate that was 3.2-fold greater than the rate in practices.

The sport with the highest fracture rate was football (4.61 broken bones per 10,000 AEs) with boys’ wrestling a distant second (2.64), followed by boys’ soccer (2.17). The girls’ sport with the highest fracture rate was basketball (1.38 per 10,000 AEs).

In boys’ and girls’ sports with similar rules and equipment, the boys’ version consistently had higher fracture rates: Boys were 34% more likely to sustain fractures in soccer and 35% more likely than girls to do so in basketball. The fracture rate was 1.61 per 10,000 AEs in boys’ baseball and 1.54 in girls’ softball.

The hands and fingers accounted for 28% of all fractures. The next most frequently fractured body parts were the wrist (10.4%), and the lower leg (9.3%).

In all, 34% of fractures resulted in more than 3 weeks lost from play. Another 24% led to medical disqualification from participation.

Ms. McIlvain’s study was supported by the Centers for Disease Control and Prevention, the National Federation of State High School Associations, DonJoy Orthotics, and EyeBlack. She declared having no relevant financial interests.

DENVER – More than 568,000 fractures occur annually in U.S. high school athletes who participate in nine major sports, according to a new 4-year study.

Fractures accounted for 10.1% of all high school athletic injuries as well as 27% of all injuries requiring surgery, second only to complete ligament sprains, 30% of which underwent surgical repair, Natalie McIlvain said at the annual meeting of the American Public Health Association.

Foul play as determined by referee, coach, or athletic trainer played a role in 9.3% of all fractures, according to Ms. McIlvain of the center for injury research and policy at Nationwide Children’s Hospital in Columbus, Ohio.

She presented a study in which certified athletic trainers, who were on-site at a nationally representative sample of 100 U.S. high schools, recorded (in an Internet-based data collection tool) all the injuries that were incurred during practice and competition in 2005-2009. The researchers thereby captured the details of 18,316 fractures, which extrapolated to 568,177 fractures occurring annually.

Overall, 16.1% of fractures required surgery. The outliers were boys’ baseball, in which 26% of all fractures required surgery, and girls’ volleyball, in which surgery was needed in only 6% of fractures.

Fractures occurred at an overall rate of 2.48 per 10,000 athletic exposures (defined as one practice or competitive event). The rate was 4.97 fractures per 10,000 AEs during the heat of competition, a rate that was 3.2-fold greater than the rate in practices.

The sport with the highest fracture rate was football (4.61 broken bones per 10,000 AEs) with boys’ wrestling a distant second (2.64), followed by boys’ soccer (2.17). The girls’ sport with the highest fracture rate was basketball (1.38 per 10,000 AEs).

In boys’ and girls’ sports with similar rules and equipment, the boys’ version consistently had higher fracture rates: Boys were 34% more likely to sustain fractures in soccer and 35% more likely than girls to do so in basketball. The fracture rate was 1.61 per 10,000 AEs in boys’ baseball and 1.54 in girls’ softball.

The hands and fingers accounted for 28% of all fractures. The next most frequently fractured body parts were the wrist (10.4%), and the lower leg (9.3%).

In all, 34% of fractures resulted in more than 3 weeks lost from play. Another 24% led to medical disqualification from participation.

Ms. McIlvain’s study was supported by the Centers for Disease Control and Prevention, the National Federation of State High School Associations, DonJoy Orthotics, and EyeBlack. She declared having no relevant financial interests.

DENVER – More than 568,000 fractures occur annually in U.S. high school athletes who participate in nine major sports, according to a new 4-year study.

Fractures accounted for 10.1% of all high school athletic injuries as well as 27% of all injuries requiring surgery, second only to complete ligament sprains, 30% of which underwent surgical repair, Natalie McIlvain said at the annual meeting of the American Public Health Association.

Foul play as determined by referee, coach, or athletic trainer played a role in 9.3% of all fractures, according to Ms. McIlvain of the center for injury research and policy at Nationwide Children’s Hospital in Columbus, Ohio.

She presented a study in which certified athletic trainers, who were on-site at a nationally representative sample of 100 U.S. high schools, recorded (in an Internet-based data collection tool) all the injuries that were incurred during practice and competition in 2005-2009. The researchers thereby captured the details of 18,316 fractures, which extrapolated to 568,177 fractures occurring annually.

Overall, 16.1% of fractures required surgery. The outliers were boys’ baseball, in which 26% of all fractures required surgery, and girls’ volleyball, in which surgery was needed in only 6% of fractures.

Fractures occurred at an overall rate of 2.48 per 10,000 athletic exposures (defined as one practice or competitive event). The rate was 4.97 fractures per 10,000 AEs during the heat of competition, a rate that was 3.2-fold greater than the rate in practices.

The sport with the highest fracture rate was football (4.61 broken bones per 10,000 AEs) with boys’ wrestling a distant second (2.64), followed by boys’ soccer (2.17). The girls’ sport with the highest fracture rate was basketball (1.38 per 10,000 AEs).

In boys’ and girls’ sports with similar rules and equipment, the boys’ version consistently had higher fracture rates: Boys were 34% more likely to sustain fractures in soccer and 35% more likely than girls to do so in basketball. The fracture rate was 1.61 per 10,000 AEs in boys’ baseball and 1.54 in girls’ softball.

The hands and fingers accounted for 28% of all fractures. The next most frequently fractured body parts were the wrist (10.4%), and the lower leg (9.3%).

In all, 34% of fractures resulted in more than 3 weeks lost from play. Another 24% led to medical disqualification from participation.

Ms. McIlvain’s study was supported by the Centers for Disease Control and Prevention, the National Federation of State High School Associations, DonJoy Orthotics, and EyeBlack. She declared having no relevant financial interests.

DENVER – More than 568,000 fractures occur annually in U.S. high school athletes who participate in nine major sports, according to a new 4-year study.

Fractures accounted for 10.1% of all high school athletic injuries as well as 27% of all injuries requiring surgery, second only to complete ligament sprains, 30% of which underwent surgical repair, Natalie McIlvain said at the annual meeting of the American Public Health Association.

Foul play as determined by referee, coach, or athletic trainer played a role in 9.3% of all fractures, according to Ms. McIlvain of the center for injury research and policy at Nationwide Children’s Hospital in Columbus, Ohio.

She presented a study in which certified athletic trainers, who were on-site at a nationally representative sample of 100 U.S. high schools, recorded (in an Internet-based data collection tool) all the injuries that were incurred during practice and competition in 2005-2009. The researchers thereby captured the details of 18,316 fractures, which extrapolated to 568,177 fractures occurring annually.

Overall, 16.1% of fractures required surgery. The outliers were boys’ baseball, in which 26% of all fractures required surgery, and girls’ volleyball, in which surgery was needed in only 6% of fractures.

Fractures occurred at an overall rate of 2.48 per 10,000 athletic exposures (defined as one practice or competitive event). The rate was 4.97 fractures per 10,000 AEs during the heat of competition, a rate that was 3.2-fold greater than the rate in practices.

The sport with the highest fracture rate was football (4.61 broken bones per 10,000 AEs) with boys’ wrestling a distant second (2.64), followed by boys’ soccer (2.17). The girls’ sport with the highest fracture rate was basketball (1.38 per 10,000 AEs).

In boys’ and girls’ sports with similar rules and equipment, the boys’ version consistently had higher fracture rates: Boys were 34% more likely to sustain fractures in soccer and 35% more likely than girls to do so in basketball. The fracture rate was 1.61 per 10,000 AEs in boys’ baseball and 1.54 in girls’ softball.

The hands and fingers accounted for 28% of all fractures. The next most frequently fractured body parts were the wrist (10.4%), and the lower leg (9.3%).

In all, 34% of fractures resulted in more than 3 weeks lost from play. Another 24% led to medical disqualification from participation.

Ms. McIlvain’s study was supported by the Centers for Disease Control and Prevention, the National Federation of State High School Associations, DonJoy Orthotics, and EyeBlack. She declared having no relevant financial interests.

DENVER – More than 568,000 fractures occur annually in U.S. high school athletes who participate in nine major sports, according to a new 4-year study.

Fractures accounted for 10.1% of all high school athletic injuries as well as 27% of all injuries requiring surgery, second only to complete ligament sprains, 30% of which underwent surgical repair, Natalie McIlvain said at the annual meeting of the American Public Health Association.

Foul play as determined by referee, coach, or athletic trainer played a role in 9.3% of all fractures, according to Ms. McIlvain of the center for injury research and policy at Nationwide Children’s Hospital in Columbus, Ohio.

She presented a study in which certified athletic trainers, who were on-site at a nationally representative sample of 100 U.S. high schools, recorded (in an Internet-based data collection tool) all the injuries that were incurred during practice and competition in 2005-2009. The researchers thereby captured the details of 18,316 fractures, which extrapolated to 568,177 fractures occurring annually.

Overall, 16.1% of fractures required surgery. The outliers were boys’ baseball, in which 26% of all fractures required surgery, and girls’ volleyball, in which surgery was needed in only 6% of fractures.

Fractures occurred at an overall rate of 2.48 per 10,000 athletic exposures (defined as one practice or competitive event). The rate was 4.97 fractures per 10,000 AEs during the heat of competition, a rate that was 3.2-fold greater than the rate in practices.

The sport with the highest fracture rate was football (4.61 broken bones per 10,000 AEs) with boys’ wrestling a distant second (2.64), followed by boys’ soccer (2.17). The girls’ sport with the highest fracture rate was basketball (1.38 per 10,000 AEs).

In boys’ and girls’ sports with similar rules and equipment, the boys’ version consistently had higher fracture rates: Boys were 34% more likely to sustain fractures in soccer and 35% more likely than girls to do so in basketball. The fracture rate was 1.61 per 10,000 AEs in boys’ baseball and 1.54 in girls’ softball.

