Business of Medicine

Sexual harassment, bullying, and gender bias are still very real occupational hazards for ob.gyn. trainees and practitioners alike — even in this female-dominated field, a systematic evidence review found.

Published in JAMA Network Open, by Ankita Gupta, MD, MPH, a urogynecology and reconstructive pelvic surgery specialist at the University of Louisville in Kentucky, and colleagues, the analysis found rates as high as 71% for sexual harassment, coercion, or unwanted advances. It also noted high rates of bullying, gender bias, and microaggressions. “We were struck by the continued high rates of harassment,” Dr. Gupta said in an interview. “Much of the literature within academic medicine has suggested the unequal distribution of women among medical specialties is the cause of sexual and gender harassment, but despite ob.gyns. being overwhelmingly female, we found that gender bias continues to occur at alarmingly high rates.”

Furthermore, among studies where this was reported, almost 25% of respondents had experienced sexual coercion. Not unexpectedly, this mistreatment often went unreported to institutional leadership out of fear of retaliation.

“We were also surprised to find a high rate of 51% for sexual harassment among male respondents as well, suggesting that both gender and power dynamics play a role in harassment,” Dr. Gupta said.

The primary perpetrators of unwanted behaviors were other doctors, overwhelmingly attending physicians, although residents and fellows were also identified as perpetrators, especially when harassment was reported by medical students, she added. “This once again points to the underreported abuse of professional power.” Women were rarely the perpetrators — just 10% — although they were the perpetrators in 57.7% of cases when the victim was male.

“Another interesting aspect of this is gender bias and microaggressions in the operating room,” she continued. While female surgeons often experience bias coming from OR staff, the review found that 94.4% of female ob.gyns. had been mistaken for non-physicians, 88.9% had pre-apologized for asking for something from a surgical technician or nurse, and 83.3% needed to make such requests multiple times. “These instances demonstrate gender bias in both male and female operating room staff toward female ob.gyns.”

Undermining and bullying behaviors are common in surgical specialties, Dr. Gupta explained, and the tantrums, swearing, and humiliation of trainees may be considered as much a rite of passage as the long hours. “As a trainee, you are taught to ignore such behavior as reporting it comes with fear of repercussions.”

This review bore this out, with only 8%-12% of respondents across studies reporting harassment and then predominantly to another trainee. “Sexual harassment and microaggressions can further lead to loss of career opportunities and burnout and I have come across many ob.gyns. who have chosen alternate paths owing to negative experiences,” Dr. Gupta said.

The Analysis

A joint effort by the Society of Gynecologic Surgeons and the and Society of Gynecologic Oncology, the analysis looked at existing literature from inception through June 2023.

A total of 10 eligible studies with 5852 participants addressed prevalence and 12 eligible studies in 2906 participants addressed interventions. Among the findings across different studies:

• Sexual harassment was noted by 250 of 907 physicians (27.6%) and 181 of 255 female gynecologic oncologists (70.9%).
• Workplace discrimination ranged from 142 of 249 female gynecologic oncologists (57.0%) to 354 of 527 female gynecologic oncologists (67.2%); among male gynecologic oncologists 138 of 358 (38.5%) reported discrimination.
• Bullying was reported by 131 of 248 female gynecologic oncologists (52.8%).
• Ob.gyn. trainees commonly experienced sexual harassment: 253 of 366 respondents (69.1%); this included gender harassment, unwanted sexual attention, and sexual coercion.
• Mistreatment of medical students during ob.gyn. rotation was indicated by 168 of 668 (25.1%).
• Perpetrators of harassment included physicians (30.1%), other trainees (13.1%), and OR staff (7.7%).

These findings are consistent with those of other recent investigations. A systematic review from 2022 found that 25% of ob.gyn., 32% of general surgery, and 21% of medical interns and students reported bullying .

In another 2022 review, in which ob.gyn. program directors were mainly women and department chairs mainly men, the prevalence of sexual harassment did not differ based on the gender of program directors and chairs.

A study from 2021 reported that 27% of academic surgical trainees, including ob.gyns., reported sexual harassment.

Going back to 2004, a study across multiple medical specialties found that ob.gyn. was second only to general surgery as the specialty associated with the highest rates of sexual harassment.

Despite institutional anti-discrimination policies, real-life interventions seem ineffective. “Disappointingly, we found that most interventions to address harassment had not been appropriately evaluated and did not show a decrease in sexual harassment,” Dr. Gupta said. “Interventions that were successful in reducing mistreatment of trainees required institutional buy-in at multiple levels, including leadership, management, and administration,” she said.

