The impact of medical tourism on colorectal screening among Korean Americans: A community-based cross-sectional study

Abstract

Background

Colorectal cancer (CRC) remains the most commonly diagnosed cancer among Korean Americans (KAs) in part due to low screening rates. Recent studies suggest that some KA patients engage in medical tourism and receive medical care in their home country. The impact of medical tourism on CRC screening is unknown. The purpose of this paper was to 1) investigate the frequency of medical tourism, 2) examine the association between medical tourism and CRC screening, and 3) characterize KA patients who engage in medical tourism.

Methods

This is a community-based, cross-sectional study involving self-administered questionnaires conducted from August 2013 to October 2013. Data was collected on 193 KA patients, ages 50–75, residing in the Seattle metropolitan area. The outcome variable is up-to-date with CRC screening, defined as having had a stool test (Fecal Occult Blood Test or Fecal Immunochemical Test) within the past year or a colonoscopy within 10 years. Predictor variables are socio-demographics, health factors, acculturation, knowledge, financial concerns for medical care costs, and medical tourism.

Results

In multi-variate modeling, medical tourism was significantly related to being up-to-date with CRC screening. Participants who engaged in medical tourism had 8.91 (95% CI: 3.89–23.89) greater odds of being up-to-date with CRC screening compared to those who did not travel for healthcare. Factors associated with engaging in medical tourism were lack of insurance coverage (P = 0.008), higher levels of education (P = 0.003), not having a usual place of care (P = 0.002), older age at immigration (P = 0.009), shorter years-of-stay in the US (P = 0.003), and being less likely to speak English well (P = 0.03).

Conclusions

This study identifies the impact of medical tourism on CRC screening and characteristics of KA patients who report engaging in medical tourism. Healthcare providers in the US should be aware of the customary nature of medical tourism among KAs and consider assessing medical tests done abroad when providing cancer care.

Trial registration

Not applicable.

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A case of extragastrointestinal stromal tumor complicated by severe hypoglycemia: a unique presentation of a rare tumor

Abstract

Background

Non-Islet Cell Tumor Hypoglycemia (NICTH) is a rare paraneoplastic cause of hypoglycemia arising from excess tumor production of insulin-like growth factor. The objective of this report is to describe an unusual case of Extragastrointestinal Stromal Tumor (EGIST) associated NICTH.

Case presentation

A 64 year-old African female was brought to the emergency room with a 1-month history of recurrent syncope, weight loss, and abdominal bloating. Serum blood glucose was discovered to 39 mg/dL, when insulin, proinsulin, and C-peptide were suppressed. Computed tomography scan revealed a diffuse extraintestinal metastatic disease process, and a biopsy confirmed the diagnosis of an Extragastrointestinal Stromal Tumor (EGIST). IGF-I and II levels were 27 ng/ml and 262 ng/ml respectively, and the ratio of IGF-II to IGF-I was calculated as 9.7:1, suggestive of IGF-II-mediated NICTH. Acutely, the patient's hypoglycemia resolved with dextrose and glucagon infusion. Long-term euglycemia was achieved with prednisone and imatinib therapy.

Conclusions

NICTH should be considered when hypoglycemia occurs in the setting of low serum insulin levels. Whereas definitive treatment of EGIST involves surgical resection, immunotherapy with tyrosine kinase inhibitors and corticosteroids have been shown to alleviate hypoglycemia in cases where surgery is delayed or not feasible.

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Role of geriatric intervention in the treatment of older patients with cancer: rationale and design of a phase III multicenter trial

Abstract

Background

In the general geriatric population, programs linking geriatric evaluation with interventions are effective for improving functional status and survival of the patients. Whether or not these interventions improve health related quality of life (HRQoL) or overall survival (OS) in older patients with cancer is not yet clear. Indeed, randomized data on the effect of such interventions on survival and HRQoL are rare and conflicting. We describe the rationale and design of a phase III multicenter trial aimed at assessing the efficacy of geriatric intervention in the management of elderly patients with cancer.

Methods/design

Approximately 1200 patients, 70 years and older, considered in need of a geriatric intervention based on the G8 screening tool will be randomized into two intervention arms. The 'Usual-care' arm involves standard oncological care based on pre-defined oncological protocols. In addition to the standard oncological care, the 'Case-management' arm involves a multidimensional geriatric assessment and interventions tailored for the patient. Efficacy will be assessed using a co-primary endpoint encompassing OS and HRQoL.

Discussion

This trial has been designed to assess whether focused geriatric case management can either improve OS or HRQoL in elderly cancer patients considered in need of geriatric assessment.

Trial registration

Clinicaltrials.gov ID: NCT02704832.

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Erratum to: Insulin-like growth factor 1 receptor mediated tyrosine 845 phosphorylation of epidermal growth factor receptor in the presence of monoclonal antibody cetuximab

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Computational prediction of multidisciplinary team decision-making for adjuvant breast cancer drug therapies: a machine learning approach

Abstract

Background

Multidisciplinary team (MDT) meetings are used to optimise expert decision-making about treatment options, but such expertise is not digitally transferable between centres. To help standardise medical decision-making, we developed a machine learning model designed to predict MDT decisions about adjuvant breast cancer treatments.