The hands and fingers accounted for 28% of all fractures. The next most frequently fractured body parts were the wrist (10.4%), and the lower leg (9.3%).

In all, 34% of fractures resulted in more than 3 weeks lost from play. Another 24% led to medical disqualification from participation.

Ms. McIlvain’s study was supported by the Centers for Disease Control and Prevention, the National Federation of State High School Associations, DonJoy Orthotics, and EyeBlack. She declared having no relevant financial interests.

DENVER – More than 568,000 fractures occur annually in U.S. high school athletes who participate in nine major sports, according to a new 4-year study.

Fractures accounted for 10.1% of all high school athletic injuries as well as 27% of all injuries requiring surgery, second only to complete ligament sprains, 30% of which underwent surgical repair, Natalie McIlvain said at the annual meeting of the American Public Health Association.

Foul play as determined by referee, coach, or athletic trainer played a role in 9.3% of all fractures, according to Ms. McIlvain of the center for injury research and policy at Nationwide Children’s Hospital in Columbus, Ohio.

She presented a study in which certified athletic trainers, who were on-site at a nationally representative sample of 100 U.S. high schools, recorded (in an Internet-based data collection tool) all the injuries that were incurred during practice and competition in 2005-2009. The researchers thereby captured the details of 18,316 fractures, which extrapolated to 568,177 fractures occurring annually.

Overall, 16.1% of fractures required surgery. The outliers were boys’ baseball, in which 26% of all fractures required surgery, and girls’ volleyball, in which surgery was needed in only 6% of fractures.

Fractures occurred at an overall rate of 2.48 per 10,000 athletic exposures (defined as one practice or competitive event). The rate was 4.97 fractures per 10,000 AEs during the heat of competition, a rate that was 3.2-fold greater than the rate in practices.

The sport with the highest fracture rate was football (4.61 broken bones per 10,000 AEs) with boys’ wrestling a distant second (2.64), followed by boys’ soccer (2.17). The girls’ sport with the highest fracture rate was basketball (1.38 per 10,000 AEs).

In boys’ and girls’ sports with similar rules and equipment, the boys’ version consistently had higher fracture rates: Boys were 34% more likely to sustain fractures in soccer and 35% more likely than girls to do so in basketball. The fracture rate was 1.61 per 10,000 AEs in boys’ baseball and 1.54 in girls’ softball.

The hands and fingers accounted for 28% of all fractures. The next most frequently fractured body parts were the wrist (10.4%), and the lower leg (9.3%).

In all, 34% of fractures resulted in more than 3 weeks lost from play. Another 24% led to medical disqualification from participation.

Ms. McIlvain’s study was supported by the Centers for Disease Control and Prevention, the National Federation of State High School Associations, DonJoy Orthotics, and EyeBlack. She declared having no relevant financial interests.

DENVER — Parents of children with cancer are requesting a more balanced approach to hospital-visiting restrictions this flu season, one that recognizes the hardships that these restrictions impose on patients and their families.

A national survey that was conducted in January 2010 of 205 parent members of SuperSibs! (a nonprofit childhood cancer support group) indicates that visiting restrictions aimed at limiting the spread of H1N1 influenza at the time of the survey exacerbated the adverse emotional and economic impact of cancer on patients and their families, Melanie Goldish reported at the annual meeting of the American Public Health Association.

Although parents understood and appreciated the reasons why the H1N1-related visitation restrictions were in place, most felt they were too restrictive, harsh, and potentially ineffective, said Ms. Goldish, executive director and founder of SuperSibs! in Palatine, Ill. 

Although visiting restrictions varied among institutions, 62% of parents reported that siblings younger than a specified age weren’t allowed in the hospital at all, and 24% said that siblings younger than a certain age were allowed only in the lobby area.

Among the respondents, 64% indicated that they as parents had been negatively affected by H1N1-related visiting restrictions, as were 50% of their children with cancer and 56% of the siblings.

The parents reported that 34% of siblings younger than age 8 years became markedly more anxious because they couldn’t visit the patient, and 27% experienced separation anxiety because of their inability to see the parent who was isolated along with the hospitalized child.

These same issues were even more pronounced among siblings aged 8-12 years, who often also developed psychosomatic symptoms and acting-out behaviors that were attributed by parents to the forced isolation.

Three-quarters of parents said that the H1N1-related visiting restrictions had required them to make burdensome changes, including fewer or shorter visits with the hospitalized child, altered work schedules, more frequent hiring of babysitters, and the need to have siblings stay with relatives or friends.

The survey respondents called for changes to hospital-visiting restrictions that strike a balance between preserving the safety of the hospitalized child and avoiding undue added emotional distress for parents and siblings, according to Ms. Goldish.

Among the survey respondents’ specific suggestions were the following:

• Allow the non-sick siblings and parents in the patient’s hospital room, provided they have had a documented influenza vaccination.

• Offer vaccinations on-site.

• Require visitors to use masks and hand sanitizers while in the patient’s room.

• Use Internet-based Webcams to allow siblings at home to visit with the patient and parent in the hospital.

• Provide access to off-site social workers and caregiver services.

SuperSibs! provides detailed recommendations for parents and medical professionals regarding H1N1-related visiting restrictions.

Ms. Goldish reported having no relevant financial interests.

DENVER — Parents of children with cancer are requesting a more balanced approach to hospital-visiting restrictions this flu season, one that recognizes the hardships that these restrictions impose on patients and their families.

A national survey that was conducted in January 2010 of 205 parent members of SuperSibs! (a nonprofit childhood cancer support group) indicates that visiting restrictions aimed at limiting the spread of H1N1 influenza at the time of the survey exacerbated the adverse emotional and economic impact of cancer on patients and their families, Melanie Goldish reported at the annual meeting of the American Public Health Association.

Although parents understood and appreciated the reasons why the H1N1-related visitation restrictions were in place, most felt they were too restrictive, harsh, and potentially ineffective, said Ms. Goldish, executive director and founder of SuperSibs! in Palatine, Ill. 

Although visiting restrictions varied among institutions, 62% of parents reported that siblings younger than a specified age weren’t allowed in the hospital at all, and 24% said that siblings younger than a certain age were allowed only in the lobby area.

Among the respondents, 64% indicated that they as parents had been negatively affected by H1N1-related visiting restrictions, as were 50% of their children with cancer and 56% of the siblings.

The parents reported that 34% of siblings younger than age 8 years became markedly more anxious because they couldn’t visit the patient, and 27% experienced separation anxiety because of their inability to see the parent who was isolated along with the hospitalized child.

These same issues were even more pronounced among siblings aged 8-12 years, who often also developed psychosomatic symptoms and acting-out behaviors that were attributed by parents to the forced isolation.

Three-quarters of parents said that the H1N1-related visiting restrictions had required them to make burdensome changes, including fewer or shorter visits with the hospitalized child, altered work schedules, more frequent hiring of babysitters, and the need to have siblings stay with relatives or friends.

The survey respondents called for changes to hospital-visiting restrictions that strike a balance between preserving the safety of the hospitalized child and avoiding undue added emotional distress for parents and siblings, according to Ms. Goldish.

Among the survey respondents’ specific suggestions were the following:

• Allow the non-sick siblings and parents in the patient’s hospital room, provided they have had a documented influenza vaccination.

• Offer vaccinations on-site.

• Require visitors to use masks and hand sanitizers while in the patient’s room.

• Use Internet-based Webcams to allow siblings at home to visit with the patient and parent in the hospital.

• Provide access to off-site social workers and caregiver services.

SuperSibs! provides detailed recommendations for parents and medical professionals regarding H1N1-related visiting restrictions.

Ms. Goldish reported having no relevant financial interests.

DENVER — Parents of children with cancer are requesting a more balanced approach to hospital-visiting restrictions this flu season, one that recognizes the hardships that these restrictions impose on patients and their families.

A national survey that was conducted in January 2010 of 205 parent members of SuperSibs! (a nonprofit childhood cancer support group) indicates that visiting restrictions aimed at limiting the spread of H1N1 influenza at the time of the survey exacerbated the adverse emotional and economic impact of cancer on patients and their families, Melanie Goldish reported at the annual meeting of the American Public Health Association.

Although parents understood and appreciated the reasons why the H1N1-related visitation restrictions were in place, most felt they were too restrictive, harsh, and potentially ineffective, said Ms. Goldish, executive director and founder of SuperSibs! in Palatine, Ill. 

Although visiting restrictions varied among institutions, 62% of parents reported that siblings younger than a specified age weren’t allowed in the hospital at all, and 24% said that siblings younger than a certain age were allowed only in the lobby area.

Among the respondents, 64% indicated that they as parents had been negatively affected by H1N1-related visiting restrictions, as were 50% of their children with cancer and 56% of the siblings.

The parents reported that 34% of siblings younger than age 8 years became markedly more anxious because they couldn’t visit the patient, and 27% experienced separation anxiety because of their inability to see the parent who was isolated along with the hospitalized child.

These same issues were even more pronounced among siblings aged 8-12 years, who often also developed psychosomatic symptoms and acting-out behaviors that were attributed by parents to the forced isolation.

Three-quarters of parents said that the H1N1-related visiting restrictions had required them to make burdensome changes, including fewer or shorter visits with the hospitalized child, altered work schedules, more frequent hiring of babysitters, and the need to have siblings stay with relatives or friends.

The survey respondents called for changes to hospital-visiting restrictions that strike a balance between preserving the safety of the hospitalized child and avoiding undue added emotional distress for parents and siblings, according to Ms. Goldish.

Among the survey respondents’ specific suggestions were the following:

• Allow the non-sick siblings and parents in the patient’s hospital room, provided they have had a documented influenza vaccination.