Multi-pronged strategies might include providing tools to educate healthcare staff about harassment and empowering bystanders to intervene when encountering such situations. “Further, independent offices where all complaints are evaluated by an intermediary third party and requiring professionalism to be a criterion for promotion criterion can be useful strategies,” she said.

She noted that residents may model harassing behavior perpetrated by senior attending physicians, thereby creating a cycle of mistreatment. “Equipping clinicians to be better surgical educators, providing clinical support, and modeling positive behavior may help disrupt the culture of harassment.” While the best solutions may be unclear, it is clear that much work remains to be done before the ob.gyn. working environment catches up to official institutional anti-discrimination policies.

This study was supported by the Society of Gynecologic Surgeons. Dr. Gupta disclosed no competing interests. Several coauthors disclosed relationships with multiple pharmaceutical or biomedical companies.

Sexual harassment, bullying, and gender bias are still very real occupational hazards for ob.gyn. trainees and practitioners alike — even in this female-dominated field, a systematic evidence review found.

Published in JAMA Network Open, by Ankita Gupta, MD, MPH, a urogynecology and reconstructive pelvic surgery specialist at the University of Louisville in Kentucky, and colleagues, the analysis found rates as high as 71% for sexual harassment, coercion, or unwanted advances. It also noted high rates of bullying, gender bias, and microaggressions. “We were struck by the continued high rates of harassment,” Dr. Gupta said in an interview. “Much of the literature within academic medicine has suggested the unequal distribution of women among medical specialties is the cause of sexual and gender harassment, but despite ob.gyns. being overwhelmingly female, we found that gender bias continues to occur at alarmingly high rates.”

Furthermore, among studies where this was reported, almost 25% of respondents had experienced sexual coercion. Not unexpectedly, this mistreatment often went unreported to institutional leadership out of fear of retaliation.

“We were also surprised to find a high rate of 51% for sexual harassment among male respondents as well, suggesting that both gender and power dynamics play a role in harassment,” Dr. Gupta said.

The primary perpetrators of unwanted behaviors were other doctors, overwhelmingly attending physicians, although residents and fellows were also identified as perpetrators, especially when harassment was reported by medical students, she added. “This once again points to the underreported abuse of professional power.” Women were rarely the perpetrators — just 10% — although they were the perpetrators in 57.7% of cases when the victim was male.

“Another interesting aspect of this is gender bias and microaggressions in the operating room,” she continued. While female surgeons often experience bias coming from OR staff, the review found that 94.4% of female ob.gyns. had been mistaken for non-physicians, 88.9% had pre-apologized for asking for something from a surgical technician or nurse, and 83.3% needed to make such requests multiple times. “These instances demonstrate gender bias in both male and female operating room staff toward female ob.gyns.”

Undermining and bullying behaviors are common in surgical specialties, Dr. Gupta explained, and the tantrums, swearing, and humiliation of trainees may be considered as much a rite of passage as the long hours. “As a trainee, you are taught to ignore such behavior as reporting it comes with fear of repercussions.”

This review bore this out, with only 8%-12% of respondents across studies reporting harassment and then predominantly to another trainee. “Sexual harassment and microaggressions can further lead to loss of career opportunities and burnout and I have come across many ob.gyns. who have chosen alternate paths owing to negative experiences,” Dr. Gupta said.

The Analysis

A joint effort by the Society of Gynecologic Surgeons and the and Society of Gynecologic Oncology, the analysis looked at existing literature from inception through June 2023.

A total of 10 eligible studies with 5852 participants addressed prevalence and 12 eligible studies in 2906 participants addressed interventions. Among the findings across different studies:

• Sexual harassment was noted by 250 of 907 physicians (27.6%) and 181 of 255 female gynecologic oncologists (70.9%).
• Workplace discrimination ranged from 142 of 249 female gynecologic oncologists (57.0%) to 354 of 527 female gynecologic oncologists (67.2%); among male gynecologic oncologists 138 of 358 (38.5%) reported discrimination.
• Bullying was reported by 131 of 248 female gynecologic oncologists (52.8%).
• Ob.gyn. trainees commonly experienced sexual harassment: 253 of 366 respondents (69.1%); this included gender harassment, unwanted sexual attention, and sexual coercion.
• Mistreatment of medical students during ob.gyn. rotation was indicated by 168 of 668 (25.1%).
• Perpetrators of harassment included physicians (30.1%), other trainees (13.1%), and OR staff (7.7%).

These findings are consistent with those of other recent investigations. A systematic review from 2022 found that 25% of ob.gyn., 32% of general surgery, and 21% of medical interns and students reported bullying .