Methods

We analysed MDT decisions regarding adjuvant systemic therapy for 1065 breast cancer cases over eight years. Machine learning classifiers with and without bootstrap aggregation were correlated with MDT decisions (recommended, not recommended, or discussable) regarding adjuvant cytotoxic, endocrine and biologic/targeted therapies, then tested for predictability using stratified ten-fold cross-validations. The predictions so derived were duly compared with those based on published (ESMO and NCCN) cancer guidelines.

Results

Machine learning more accurately predicted adjuvant chemotherapy MDT decisions than did simple application of guidelines. No differences were found between MDT- vs. ESMO/NCCN- based decisions to prescribe either adjuvant endocrine (97%, p = 0.44/0.74) or biologic/targeted therapies (98%, p = 0.82/0.59). In contrast, significant discrepancies were evident between MDT- and guideline-based decisions to prescribe chemotherapy (87%, p < 0.01, representing 43% and 53% variations from ESMO/NCCN guidelines, respectively). Using ten-fold cross-validation, the best classifiers achieved areas under the receiver operating characteristic curve (AUC) of 0.940 for chemotherapy (95% C.I., 0.922—0.958), 0.899 for the endocrine therapy (95% C.I., 0.880—0.918), and 0.977 for trastuzumab therapy (95% C.I., 0.955—0.999) respectively. Overall, bootstrap aggregated classifiers performed better among all evaluated machine learning models.

Conclusions

A machine learning approach based on clinicopathologic characteristics can predict MDT decisions about adjuvant breast cancer drug therapies. The discrepancy between MDT- and guideline-based decisions regarding adjuvant chemotherapy implies that certain non-clincopathologic criteria, such as patient preference and resource availability, are factored into clinical decision-making by local experts but not captured by guidelines.

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IL-17A produced by peritoneal macrophages promote the accumulation and function of granulocytic myeloid-derived suppressor cells in the development of colitis-associated cancer

Abstract

It is widely acknowledged that a close relationship is between inflammation and colon cancer. Interleukin (IL)-17A and myeloid-derived suppressor cells (MDSCs) play an important role in the development of colitis-associated cancer (CAC). However, the precise changes of IL-17, MDSCs, and Th17 cells during the CAC progression have not been observed in the colorectal chronic inflammation-dependent tumor. In this study, we found the level of IL-17 was increased in pathogenic colon site during the early stage of CAC model. Further experiments showed the increased IL-17 was probably secreted by peritoneal macrophages when exposed to dextran sulfate sodium (DSS). In vitro, we found that IL-17 could enhance survival and suppressive function of granulocytic (G)-MDSCs, the subset associated with inflammation. With the development of CAC, the proportions of MDSCs and Th17 cells were continuously increased by the high level of IL-17 produced by macrophages. However, the increase of MDSCs was earlier and acuter than that of Th17 cells. Selective depletion of MDSCs not only slowed down CAC process but also significantly reduce Th17 cells in vivo. Thereafter, we demonstrated that in the development of CAC, IL-17 secreted by peritoneal macrophages could promote the accumulation of G-MDSCs, then the proportion of Th17 cells was increased, and finally promote the development of CAC.

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Palliative Care and Palliative Radiotherapy Education in Radiation Oncology: A Survey of US Radiation Oncology Program Directors

Publication date: Available online 1 December 2016
Source:Practical Radiation Oncology
Author(s): Randy L. Wei, Lauren E. Colbert, Joshua Jones, Margarita Racsa, Gabrielle Kane, Steve Lutz, Neha Vapiwala, Kavita Dharmarajan
Purpose/ObjectiveTo assess the state of palliative and supportive care (PSC) and palliative radiotherapy educational curricula in radiation oncology residency programs in the United States.Materials and methodsWe surveyed 87 program directors of radiation oncology residency programs in the United States from September 2015 to November 2015. An electronic survey on PSC and palliative radiotherapy education during residency was sent to all program directors. The survey consisted of questions on (1) perceived relevance of PSC and palliative radiotherapy to radiation oncology training, (2) formal didactic sessions on domains of PSC and palliative radiotherapy, (3) effective teaching formats for PSC and palliative radiotherapy education, (4) and perceived barriers for integrating PSC and palliative radiotherapy into the residency curriculum.ResultsA total of 57 responses (63%) were received. Most program directors agreed or strongly agreed that PSC (93%) and palliative radiotherapy (99%) are important competency for radiation oncology residents and fellows. However, 67% of residency programs had formal educational activities in principles and practice of PSC. Most programs had one or more hours of formal didactics on management of pain (67%), management of neuropathic pain (65%), and management of nausea and vomiting (63%). However, only 35%, 33%, and 30% had dedicated lectures on initial management of fatigue, assessing role of spirituality, and discussing advance care directives, respectively. Lastly, 85% of programs reported having a formal curriculum on palliative radiotherapy. Programs were most likely to have education on palliative radiation to brain, bone, and spine, but less likely on visceral, or skin metastasis.ConclusionResidency program directors believe that PSC and palliative radiotherapy are important competencies for their trainees and support increasing education in these two educational domains. Many residency programs have structured curricula on PSC and palliative radiation education, but room for improvement exists in management of fatigue, assessing role of spirituality and discussion regarding advance care planning.



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