• Offer vaccinations on-site.

• Require visitors to use masks and hand sanitizers while in the patient’s room.

• Use Internet-based Webcams to allow siblings at home to visit with the patient and parent in the hospital.

• Provide access to off-site social workers and caregiver services.

SuperSibs! provides detailed recommendations for parents and medical professionals regarding H1N1-related visiting restrictions.

Ms. Goldish reported having no relevant financial interests.

CHICAGO — Repeated myocardial perfusion imaging is common and associated with high cumulative radiation doses that are well within the range believed to increase cancer risk, according to a large, single-center study.

This retrospective study of 1,097 consecutive patients who underwent MPI at Columbia University Medical Center, New York, in the first 100 days of 2006 showed that 39% of them received more than one MPI during the study period running from 1988 through June 2008; 18% had at least three MPIs, and 5% had five or more, Dr. Andrew J. Einstein reported at the annual scientific sessions of the American Heart Association.

Among patients with multiple MPIs, the median time between the imaging studies was just under 2 years. However, 56% of patients with multiple MPIs had two within 2 years, and 28% had two within 1 year.

Patients with more than one MPI had a median 121-mSv cumulative estimated effective radiation dose from all medical sources. That’s more than in Japanese atomic bomb survivors, as documented in the landmark Life Span Study. By comparison, 1 year’s background radiation exposure is about 3 mSv, noted Dr. Einstein, a cardiologist at Columbia.

The radiation burden accruing from CT scans has drawn much attention in recent years, but in fact MPI entails the highest radiation exposure of all imaging procedures. Moreover, MPI is booming in popularity: The volume in the United States rose from fewer than 3 million of the imaging procedures in 1990 to 9.3 million in 2002.

In the Columbia University series, men, whites, and patients with health insurance had significantly greater likelihood of undergoing multiple MPIs, compared with women, nonwhites, and the uninsured. They also received higher cumulative radiation doses over the 20-year study period. But whether this increased utilization resulted in improved cardiovascular outcomes requires further study.

The great majority of MPIs ordered in the Columbia study were medically justified as an aid to therapeutic decision making, given that more than 80% of initial MPIs and 90% of repeat procedures were performed in patients with known cardiac disease or symptoms consistent with it. But in ordering these imaging studies, physicians often don’t consider that patients with heart disease undergo numerous additional procedures involving radiation exposure, including cardiac catheterizations. Indeed, the 1,097 patients in this study had a median of 15 procedures involving radiation exposure, including 4 high-dose procedures, Dr. Einstein noted.

Alternative tests without radiation exposure include stress MRI, stress echocardiography, and exercise ECG. Lower radiation exposure alternatives to MPI for use in ruling out cardiac causes of atypical symptoms are CT angiography and percutaneous angiography, he said.

In addition to utilizing tests other than MPI when appropriate, another means of reducing cumulative radiation doses is to avoid the dual-isotope MPI imaging protocol, which typically entails more than twice as great a radiation dose than does technetium-99m MPI, the cardiologist added.

Although the high cumulative radiation doses documented in the Columbia study are "certainly a matter of concern and an important target for improvement," in Dr. Einstein’s view it is worth bearing in mind that solid tumors generally don’t develop until at least 5-10 years following radiation exposure. Patients undergoing MPI are typically older than the general population, and they have a shorter-than-average life expectancy for their age because of their cardiac disease. So the risk:benefit ratio of radiation exposure from MPIs isn’t the same as a similar exposure would be in healthy young adults.

The study was published simultaneously with his presentation at the American Heart Association meeting (JAMA 2010;304:2137-44).

Dr. Einstein’s study was supported by the National Institutes of Health and university research grants. He declared having served as a consultant to the International Atomic Energy Agency as well as GE Healthcare.

CHICAGO — Repeated myocardial perfusion imaging is common and associated with high cumulative radiation doses that are well within the range believed to increase cancer risk, according to a large, single-center study.

This retrospective study of 1,097 consecutive patients who underwent MPI at Columbia University Medical Center, New York, in the first 100 days of 2006 showed that 39% of them received more than one MPI during the study period running from 1988 through June 2008; 18% had at least three MPIs, and 5% had five or more, Dr. Andrew J. Einstein reported at the annual scientific sessions of the American Heart Association.

Among patients with multiple MPIs, the median time between the imaging studies was just under 2 years. However, 56% of patients with multiple MPIs had two within 2 years, and 28% had two within 1 year.

Patients with more than one MPI had a median 121-mSv cumulative estimated effective radiation dose from all medical sources. That’s more than in Japanese atomic bomb survivors, as documented in the landmark Life Span Study. By comparison, 1 year’s background radiation exposure is about 3 mSv, noted Dr. Einstein, a cardiologist at Columbia.

The radiation burden accruing from CT scans has drawn much attention in recent years, but in fact MPI entails the highest radiation exposure of all imaging procedures. Moreover, MPI is booming in popularity: The volume in the United States rose from fewer than 3 million of the imaging procedures in 1990 to 9.3 million in 2002.

In the Columbia University series, men, whites, and patients with health insurance had significantly greater likelihood of undergoing multiple MPIs, compared with women, nonwhites, and the uninsured. They also received higher cumulative radiation doses over the 20-year study period. But whether this increased utilization resulted in improved cardiovascular outcomes requires further study.

The great majority of MPIs ordered in the Columbia study were medically justified as an aid to therapeutic decision making, given that more than 80% of initial MPIs and 90% of repeat procedures were performed in patients with known cardiac disease or symptoms consistent with it. But in ordering these imaging studies, physicians often don’t consider that patients with heart disease undergo numerous additional procedures involving radiation exposure, including cardiac catheterizations. Indeed, the 1,097 patients in this study had a median of 15 procedures involving radiation exposure, including 4 high-dose procedures, Dr. Einstein noted.

Alternative tests without radiation exposure include stress MRI, stress echocardiography, and exercise ECG. Lower radiation exposure alternatives to MPI for use in ruling out cardiac causes of atypical symptoms are CT angiography and percutaneous angiography, he said.

In addition to utilizing tests other than MPI when appropriate, another means of reducing cumulative radiation doses is to avoid the dual-isotope MPI imaging protocol, which typically entails more than twice as great a radiation dose than does technetium-99m MPI, the cardiologist added.

Although the high cumulative radiation doses documented in the Columbia study are "certainly a matter of concern and an important target for improvement," in Dr. Einstein’s view it is worth bearing in mind that solid tumors generally don’t develop until at least 5-10 years following radiation exposure. Patients undergoing MPI are typically older than the general population, and they have a shorter-than-average life expectancy for their age because of their cardiac disease. So the risk:benefit ratio of radiation exposure from MPIs isn’t the same as a similar exposure would be in healthy young adults.

The study was published simultaneously with his presentation at the American Heart Association meeting (JAMA 2010;304:2137-44).

Dr. Einstein’s study was supported by the National Institutes of Health and university research grants. He declared having served as a consultant to the International Atomic Energy Agency as well as GE Healthcare.

CHICAGO — Repeated myocardial perfusion imaging is common and associated with high cumulative radiation doses that are well within the range believed to increase cancer risk, according to a large, single-center study.

This retrospective study of 1,097 consecutive patients who underwent MPI at Columbia University Medical Center, New York, in the first 100 days of 2006 showed that 39% of them received more than one MPI during the study period running from 1988 through June 2008; 18% had at least three MPIs, and 5% had five or more, Dr. Andrew J. Einstein reported at the annual scientific sessions of the American Heart Association.

Among patients with multiple MPIs, the median time between the imaging studies was just under 2 years. However, 56% of patients with multiple MPIs had two within 2 years, and 28% had two within 1 year.

Patients with more than one MPI had a median 121-mSv cumulative estimated effective radiation dose from all medical sources. That’s more than in Japanese atomic bomb survivors, as documented in the landmark Life Span Study. By comparison, 1 year’s background radiation exposure is about 3 mSv, noted Dr. Einstein, a cardiologist at Columbia.

The radiation burden accruing from CT scans has drawn much attention in recent years, but in fact MPI entails the highest radiation exposure of all imaging procedures. Moreover, MPI is booming in popularity: The volume in the United States rose from fewer than 3 million of the imaging procedures in 1990 to 9.3 million in 2002.

In the Columbia University series, men, whites, and patients with health insurance had significantly greater likelihood of undergoing multiple MPIs, compared with women, nonwhites, and the uninsured. They also received higher cumulative radiation doses over the 20-year study period. But whether this increased utilization resulted in improved cardiovascular outcomes requires further study.

The great majority of MPIs ordered in the Columbia study were medically justified as an aid to therapeutic decision making, given that more than 80% of initial MPIs and 90% of repeat procedures were performed in patients with known cardiac disease or symptoms consistent with it. But in ordering these imaging studies, physicians often don’t consider that patients with heart disease undergo numerous additional procedures involving radiation exposure, including cardiac catheterizations. Indeed, the 1,097 patients in this study had a median of 15 procedures involving radiation exposure, including 4 high-dose procedures, Dr. Einstein noted.

Alternative tests without radiation exposure include stress MRI, stress echocardiography, and exercise ECG. Lower radiation exposure alternatives to MPI for use in ruling out cardiac causes of atypical symptoms are CT angiography and percutaneous angiography, he said.

In addition to utilizing tests other than MPI when appropriate, another means of reducing cumulative radiation doses is to avoid the dual-isotope MPI imaging protocol, which typically entails more than twice as great a radiation dose than does technetium-99m MPI, the cardiologist added.

Although the high cumulative radiation doses documented in the Columbia study are "certainly a matter of concern and an important target for improvement," in Dr. Einstein’s view it is worth bearing in mind that solid tumors generally don’t develop until at least 5-10 years following radiation exposure. Patients undergoing MPI are typically older than the general population, and they have a shorter-than-average life expectancy for their age because of their cardiac disease. So the risk:benefit ratio of radiation exposure from MPIs isn’t the same as a similar exposure would be in healthy young adults.