In another 2022 review, in which ob.gyn. program directors were mainly women and department chairs mainly men, the prevalence of sexual harassment did not differ based on the gender of program directors and chairs.

A study from 2021 reported that 27% of academic surgical trainees, including ob.gyns., reported sexual harassment.

Going back to 2004, a study across multiple medical specialties found that ob.gyn. was second only to general surgery as the specialty associated with the highest rates of sexual harassment.

Despite institutional anti-discrimination policies, real-life interventions seem ineffective. “Disappointingly, we found that most interventions to address harassment had not been appropriately evaluated and did not show a decrease in sexual harassment,” Dr. Gupta said. “Interventions that were successful in reducing mistreatment of trainees required institutional buy-in at multiple levels, including leadership, management, and administration,” she said.

Multi-pronged strategies might include providing tools to educate healthcare staff about harassment and empowering bystanders to intervene when encountering such situations. “Further, independent offices where all complaints are evaluated by an intermediary third party and requiring professionalism to be a criterion for promotion criterion can be useful strategies,” she said.

She noted that residents may model harassing behavior perpetrated by senior attending physicians, thereby creating a cycle of mistreatment. “Equipping clinicians to be better surgical educators, providing clinical support, and modeling positive behavior may help disrupt the culture of harassment.” While the best solutions may be unclear, it is clear that much work remains to be done before the ob.gyn. working environment catches up to official institutional anti-discrimination policies.

This study was supported by the Society of Gynecologic Surgeons. Dr. Gupta disclosed no competing interests. Several coauthors disclosed relationships with multiple pharmaceutical or biomedical companies.

Sexual harassment, bullying, and gender bias are still very real occupational hazards for ob.gyn. trainees and practitioners alike — even in this female-dominated field, a systematic evidence review found.

Published in JAMA Network Open, by Ankita Gupta, MD, MPH, a urogynecology and reconstructive pelvic surgery specialist at the University of Louisville in Kentucky, and colleagues, the analysis found rates as high as 71% for sexual harassment, coercion, or unwanted advances. It also noted high rates of bullying, gender bias, and microaggressions. “We were struck by the continued high rates of harassment,” Dr. Gupta said in an interview. “Much of the literature within academic medicine has suggested the unequal distribution of women among medical specialties is the cause of sexual and gender harassment, but despite ob.gyns. being overwhelmingly female, we found that gender bias continues to occur at alarmingly high rates.”

Furthermore, among studies where this was reported, almost 25% of respondents had experienced sexual coercion. Not unexpectedly, this mistreatment often went unreported to institutional leadership out of fear of retaliation.

“We were also surprised to find a high rate of 51% for sexual harassment among male respondents as well, suggesting that both gender and power dynamics play a role in harassment,” Dr. Gupta said.

The primary perpetrators of unwanted behaviors were other doctors, overwhelmingly attending physicians, although residents and fellows were also identified as perpetrators, especially when harassment was reported by medical students, she added. “This once again points to the underreported abuse of professional power.” Women were rarely the perpetrators — just 10% — although they were the perpetrators in 57.7% of cases when the victim was male.

“Another interesting aspect of this is gender bias and microaggressions in the operating room,” she continued. While female surgeons often experience bias coming from OR staff, the review found that 94.4% of female ob.gyns. had been mistaken for non-physicians, 88.9% had pre-apologized for asking for something from a surgical technician or nurse, and 83.3% needed to make such requests multiple times. “These instances demonstrate gender bias in both male and female operating room staff toward female ob.gyns.”

Undermining and bullying behaviors are common in surgical specialties, Dr. Gupta explained, and the tantrums, swearing, and humiliation of trainees may be considered as much a rite of passage as the long hours. “As a trainee, you are taught to ignore such behavior as reporting it comes with fear of repercussions.”

This review bore this out, with only 8%-12% of respondents across studies reporting harassment and then predominantly to another trainee. “Sexual harassment and microaggressions can further lead to loss of career opportunities and burnout and I have come across many ob.gyns. who have chosen alternate paths owing to negative experiences,” Dr. Gupta said.

The Analysis

A joint effort by the Society of Gynecologic Surgeons and the and Society of Gynecologic Oncology, the analysis looked at existing literature from inception through June 2023.