The study was published simultaneously with his presentation at the American Heart Association meeting (JAMA 2010;304:2137-44).

Dr. Einstein’s study was supported by the National Institutes of Health and university research grants. He declared having served as a consultant to the International Atomic Energy Agency as well as GE Healthcare.

CHICAGO — Repeated myocardial perfusion imaging is common and associated with high cumulative radiation doses that are well within the range believed to increase cancer risk, according to a large, single-center study.

This retrospective study of 1,097 consecutive patients who underwent MPI at Columbia University Medical Center, New York, in the first 100 days of 2006 showed that 39% of them received more than one MPI during the study period running from 1988 through June 2008; 18% had at least three MPIs, and 5% had five or more, Dr. Andrew J. Einstein reported at the annual scientific sessions of the American Heart Association.

Among patients with multiple MPIs, the median time between the imaging studies was just under 2 years. However, 56% of patients with multiple MPIs had two within 2 years, and 28% had two within 1 year.

Patients with more than one MPI had a median 121-mSv cumulative estimated effective radiation dose from all medical sources. That’s more than in Japanese atomic bomb survivors, as documented in the landmark Life Span Study. By comparison, 1 year’s background radiation exposure is about 3 mSv, noted Dr. Einstein, a cardiologist at Columbia.

The radiation burden accruing from CT scans has drawn much attention in recent years, but in fact MPI entails the highest radiation exposure of all imaging procedures. Moreover, MPI is booming in popularity: The volume in the United States rose from fewer than 3 million of the imaging procedures in 1990 to 9.3 million in 2002.

In the Columbia University series, men, whites, and patients with health insurance had significantly greater likelihood of undergoing multiple MPIs, compared with women, nonwhites, and the uninsured. They also received higher cumulative radiation doses over the 20-year study period. But whether this increased utilization resulted in improved cardiovascular outcomes requires further study.

The great majority of MPIs ordered in the Columbia study were medically justified as an aid to therapeutic decision making, given that more than 80% of initial MPIs and 90% of repeat procedures were performed in patients with known cardiac disease or symptoms consistent with it. But in ordering these imaging studies, physicians often don’t consider that patients with heart disease undergo numerous additional procedures involving radiation exposure, including cardiac catheterizations. Indeed, the 1,097 patients in this study had a median of 15 procedures involving radiation exposure, including 4 high-dose procedures, Dr. Einstein noted.

Alternative tests without radiation exposure include stress MRI, stress echocardiography, and exercise ECG. Lower radiation exposure alternatives to MPI for use in ruling out cardiac causes of atypical symptoms are CT angiography and percutaneous angiography, he said.

In addition to utilizing tests other than MPI when appropriate, another means of reducing cumulative radiation doses is to avoid the dual-isotope MPI imaging protocol, which typically entails more than twice as great a radiation dose than does technetium-99m MPI, the cardiologist added.

Although the high cumulative radiation doses documented in the Columbia study are "certainly a matter of concern and an important target for improvement," in Dr. Einstein’s view it is worth bearing in mind that solid tumors generally don’t develop until at least 5-10 years following radiation exposure. Patients undergoing MPI are typically older than the general population, and they have a shorter-than-average life expectancy for their age because of their cardiac disease. So the risk:benefit ratio of radiation exposure from MPIs isn’t the same as a similar exposure would be in healthy young adults.

The study was published simultaneously with his presentation at the American Heart Association meeting (JAMA 2010;304:2137-44).

Dr. Einstein’s study was supported by the National Institutes of Health and university research grants. He declared having served as a consultant to the International Atomic Energy Agency as well as GE Healthcare.

CHICAGO — Repeated myocardial perfusion imaging is common and associated with high cumulative radiation doses that are well within the range believed to increase cancer risk, according to a large, single-center study.

This retrospective study of 1,097 consecutive patients who underwent MPI at Columbia University Medical Center, New York, in the first 100 days of 2006 showed that 39% of them received more than one MPI during the study period running from 1988 through June 2008; 18% had at least three MPIs, and 5% had five or more, Dr. Andrew J. Einstein reported at the annual scientific sessions of the American Heart Association.

Among patients with multiple MPIs, the median time between the imaging studies was just under 2 years. However, 56% of patients with multiple MPIs had two within 2 years, and 28% had two within 1 year.

Patients with more than one MPI had a median 121-mSv cumulative estimated effective radiation dose from all medical sources. That’s more than in Japanese atomic bomb survivors, as documented in the landmark Life Span Study. By comparison, 1 year’s background radiation exposure is about 3 mSv, noted Dr. Einstein, a cardiologist at Columbia.

The radiation burden accruing from CT scans has drawn much attention in recent years, but in fact MPI entails the highest radiation exposure of all imaging procedures. Moreover, MPI is booming in popularity: The volume in the United States rose from fewer than 3 million of the imaging procedures in 1990 to 9.3 million in 2002.

In the Columbia University series, men, whites, and patients with health insurance had significantly greater likelihood of undergoing multiple MPIs, compared with women, nonwhites, and the uninsured. They also received higher cumulative radiation doses over the 20-year study period. But whether this increased utilization resulted in improved cardiovascular outcomes requires further study.

The great majority of MPIs ordered in the Columbia study were medically justified as an aid to therapeutic decision making, given that more than 80% of initial MPIs and 90% of repeat procedures were performed in patients with known cardiac disease or symptoms consistent with it. But in ordering these imaging studies, physicians often don’t consider that patients with heart disease undergo numerous additional procedures involving radiation exposure, including cardiac catheterizations. Indeed, the 1,097 patients in this study had a median of 15 procedures involving radiation exposure, including 4 high-dose procedures, Dr. Einstein noted.

Alternative tests without radiation exposure include stress MRI, stress echocardiography, and exercise ECG. Lower radiation exposure alternatives to MPI for use in ruling out cardiac causes of atypical symptoms are CT angiography and percutaneous angiography, he said.

In addition to utilizing tests other than MPI when appropriate, another means of reducing cumulative radiation doses is to avoid the dual-isotope MPI imaging protocol, which typically entails more than twice as great a radiation dose than does technetium-99m MPI, the cardiologist added.

Although the high cumulative radiation doses documented in the Columbia study are "certainly a matter of concern and an important target for improvement," in Dr. Einstein’s view it is worth bearing in mind that solid tumors generally don’t develop until at least 5-10 years following radiation exposure. Patients undergoing MPI are typically older than the general population, and they have a shorter-than-average life expectancy for their age because of their cardiac disease. So the risk:benefit ratio of radiation exposure from MPIs isn’t the same as a similar exposure would be in healthy young adults.

The study was published simultaneously with his presentation at the American Heart Association meeting (JAMA 2010;304:2137-44).

Dr. Einstein’s study was supported by the National Institutes of Health and university research grants. He declared having served as a consultant to the International Atomic Energy Agency as well as GE Healthcare.

CHICAGO — Repeated myocardial perfusion imaging is common and associated with high cumulative radiation doses that are well within the range believed to increase cancer risk, according to a large, single-center study.

This retrospective study of 1,097 consecutive patients who underwent MPI at Columbia University Medical Center, New York, in the first 100 days of 2006 showed that 39% of them received more than one MPI during the study period running from 1988 through June 2008; 18% had at least three MPIs, and 5% had five or more, Dr. Andrew J. Einstein reported at the annual scientific sessions of the American Heart Association.

Among patients with multiple MPIs, the median time between the imaging studies was just under 2 years. However, 56% of patients with multiple MPIs had two within 2 years, and 28% had two within 1 year.

Patients with more than one MPI had a median 121-mSv cumulative estimated effective radiation dose from all medical sources. That’s more than in Japanese atomic bomb survivors, as documented in the landmark Life Span Study. By comparison, 1 year’s background radiation exposure is about 3 mSv, noted Dr. Einstein, a cardiologist at Columbia.

The radiation burden accruing from CT scans has drawn much attention in recent years, but in fact MPI entails the highest radiation exposure of all imaging procedures. Moreover, MPI is booming in popularity: The volume in the United States rose from fewer than 3 million of the imaging procedures in 1990 to 9.3 million in 2002.

In the Columbia University series, men, whites, and patients with health insurance had significantly greater likelihood of undergoing multiple MPIs, compared with women, nonwhites, and the uninsured. They also received higher cumulative radiation doses over the 20-year study period. But whether this increased utilization resulted in improved cardiovascular outcomes requires further study.

The great majority of MPIs ordered in the Columbia study were medically justified as an aid to therapeutic decision making, given that more than 80% of initial MPIs and 90% of repeat procedures were performed in patients with known cardiac disease or symptoms consistent with it. But in ordering these imaging studies, physicians often don’t consider that patients with heart disease undergo numerous additional procedures involving radiation exposure, including cardiac catheterizations. Indeed, the 1,097 patients in this study had a median of 15 procedures involving radiation exposure, including 4 high-dose procedures, Dr. Einstein noted.

Alternative tests without radiation exposure include stress MRI, stress echocardiography, and exercise ECG. Lower radiation exposure alternatives to MPI for use in ruling out cardiac causes of atypical symptoms are CT angiography and percutaneous angiography, he said.

In addition to utilizing tests other than MPI when appropriate, another means of reducing cumulative radiation doses is to avoid the dual-isotope MPI imaging protocol, which typically entails more than twice as great a radiation dose than does technetium-99m MPI, the cardiologist added.

Although the high cumulative radiation doses documented in the Columbia study are "certainly a matter of concern and an important target for improvement," in Dr. Einstein’s view it is worth bearing in mind that solid tumors generally don’t develop until at least 5-10 years following radiation exposure. Patients undergoing MPI are typically older than the general population, and they have a shorter-than-average life expectancy for their age because of their cardiac disease. So the risk:benefit ratio of radiation exposure from MPIs isn’t the same as a similar exposure would be in healthy young adults.

The study was published simultaneously with his presentation at the American Heart Association meeting (JAMA 2010;304:2137-44).

Dr. Einstein’s study was supported by the National Institutes of Health and university research grants. He declared having served as a consultant to the International Atomic Energy Agency as well as GE Healthcare.

SAN ANTONIO – Prophylactic bilateral oophorectomy is the standard of care for prevention of breast and ovarian cancer in BRCA1 and -2 mutation carriers, but the benefit may be outweighed by sharply increased subsequent all-cause mortality, mostly due to cardiovascular disease, when oophorectomy is performed in obese women at a young age, a study has shown.

"This could have very clear relevance for clinical practice. Those women who’ve had oophorectomy in the past may need to be followed more carefully and encouraged to maintain a healthy weight. And these findings may also play into planning about prophylactic surgery, as well – weighing a woman’s cardiovascular risk and obesity level in deciding whether to do a prophylactic oophorectomy," Dr. Anne Marie McCarthy said at the San Antonio Breast Cancer Symposium.

Prophylactic oophorectomy as a strategy for prevention of ovarian and breast cancer in BRCA mutation carriers is too recent a development for follow-up studies to be sufficiently mature to assess the cardiovascular impact of abrupt surgical deprivation of estrogen and androgens in premenopausal women. After all, the longest follow-up reported to date in such studies is only 6 years.

For this reason, Dr. McCarthy and her coworkers turned instead to the third National Health and Nutrition Examination Survey (NHANES III), where they zeroed in on a nationally representative sample of women aged 40 or older when interviewed during 1988-1994. They compared 474 women who had previously undergone bilateral oophorectomy, with 3,047 women with intact ovaries. Through 2006, 1,106 women had died.

Women with bilateral oophorectomy were typically older, more likely to be of lower socioeconomic and educational status, and had higher usage of hormone therapy than did those with intact ovaries. In a multivariate analysis adjusted for these and other potential confounding factors, women with a body mass index of 30 kg/m2 or more who underwent oophorectomy before age 40 had a 2.4-fold greater risk of all-cause mortality than women with intact ovaries (P = .004). The risk was similarly increased in users and never-users of hormone therapy, according to Dr. McCarthy of Johns Hopkins University, Baltimore.

Obesity was also independently associated with increased all-cause mortality in the overall study population, where a BMI of 30 kg/m2 or more conferred a 37% greater risk than seen in women with a BMI of less than 25 kg/m2 (P = .001). However, this adiposity-related increase in mortality risk was further magnified nearly sevenfold when obese women who underwent oophorectomy prior to age 40 were compared with obese women with intact ovaries.

Session cochair Dr. Graham Colditz said the new NHANES III analysis is consistent with an earlier report from the Nurses’ Health Study (Obstet.Gynecol. 2009;113:1027-37), which showed increased mortality from coronary heart disease and stroke in participants who underwent bilateral oophorectomy. Moreover, this risk was increased most dramatically in nurses with oophorectomy at a young age.

But there is an important and potentially worrisome difference between the Nurses’ Health Study population and women who undergo prophylactic bilateral oophorectomy today, he added. Enrollment in the Nurses’ Health Study began in the mid-1970s, and 70% of participants had a BMI below 25 kg/m2.

"Many of us can barely remember the days when the majority of U.S. women had a BMI less than 25 kg/m2; we’ve now shifted to where 70% are over 25 kg/m2," noted Dr. Colditz, professor of surgery at Washington University in St. Louis.

If the new NHANES III analysis is indeed correct and adiposity accentuates the adverse cardiovascular impact of bilateral oophorectomy performed at a young age, then the ongoing obesity epidemic spells trouble for the strategy of prophylactic oophorectomy for the prevention of breast and ovarian cancer.

"Are women really thinking about their overall mortality risk when they decide about prophylactic oophorectomy, or are they focusing on breast cancer mortality and disease-free survival?" he asked.

Dr. Carol J. Fabian commented that Dr. McCarthy’s study dovetails nicely with an earlier Mayo Clinic report (Lancet Oncol. 2006;7:821-8) showing that women who underwent oophorectomy before age 45 not only had a dramatic increase in cardiovascular mortality, they also had increased rates of Parkinson’s disease and self-reported cognitive deficits.

The good news: All of these increased risks were negated by hormone therapy with estrogen alone, which was an option because many of these women underwent hysterectomy at the time of oophorectomy, she said.

"It’s a really important point: If we’re going to perform oophorectomy on these very high-risk women at a very young age, there are going to be more cardiovascular outcomes, and we have to really think hard about how to prevent these," noted Dr. Fabian of the University of Kansas Cancer Center in Kansas City.

The NHANES III analysis is particularly relevant because prophylactic oophorectomy is generally recommended in BRCA mutation carriers after their last child is born or after age 35, but before age 45, whichever comes first. "These women are getting oophorectomy at an extremely young age," she noted.

Dr. McCarthy said she had no relevant financial disclosures.

SAN ANTONIO – Prophylactic bilateral oophorectomy is the standard of care for prevention of breast and ovarian cancer in BRCA1 and -2 mutation carriers, but the benefit may be outweighed by sharply increased subsequent all-cause mortality, mostly due to cardiovascular disease, when oophorectomy is performed in obese women at a young age, a study has shown.

"This could have very clear relevance for clinical practice. Those women who’ve had oophorectomy in the past may need to be followed more carefully and encouraged to maintain a healthy weight. And these findings may also play into planning about prophylactic surgery, as well – weighing a woman’s cardiovascular risk and obesity level in deciding whether to do a prophylactic oophorectomy," Dr. Anne Marie McCarthy said at the San Antonio Breast Cancer Symposium.

Prophylactic oophorectomy as a strategy for prevention of ovarian and breast cancer in BRCA mutation carriers is too recent a development for follow-up studies to be sufficiently mature to assess the cardiovascular impact of abrupt surgical deprivation of estrogen and androgens in premenopausal women. After all, the longest follow-up reported to date in such studies is only 6 years.

For this reason, Dr. McCarthy and her coworkers turned instead to the third National Health and Nutrition Examination Survey (NHANES III), where they zeroed in on a nationally representative sample of women aged 40 or older when interviewed during 1988-1994. They compared 474 women who had previously undergone bilateral oophorectomy, with 3,047 women with intact ovaries. Through 2006, 1,106 women had died.

Women with bilateral oophorectomy were typically older, more likely to be of lower socioeconomic and educational status, and had higher usage of hormone therapy than did those with intact ovaries. In a multivariate analysis adjusted for these and other potential confounding factors, women with a body mass index of 30 kg/m2 or more who underwent oophorectomy before age 40 had a 2.4-fold greater risk of all-cause mortality than women with intact ovaries (P = .004). The risk was similarly increased in users and never-users of hormone therapy, according to Dr. McCarthy of Johns Hopkins University, Baltimore.

Obesity was also independently associated with increased all-cause mortality in the overall study population, where a BMI of 30 kg/m2 or more conferred a 37% greater risk than seen in women with a BMI of less than 25 kg/m2 (P = .001). However, this adiposity-related increase in mortality risk was further magnified nearly sevenfold when obese women who underwent oophorectomy prior to age 40 were compared with obese women with intact ovaries.

Session cochair Dr. Graham Colditz said the new NHANES III analysis is consistent with an earlier report from the Nurses’ Health Study (Obstet.Gynecol. 2009;113:1027-37), which showed increased mortality from coronary heart disease and stroke in participants who underwent bilateral oophorectomy. Moreover, this risk was increased most dramatically in nurses with oophorectomy at a young age.

But there is an important and potentially worrisome difference between the Nurses’ Health Study population and women who undergo prophylactic bilateral oophorectomy today, he added. Enrollment in the Nurses’ Health Study began in the mid-1970s, and 70% of participants had a BMI below 25 kg/m2.

"Many of us can barely remember the days when the majority of U.S. women had a BMI less than 25 kg/m2; we’ve now shifted to where 70% are over 25 kg/m2," noted Dr. Colditz, professor of surgery at Washington University in St. Louis.

If the new NHANES III analysis is indeed correct and adiposity accentuates the adverse cardiovascular impact of bilateral oophorectomy performed at a young age, then the ongoing obesity epidemic spells trouble for the strategy of prophylactic oophorectomy for the prevention of breast and ovarian cancer.

"Are women really thinking about their overall mortality risk when they decide about prophylactic oophorectomy, or are they focusing on breast cancer mortality and disease-free survival?" he asked.

Dr. Carol J. Fabian commented that Dr. McCarthy’s study dovetails nicely with an earlier Mayo Clinic report (Lancet Oncol. 2006;7:821-8) showing that women who underwent oophorectomy before age 45 not only had a dramatic increase in cardiovascular mortality, they also had increased rates of Parkinson’s disease and self-reported cognitive deficits.

The good news: All of these increased risks were negated by hormone therapy with estrogen alone, which was an option because many of these women underwent hysterectomy at the time of oophorectomy, she said.

"It’s a really important point: If we’re going to perform oophorectomy on these very high-risk women at a very young age, there are going to be more cardiovascular outcomes, and we have to really think hard about how to prevent these," noted Dr. Fabian of the University of Kansas Cancer Center in Kansas City.

The NHANES III analysis is particularly relevant because prophylactic oophorectomy is generally recommended in BRCA mutation carriers after their last child is born or after age 35, but before age 45, whichever comes first. "These women are getting oophorectomy at an extremely young age," she noted.