A total of 10 eligible studies with 5852 participants addressed prevalence and 12 eligible studies in 2906 participants addressed interventions. Among the findings across different studies:

• Sexual harassment was noted by 250 of 907 physicians (27.6%) and 181 of 255 female gynecologic oncologists (70.9%).
• Workplace discrimination ranged from 142 of 249 female gynecologic oncologists (57.0%) to 354 of 527 female gynecologic oncologists (67.2%); among male gynecologic oncologists 138 of 358 (38.5%) reported discrimination.
• Bullying was reported by 131 of 248 female gynecologic oncologists (52.8%).
• Ob.gyn. trainees commonly experienced sexual harassment: 253 of 366 respondents (69.1%); this included gender harassment, unwanted sexual attention, and sexual coercion.
• Mistreatment of medical students during ob.gyn. rotation was indicated by 168 of 668 (25.1%).
• Perpetrators of harassment included physicians (30.1%), other trainees (13.1%), and OR staff (7.7%).

These findings are consistent with those of other recent investigations. A systematic review from 2022 found that 25% of ob.gyn., 32% of general surgery, and 21% of medical interns and students reported bullying .

In another 2022 review, in which ob.gyn. program directors were mainly women and department chairs mainly men, the prevalence of sexual harassment did not differ based on the gender of program directors and chairs.

A study from 2021 reported that 27% of academic surgical trainees, including ob.gyns., reported sexual harassment.

Going back to 2004, a study across multiple medical specialties found that ob.gyn. was second only to general surgery as the specialty associated with the highest rates of sexual harassment.

Despite institutional anti-discrimination policies, real-life interventions seem ineffective. “Disappointingly, we found that most interventions to address harassment had not been appropriately evaluated and did not show a decrease in sexual harassment,” Dr. Gupta said. “Interventions that were successful in reducing mistreatment of trainees required institutional buy-in at multiple levels, including leadership, management, and administration,” she said.

Multi-pronged strategies might include providing tools to educate healthcare staff about harassment and empowering bystanders to intervene when encountering such situations. “Further, independent offices where all complaints are evaluated by an intermediary third party and requiring professionalism to be a criterion for promotion criterion can be useful strategies,” she said.

She noted that residents may model harassing behavior perpetrated by senior attending physicians, thereby creating a cycle of mistreatment. “Equipping clinicians to be better surgical educators, providing clinical support, and modeling positive behavior may help disrupt the culture of harassment.” While the best solutions may be unclear, it is clear that much work remains to be done before the ob.gyn. working environment catches up to official institutional anti-discrimination policies.

This study was supported by the Society of Gynecologic Surgeons. Dr. Gupta disclosed no competing interests. Several coauthors disclosed relationships with multiple pharmaceutical or biomedical companies.

BOSTON — Primary care clinicians caring for patients with intellectual and developmental disabilities often recommend guardianship, a responsibility with life-altering implications. 

But only approximately 30% of primary care residency programs in the United States provide training  on how to assess the ability of patients with disabilities to make decisions for themselves, and much of this training is optional, according to a recent study cited during a workshop at the 2024 annual meeting of the Society of General Internal Medicine.

Assessing the capacity of patients with disabilities involves navigating a maze of legal, ethical, and clinical considerations, according to Mary Thomas, MD, MPH, a clinical fellow in geriatrics at Yale University School of Medicine in New Haven, Connecticut, who co-moderated the workshop.

Guardianship, while sometimes necessary, can be overly restrictive and diminish patient autonomy, she said. The legal process — ultimately decided through the courts — gives a guardian permission to manage medical care and make decisions for someone who cannot make or communicate those decisions themselves.

Clinicians can assess patients through an evaluation of functional capacity, which allows them to observe a patient’s demeanor and administer a cognition test. Alternatives such as supported decision-making may be less restrictive and can better serve patients, she said. Supported decision-making allows for a person with disabilities to receive assistance from a supporter who can help a patient process medical conditions and treatment needs. The supporter helps empower capable patients to decide on their own.

Some states have introduced legislation that would legally recognize supported decision-making as a less restrictive alternative to guardianship or conservatorship, in which a court-appointed individual manages all aspects of a person’s life. 

Sara Mixter, MD, MPH, an assistant professor of medicine and pediatrics at the Johns Hopkins University School of Medicine in Baltimore and a co-moderator of the workshop, called the use of inclusive language in patient communication the “first step toward fostering an environment where patients feel respected and understood.”

Inclusive conversations can include person-first language and using words such as “caregiver” rather than “caretaker.” 

Dr. Thomas and Dr. Mixter also called for the directors of residency programs to provide more training on disabilities. They cited a 2023 survey of directors, many of whom said that educational boards do not require training in disability-specific care and that experts in the care of people with disabilities are few and far between.

“Education and awareness are key to overcoming the challenges we face,” Dr. Thomas said. “Improving our training programs means we can ensure that all patients receive the care and respect they deserve.”

Dr. Thomas and Dr. Mixter report no relevant disclosures.

A version of this article first appeared on Medscape.com.