Dr. McCarthy said she had no relevant financial disclosures.

SAN ANTONIO – Prophylactic bilateral oophorectomy is the standard of care for prevention of breast and ovarian cancer in BRCA1 and -2 mutation carriers, but the benefit may be outweighed by sharply increased subsequent all-cause mortality, mostly due to cardiovascular disease, when oophorectomy is performed in obese women at a young age, a study has shown.

"This could have very clear relevance for clinical practice. Those women who’ve had oophorectomy in the past may need to be followed more carefully and encouraged to maintain a healthy weight. And these findings may also play into planning about prophylactic surgery, as well – weighing a woman’s cardiovascular risk and obesity level in deciding whether to do a prophylactic oophorectomy," Dr. Anne Marie McCarthy said at the San Antonio Breast Cancer Symposium.

Prophylactic oophorectomy as a strategy for prevention of ovarian and breast cancer in BRCA mutation carriers is too recent a development for follow-up studies to be sufficiently mature to assess the cardiovascular impact of abrupt surgical deprivation of estrogen and androgens in premenopausal women. After all, the longest follow-up reported to date in such studies is only 6 years.

For this reason, Dr. McCarthy and her coworkers turned instead to the third National Health and Nutrition Examination Survey (NHANES III), where they zeroed in on a nationally representative sample of women aged 40 or older when interviewed during 1988-1994. They compared 474 women who had previously undergone bilateral oophorectomy, with 3,047 women with intact ovaries. Through 2006, 1,106 women had died.

Women with bilateral oophorectomy were typically older, more likely to be of lower socioeconomic and educational status, and had higher usage of hormone therapy than did those with intact ovaries. In a multivariate analysis adjusted for these and other potential confounding factors, women with a body mass index of 30 kg/m2 or more who underwent oophorectomy before age 40 had a 2.4-fold greater risk of all-cause mortality than women with intact ovaries (P = .004). The risk was similarly increased in users and never-users of hormone therapy, according to Dr. McCarthy of Johns Hopkins University, Baltimore.

Obesity was also independently associated with increased all-cause mortality in the overall study population, where a BMI of 30 kg/m2 or more conferred a 37% greater risk than seen in women with a BMI of less than 25 kg/m2 (P = .001). However, this adiposity-related increase in mortality risk was further magnified nearly sevenfold when obese women who underwent oophorectomy prior to age 40 were compared with obese women with intact ovaries.

Session cochair Dr. Graham Colditz said the new NHANES III analysis is consistent with an earlier report from the Nurses’ Health Study (Obstet.Gynecol. 2009;113:1027-37), which showed increased mortality from coronary heart disease and stroke in participants who underwent bilateral oophorectomy. Moreover, this risk was increased most dramatically in nurses with oophorectomy at a young age.

But there is an important and potentially worrisome difference between the Nurses’ Health Study population and women who undergo prophylactic bilateral oophorectomy today, he added. Enrollment in the Nurses’ Health Study began in the mid-1970s, and 70% of participants had a BMI below 25 kg/m2.

"Many of us can barely remember the days when the majority of U.S. women had a BMI less than 25 kg/m2; we’ve now shifted to where 70% are over 25 kg/m2," noted Dr. Colditz, professor of surgery at Washington University in St. Louis.

If the new NHANES III analysis is indeed correct and adiposity accentuates the adverse cardiovascular impact of bilateral oophorectomy performed at a young age, then the ongoing obesity epidemic spells trouble for the strategy of prophylactic oophorectomy for the prevention of breast and ovarian cancer.

"Are women really thinking about their overall mortality risk when they decide about prophylactic oophorectomy, or are they focusing on breast cancer mortality and disease-free survival?" he asked.

Dr. Carol J. Fabian commented that Dr. McCarthy’s study dovetails nicely with an earlier Mayo Clinic report (Lancet Oncol. 2006;7:821-8) showing that women who underwent oophorectomy before age 45 not only had a dramatic increase in cardiovascular mortality, they also had increased rates of Parkinson’s disease and self-reported cognitive deficits.

The good news: All of these increased risks were negated by hormone therapy with estrogen alone, which was an option because many of these women underwent hysterectomy at the time of oophorectomy, she said.

"It’s a really important point: If we’re going to perform oophorectomy on these very high-risk women at a very young age, there are going to be more cardiovascular outcomes, and we have to really think hard about how to prevent these," noted Dr. Fabian of the University of Kansas Cancer Center in Kansas City.

The NHANES III analysis is particularly relevant because prophylactic oophorectomy is generally recommended in BRCA mutation carriers after their last child is born or after age 35, but before age 45, whichever comes first. "These women are getting oophorectomy at an extremely young age," she noted.

Dr. McCarthy said she had no relevant financial disclosures.

SAN ANTONIO – Prophylactic bilateral oophorectomy is the standard of care for prevention of breast and ovarian cancer in BRCA1 and -2 mutation carriers, but the benefit may be outweighed by sharply increased subsequent all-cause mortality, mostly due to cardiovascular disease, when oophorectomy is performed in obese women at a young age, a study has shown.

"This could have very clear relevance for clinical practice. Those women who’ve had oophorectomy in the past may need to be followed more carefully and encouraged to maintain a healthy weight. And these findings may also play into planning about prophylactic surgery, as well – weighing a woman’s cardiovascular risk and obesity level in deciding whether to do a prophylactic oophorectomy," Dr. Anne Marie McCarthy said at the San Antonio Breast Cancer Symposium.

Prophylactic oophorectomy as a strategy for prevention of ovarian and breast cancer in BRCA mutation carriers is too recent a development for follow-up studies to be sufficiently mature to assess the cardiovascular impact of abrupt surgical deprivation of estrogen and androgens in premenopausal women. After all, the longest follow-up reported to date in such studies is only 6 years.

For this reason, Dr. McCarthy and her coworkers turned instead to the third National Health and Nutrition Examination Survey (NHANES III), where they zeroed in on a nationally representative sample of women aged 40 or older when interviewed during 1988-1994. They compared 474 women who had previously undergone bilateral oophorectomy, with 3,047 women with intact ovaries. Through 2006, 1,106 women had died.

Women with bilateral oophorectomy were typically older, more likely to be of lower socioeconomic and educational status, and had higher usage of hormone therapy than did those with intact ovaries. In a multivariate analysis adjusted for these and other potential confounding factors, women with a body mass index of 30 kg/m2 or more who underwent oophorectomy before age 40 had a 2.4-fold greater risk of all-cause mortality than women with intact ovaries (P = .004). The risk was similarly increased in users and never-users of hormone therapy, according to Dr. McCarthy of Johns Hopkins University, Baltimore.

Obesity was also independently associated with increased all-cause mortality in the overall study population, where a BMI of 30 kg/m2 or more conferred a 37% greater risk than seen in women with a BMI of less than 25 kg/m2 (P = .001). However, this adiposity-related increase in mortality risk was further magnified nearly sevenfold when obese women who underwent oophorectomy prior to age 40 were compared with obese women with intact ovaries.

Session cochair Dr. Graham Colditz said the new NHANES III analysis is consistent with an earlier report from the Nurses’ Health Study (Obstet.Gynecol. 2009;113:1027-37), which showed increased mortality from coronary heart disease and stroke in participants who underwent bilateral oophorectomy. Moreover, this risk was increased most dramatically in nurses with oophorectomy at a young age.

But there is an important and potentially worrisome difference between the Nurses’ Health Study population and women who undergo prophylactic bilateral oophorectomy today, he added. Enrollment in the Nurses’ Health Study began in the mid-1970s, and 70% of participants had a BMI below 25 kg/m2.

"Many of us can barely remember the days when the majority of U.S. women had a BMI less than 25 kg/m2; we’ve now shifted to where 70% are over 25 kg/m2," noted Dr. Colditz, professor of surgery at Washington University in St. Louis.

If the new NHANES III analysis is indeed correct and adiposity accentuates the adverse cardiovascular impact of bilateral oophorectomy performed at a young age, then the ongoing obesity epidemic spells trouble for the strategy of prophylactic oophorectomy for the prevention of breast and ovarian cancer.

"Are women really thinking about their overall mortality risk when they decide about prophylactic oophorectomy, or are they focusing on breast cancer mortality and disease-free survival?" he asked.

Dr. Carol J. Fabian commented that Dr. McCarthy’s study dovetails nicely with an earlier Mayo Clinic report (Lancet Oncol. 2006;7:821-8) showing that women who underwent oophorectomy before age 45 not only had a dramatic increase in cardiovascular mortality, they also had increased rates of Parkinson’s disease and self-reported cognitive deficits.

The good news: All of these increased risks were negated by hormone therapy with estrogen alone, which was an option because many of these women underwent hysterectomy at the time of oophorectomy, she said.

"It’s a really important point: If we’re going to perform oophorectomy on these very high-risk women at a very young age, there are going to be more cardiovascular outcomes, and we have to really think hard about how to prevent these," noted Dr. Fabian of the University of Kansas Cancer Center in Kansas City.

The NHANES III analysis is particularly relevant because prophylactic oophorectomy is generally recommended in BRCA mutation carriers after their last child is born or after age 35, but before age 45, whichever comes first. "These women are getting oophorectomy at an extremely young age," she noted.

Dr. McCarthy said she had no relevant financial disclosures.

SAN ANTONIO – Prophylactic bilateral oophorectomy is the standard of care for prevention of breast and ovarian cancer in BRCA1 and -2 mutation carriers, but the benefit may be outweighed by sharply increased subsequent all-cause mortality, mostly due to cardiovascular disease, when oophorectomy is performed in obese women at a young age, a study has shown.

"This could have very clear relevance for clinical practice. Those women who’ve had oophorectomy in the past may need to be followed more carefully and encouraged to maintain a healthy weight. And these findings may also play into planning about prophylactic surgery, as well – weighing a woman’s cardiovascular risk and obesity level in deciding whether to do a prophylactic oophorectomy," Dr. Anne Marie McCarthy said at the San Antonio Breast Cancer Symposium.

Prophylactic oophorectomy as a strategy for prevention of ovarian and breast cancer in BRCA mutation carriers is too recent a development for follow-up studies to be sufficiently mature to assess the cardiovascular impact of abrupt surgical deprivation of estrogen and androgens in premenopausal women. After all, the longest follow-up reported to date in such studies is only 6 years.

For this reason, Dr. McCarthy and her coworkers turned instead to the third National Health and Nutrition Examination Survey (NHANES III), where they zeroed in on a nationally representative sample of women aged 40 or older when interviewed during 1988-1994. They compared 474 women who had previously undergone bilateral oophorectomy, with 3,047 women with intact ovaries. Through 2006, 1,106 women had died.

Women with bilateral oophorectomy were typically older, more likely to be of lower socioeconomic and educational status, and had higher usage of hormone therapy than did those with intact ovaries. In a multivariate analysis adjusted for these and other potential confounding factors, women with a body mass index of 30 kg/m2 or more who underwent oophorectomy before age 40 had a 2.4-fold greater risk of all-cause mortality than women with intact ovaries (P = .004). The risk was similarly increased in users and never-users of hormone therapy, according to Dr. McCarthy of Johns Hopkins University, Baltimore.

Obesity was also independently associated with increased all-cause mortality in the overall study population, where a BMI of 30 kg/m2 or more conferred a 37% greater risk than seen in women with a BMI of less than 25 kg/m2 (P = .001). However, this adiposity-related increase in mortality risk was further magnified nearly sevenfold when obese women who underwent oophorectomy prior to age 40 were compared with obese women with intact ovaries.

Session cochair Dr. Graham Colditz said the new NHANES III analysis is consistent with an earlier report from the Nurses’ Health Study (Obstet.Gynecol. 2009;113:1027-37), which showed increased mortality from coronary heart disease and stroke in participants who underwent bilateral oophorectomy. Moreover, this risk was increased most dramatically in nurses with oophorectomy at a young age.

But there is an important and potentially worrisome difference between the Nurses’ Health Study population and women who undergo prophylactic bilateral oophorectomy today, he added. Enrollment in the Nurses’ Health Study began in the mid-1970s, and 70% of participants had a BMI below 25 kg/m2.

"Many of us can barely remember the days when the majority of U.S. women had a BMI less than 25 kg/m2; we’ve now shifted to where 70% are over 25 kg/m2," noted Dr. Colditz, professor of surgery at Washington University in St. Louis.

If the new NHANES III analysis is indeed correct and adiposity accentuates the adverse cardiovascular impact of bilateral oophorectomy performed at a young age, then the ongoing obesity epidemic spells trouble for the strategy of prophylactic oophorectomy for the prevention of breast and ovarian cancer.

"Are women really thinking about their overall mortality risk when they decide about prophylactic oophorectomy, or are they focusing on breast cancer mortality and disease-free survival?" he asked.

Dr. Carol J. Fabian commented that Dr. McCarthy’s study dovetails nicely with an earlier Mayo Clinic report (Lancet Oncol. 2006;7:821-8) showing that women who underwent oophorectomy before age 45 not only had a dramatic increase in cardiovascular mortality, they also had increased rates of Parkinson’s disease and self-reported cognitive deficits.

The good news: All of these increased risks were negated by hormone therapy with estrogen alone, which was an option because many of these women underwent hysterectomy at the time of oophorectomy, she said.

"It’s a really important point: If we’re going to perform oophorectomy on these very high-risk women at a very young age, there are going to be more cardiovascular outcomes, and we have to really think hard about how to prevent these," noted Dr. Fabian of the University of Kansas Cancer Center in Kansas City.

The NHANES III analysis is particularly relevant because prophylactic oophorectomy is generally recommended in BRCA mutation carriers after their last child is born or after age 35, but before age 45, whichever comes first. "These women are getting oophorectomy at an extremely young age," she noted.

Dr. McCarthy said she had no relevant financial disclosures.

SAN ANTONIO – Prophylactic bilateral oophorectomy is the standard of care for prevention of breast and ovarian cancer in BRCA1 and -2 mutation carriers, but the benefit may be outweighed by sharply increased subsequent all-cause mortality, mostly due to cardiovascular disease, when oophorectomy is performed in obese women at a young age, a study has shown.

"This could have very clear relevance for clinical practice. Those women who’ve had oophorectomy in the past may need to be followed more carefully and encouraged to maintain a healthy weight. And these findings may also play into planning about prophylactic surgery, as well – weighing a woman’s cardiovascular risk and obesity level in deciding whether to do a prophylactic oophorectomy," Dr. Anne Marie McCarthy said at the San Antonio Breast Cancer Symposium.

Prophylactic oophorectomy as a strategy for prevention of ovarian and breast cancer in BRCA mutation carriers is too recent a development for follow-up studies to be sufficiently mature to assess the cardiovascular impact of abrupt surgical deprivation of estrogen and androgens in premenopausal women. After all, the longest follow-up reported to date in such studies is only 6 years.

For this reason, Dr. McCarthy and her coworkers turned instead to the third National Health and Nutrition Examination Survey (NHANES III), where they zeroed in on a nationally representative sample of women aged 40 or older when interviewed during 1988-1994. They compared 474 women who had previously undergone bilateral oophorectomy, with 3,047 women with intact ovaries. Through 2006, 1,106 women had died.

Women with bilateral oophorectomy were typically older, more likely to be of lower socioeconomic and educational status, and had higher usage of hormone therapy than did those with intact ovaries. In a multivariate analysis adjusted for these and other potential confounding factors, women with a body mass index of 30 kg/m2 or more who underwent oophorectomy before age 40 had a 2.4-fold greater risk of all-cause mortality than women with intact ovaries (P = .004). The risk was similarly increased in users and never-users of hormone therapy, according to Dr. McCarthy of Johns Hopkins University, Baltimore.

Obesity was also independently associated with increased all-cause mortality in the overall study population, where a BMI of 30 kg/m2 or more conferred a 37% greater risk than seen in women with a BMI of less than 25 kg/m2 (P = .001). However, this adiposity-related increase in mortality risk was further magnified nearly sevenfold when obese women who underwent oophorectomy prior to age 40 were compared with obese women with intact ovaries.

Session cochair Dr. Graham Colditz said the new NHANES III analysis is consistent with an earlier report from the Nurses’ Health Study (Obstet.Gynecol. 2009;113:1027-37), which showed increased mortality from coronary heart disease and stroke in participants who underwent bilateral oophorectomy. Moreover, this risk was increased most dramatically in nurses with oophorectomy at a young age.

But there is an important and potentially worrisome difference between the Nurses’ Health Study population and women who undergo prophylactic bilateral oophorectomy today, he added. Enrollment in the Nurses’ Health Study began in the mid-1970s, and 70% of participants had a BMI below 25 kg/m2.

"Many of us can barely remember the days when the majority of U.S. women had a BMI less than 25 kg/m2; we’ve now shifted to where 70% are over 25 kg/m2," noted Dr. Colditz, professor of surgery at Washington University in St. Louis.

If the new NHANES III analysis is indeed correct and adiposity accentuates the adverse cardiovascular impact of bilateral oophorectomy performed at a young age, then the ongoing obesity epidemic spells trouble for the strategy of prophylactic oophorectomy for the prevention of breast and ovarian cancer.

"Are women really thinking about their overall mortality risk when they decide about prophylactic oophorectomy, or are they focusing on breast cancer mortality and disease-free survival?" he asked.

Dr. Carol J. Fabian commented that Dr. McCarthy’s study dovetails nicely with an earlier Mayo Clinic report (Lancet Oncol. 2006;7:821-8) showing that women who underwent oophorectomy before age 45 not only had a dramatic increase in cardiovascular mortality, they also had increased rates of Parkinson’s disease and self-reported cognitive deficits.

The good news: All of these increased risks were negated by hormone therapy with estrogen alone, which was an option because many of these women underwent hysterectomy at the time of oophorectomy, she said.

"It’s a really important point: If we’re going to perform oophorectomy on these very high-risk women at a very young age, there are going to be more cardiovascular outcomes, and we have to really think hard about how to prevent these," noted Dr. Fabian of the University of Kansas Cancer Center in Kansas City.

The NHANES III analysis is particularly relevant because prophylactic oophorectomy is generally recommended in BRCA mutation carriers after their last child is born or after age 35, but before age 45, whichever comes first. "These women are getting oophorectomy at an extremely young age," she noted.

Dr. McCarthy said she had no relevant financial disclosures.

SAN ANTONIO – Estrogen receptor status flip-flops in 1 in 3 breast cancer patients when the primary tumor progresses to recurrence or distant metastasis, and HER2 status changes in 1 in 10, according to a Swedish study.

"Our data, together with other retrospective and prospective studies, really challenge the present management, which is to use primary tumor data for the management of metastatic disease," Dr. Jonas Bergh said in presenting the findings at the San Antonio Breast Cancer Symposium.

His argument that breast cancer relapses should be biopsied routinely for repeat hormone receptor and HER2 testing won widespread acceptance at the meeting.

"In the corridors around here the last couple of days this issue of primary tumor/metastasis heterogeneity has been the most discussed topic," Dr. Mitchell Dowsett noted in a conference-closing review highlighting the past year’s major developments in translational breast cancer research. He called the proportion of patients with marker changes in Dr. Bergh’s study "pretty startling."

"In 2010, I think the evidence supports rebiopsy if the result could affect management of the patient. And I do absolutely support this sort of analysis being mandatory in clinical trials of targeted therapy," said Dr. Dowsett, professor of translational research at Breakthrough Breast Cancer and of biochemical endocrinology at The Royal Marsden hospital, both in London.

Dr. Bergh presented a retrospective analysis that showed estrogen receptor status changed from positive in the primary to negative in the relapse specimen in 26% of 459 patients and from negative to positive in 7%.

"Hormone receptors are not stable during progression," concluded Dr. Bergh, professor of oncology at the Karolinska Institute, Stockholm.

The clinical relevance of this observation is underscored by the fact that patients who lost estrogen receptor positivity during tumor progression had a statistically significant 40% increase in the risk of dying compared with patients with stable estrogen receptor–positive disease, he added.

Moreover, among 118 patients whose HER2 status was known both in the primary tumor and the rebiopsied relapse, 7% lost their HER2 amplification and another 3% went from HER2-negative in the primary tumor to HER2-positive in the relapse.

Audience member Dr. Alastair M. Thompson rose to suggest that the time has come for biopsy of breast cancer recurrences or metastases to be considered the standard of care throughout the world. Dr. Thompson of Ninewells Hospital and Medical School, Dundee, Scotland, was lead author of the Breast Recurrence in Tissues Study (BRITS), a recent prospective 137-patient study showing that one in six women with relapse of breast cancer would have their treatment changed as a result of rebiopsy of their recurrent or metastatic disease (Breast Cancer Res. 2010;12:R92 [doi:10.1186/bcr2771]).

Dr. Lisa A. Carey, in a conference-closing summary of the past year’s progress in advanced breast cancer, noted that the 2010 ASCO meeting included three studies comprising roughly 520 patients, all showing "small but real changes" in hormone receptor and HER2 status between the primary tumor and metastatic disease.

"I think that rebiopsying at the time of relapse is a reasonable thing. The main reason to rebiopsy is to make sure you’re treating what you think you’re treating. I used to keep a list for my fellows of the psittacosis, nocardia, sarcoid, and other things that were masquerading as metastatic breast cancer," said Dr. Carey, medical director of the breast center at the University of North Carolina at Chapel Hill.

As for reanalyzing the hormone receptor and HER2 status, that is valuable, too, but with a caveat: "You have to be very cautious in using that information to guide therapy," she said. "For example, a hormone receptor–positive breast cancer that’s negative on rebiopsy may or may not reflect endocrine-insensitive disease. I think that’s a question that’s left outstanding."

Dr. Bergh disclosed that he receives honoraria for lectures from Amgen, AstraZeneca, Novartis, Pfizer, Roche, and Sanofi-Aventis.

SAN ANTONIO – Estrogen receptor status flip-flops in 1 in 3 breast cancer patients when the primary tumor progresses to recurrence or distant metastasis, and HER2 status changes in 1 in 10, according to a Swedish study.

"Our data, together with other retrospective and prospective studies, really challenge the present management, which is to use primary tumor data for the management of metastatic disease," Dr. Jonas Bergh said in presenting the findings at the San Antonio Breast Cancer Symposium.

His argument that breast cancer relapses should be biopsied routinely for repeat hormone receptor and HER2 testing won widespread acceptance at the meeting.

"In the corridors around here the last couple of days this issue of primary tumor/metastasis heterogeneity has been the most discussed topic," Dr. Mitchell Dowsett noted in a conference-closing review highlighting the past year’s major developments in translational breast cancer research. He called the proportion of patients with marker changes in Dr. Bergh’s study "pretty startling."

"In 2010, I think the evidence supports rebiopsy if the result could affect management of the patient. And I do absolutely support this sort of analysis being mandatory in clinical trials of targeted therapy," said Dr. Dowsett, professor of translational research at Breakthrough Breast Cancer and of biochemical endocrinology at The Royal Marsden hospital, both in London.

Dr. Bergh presented a retrospective analysis that showed estrogen receptor status changed from positive in the primary to negative in the relapse specimen in 26% of 459 patients and from negative to positive in 7%.

"Hormone receptors are not stable during progression," concluded Dr. Bergh, professor of oncology at the Karolinska Institute, Stockholm.

The clinical relevance of this observation is underscored by the fact that patients who lost estrogen receptor positivity during tumor progression had a statistically significant 40% increase in the risk of dying compared with patients with stable estrogen receptor–positive disease, he added.

Moreover, among 118 patients whose HER2 status was known both in the primary tumor and the rebiopsied relapse, 7% lost their HER2 amplification and another 3% went from HER2-negative in the primary tumor to HER2-positive in the relapse.

Audience member Dr. Alastair M. Thompson rose to suggest that the time has come for biopsy of breast cancer recurrences or metastases to be considered the standard of care throughout the world. Dr. Thompson of Ninewells Hospital and Medical School, Dundee, Scotland, was lead author of the Breast Recurrence in Tissues Study (BRITS), a recent prospective 137-patient study showing that one in six women with relapse of breast cancer would have their treatment changed as a result of rebiopsy of their recurrent or metastatic disease (Breast Cancer Res. 2010;12:R92 [doi:10.1186/bcr2771]).

Dr. Lisa A. Carey, in a conference-closing summary of the past year’s progress in advanced breast cancer, noted that the 2010 ASCO meeting included three studies comprising roughly 520 patients, all showing "small but real changes" in hormone receptor and HER2 status between the primary tumor and metastatic disease.

"I think that rebiopsying at the time of relapse is a reasonable thing. The main reason to rebiopsy is to make sure you’re treating what you think you’re treating. I used to keep a list for my fellows of the psittacosis, nocardia, sarcoid, and other things that were masquerading as metastatic breast cancer," said Dr. Carey, medical director of the breast center at the University of North Carolina at Chapel Hill.

As for reanalyzing the hormone receptor and HER2 status, that is valuable, too, but with a caveat: "You have to be very cautious in using that information to guide therapy," she said. "For example, a hormone receptor–positive breast cancer that’s negative on rebiopsy may or may not reflect endocrine-insensitive disease. I think that’s a question that’s left outstanding."

Dr. Bergh disclosed that he receives honoraria for lectures from Amgen, AstraZeneca, Novartis, Pfizer, Roche, and Sanofi-Aventis.

SAN ANTONIO – Estrogen receptor status flip-flops in 1 in 3 breast cancer patients when the primary tumor progresses to recurrence or distant metastasis, and HER2 status changes in 1 in 10, according to a Swedish study.

"Our data, together with other retrospective and prospective studies, really challenge the present management, which is to use primary tumor data for the management of metastatic disease," Dr. Jonas Bergh said in presenting the findings at the San Antonio Breast Cancer Symposium.

His argument that breast cancer relapses should be biopsied routinely for repeat hormone receptor and HER2 testing won widespread acceptance at the meeting.

"In the corridors around here the last couple of days this issue of primary tumor/metastasis heterogeneity has been the most discussed topic," Dr. Mitchell Dowsett noted in a conference-closing review highlighting the past year’s major developments in translational breast cancer research. He called the proportion of patients with marker changes in Dr. Bergh’s study "pretty startling."

"In 2010, I think the evidence supports rebiopsy if the result could affect management of the patient. And I do absolutely support this sort of analysis being mandatory in clinical trials of targeted therapy," said Dr. Dowsett, professor of translational research at Breakthrough Breast Cancer and of biochemical endocrinology at The Royal Marsden hospital, both in London.

Dr. Bergh presented a retrospective analysis that showed estrogen receptor status changed from positive in the primary to negative in the relapse specimen in 26% of 459 patients and from negative to positive in 7%.

"Hormone receptors are not stable during progression," concluded Dr. Bergh, professor of oncology at the Karolinska Institute, Stockholm.

The clinical relevance of this observation is underscored by the fact that patients who lost estrogen receptor positivity during tumor progression had a statistically significant 40% increase in the risk of dying compared with patients with stable estrogen receptor–positive disease, he added.

Moreover, among 118 patients whose HER2 status was known both in the primary tumor and the rebiopsied relapse, 7% lost their HER2 amplification and another 3% went from HER2-negative in the primary tumor to HER2-positive in the relapse.

Audience member Dr. Alastair M. Thompson rose to suggest that the time has come for biopsy of breast cancer recurrences or metastases to be considered the standard of care throughout the world. Dr. Thompson of Ninewells Hospital and Medical School, Dundee, Scotland, was lead author of the Breast Recurrence in Tissues Study (BRITS), a recent prospective 137-patient study showing that one in six women with relapse of breast cancer would have their treatment changed as a result of rebiopsy of their recurrent or metastatic disease (Breast Cancer Res. 2010;12:R92 [doi:10.1186/bcr2771]).

Dr. Lisa A. Carey, in a conference-closing summary of the past year’s progress in advanced breast cancer, noted that the 2010 ASCO meeting included three studies comprising roughly 520 patients, all showing "small but real changes" in hormone receptor and HER2 status between the primary tumor and metastatic disease.

"I think that rebiopsying at the time of relapse is a reasonable thing. The main reason to rebiopsy is to make sure you’re treating what you think you’re treating. I used to keep a list for my fellows of the psittacosis, nocardia, sarcoid, and other things that were masquerading as metastatic breast cancer," said Dr. Carey, medical director of the breast center at the University of North Carolina at Chapel Hill.

As for reanalyzing the hormone receptor and HER2 status, that is valuable, too, but with a caveat: "You have to be very cautious in using that information to guide therapy," she said. "For example, a hormone receptor–positive breast cancer that’s negative on rebiopsy may or may not reflect endocrine-insensitive disease. I think that’s a question that’s left outstanding."

Dr. Bergh disclosed that he receives honoraria for lectures from Amgen, AstraZeneca, Novartis, Pfizer, Roche, and Sanofi-Aventis.