BOSTON — Primary care clinicians caring for patients with intellectual and developmental disabilities often recommend guardianship, a responsibility with life-altering implications. 

But only approximately 30% of primary care residency programs in the United States provide training  on how to assess the ability of patients with disabilities to make decisions for themselves, and much of this training is optional, according to a recent study cited during a workshop at the 2024 annual meeting of the Society of General Internal Medicine.

Assessing the capacity of patients with disabilities involves navigating a maze of legal, ethical, and clinical considerations, according to Mary Thomas, MD, MPH, a clinical fellow in geriatrics at Yale University School of Medicine in New Haven, Connecticut, who co-moderated the workshop.

Guardianship, while sometimes necessary, can be overly restrictive and diminish patient autonomy, she said. The legal process — ultimately decided through the courts — gives a guardian permission to manage medical care and make decisions for someone who cannot make or communicate those decisions themselves.

Clinicians can assess patients through an evaluation of functional capacity, which allows them to observe a patient’s demeanor and administer a cognition test. Alternatives such as supported decision-making may be less restrictive and can better serve patients, she said. Supported decision-making allows for a person with disabilities to receive assistance from a supporter who can help a patient process medical conditions and treatment needs. The supporter helps empower capable patients to decide on their own.

Some states have introduced legislation that would legally recognize supported decision-making as a less restrictive alternative to guardianship or conservatorship, in which a court-appointed individual manages all aspects of a person’s life. 

Sara Mixter, MD, MPH, an assistant professor of medicine and pediatrics at the Johns Hopkins University School of Medicine in Baltimore and a co-moderator of the workshop, called the use of inclusive language in patient communication the “first step toward fostering an environment where patients feel respected and understood.”

Inclusive conversations can include person-first language and using words such as “caregiver” rather than “caretaker.” 

Dr. Thomas and Dr. Mixter also called for the directors of residency programs to provide more training on disabilities. They cited a 2023 survey of directors, many of whom said that educational boards do not require training in disability-specific care and that experts in the care of people with disabilities are few and far between.

“Education and awareness are key to overcoming the challenges we face,” Dr. Thomas said. “Improving our training programs means we can ensure that all patients receive the care and respect they deserve.”

Dr. Thomas and Dr. Mixter report no relevant disclosures.

A version of this article first appeared on Medscape.com.

BOSTON — Primary care clinicians caring for patients with intellectual and developmental disabilities often recommend guardianship, a responsibility with life-altering implications. 

But only approximately 30% of primary care residency programs in the United States provide training  on how to assess the ability of patients with disabilities to make decisions for themselves, and much of this training is optional, according to a recent study cited during a workshop at the 2024 annual meeting of the Society of General Internal Medicine.

Assessing the capacity of patients with disabilities involves navigating a maze of legal, ethical, and clinical considerations, according to Mary Thomas, MD, MPH, a clinical fellow in geriatrics at Yale University School of Medicine in New Haven, Connecticut, who co-moderated the workshop.

Guardianship, while sometimes necessary, can be overly restrictive and diminish patient autonomy, she said. The legal process — ultimately decided through the courts — gives a guardian permission to manage medical care and make decisions for someone who cannot make or communicate those decisions themselves.

Clinicians can assess patients through an evaluation of functional capacity, which allows them to observe a patient’s demeanor and administer a cognition test. Alternatives such as supported decision-making may be less restrictive and can better serve patients, she said. Supported decision-making allows for a person with disabilities to receive assistance from a supporter who can help a patient process medical conditions and treatment needs. The supporter helps empower capable patients to decide on their own.

Some states have introduced legislation that would legally recognize supported decision-making as a less restrictive alternative to guardianship or conservatorship, in which a court-appointed individual manages all aspects of a person’s life. 

Sara Mixter, MD, MPH, an assistant professor of medicine and pediatrics at the Johns Hopkins University School of Medicine in Baltimore and a co-moderator of the workshop, called the use of inclusive language in patient communication the “first step toward fostering an environment where patients feel respected and understood.”

Inclusive conversations can include person-first language and using words such as “caregiver” rather than “caretaker.” 

Dr. Thomas and Dr. Mixter also called for the directors of residency programs to provide more training on disabilities. They cited a 2023 survey of directors, many of whom said that educational boards do not require training in disability-specific care and that experts in the care of people with disabilities are few and far between.

“Education and awareness are key to overcoming the challenges we face,” Dr. Thomas said. “Improving our training programs means we can ensure that all patients receive the care and respect they deserve.”

Dr. Thomas and Dr. Mixter report no relevant disclosures.

A version of this article first appeared on Medscape.com.

BOSTON — Online patient portals have shifted patient expectations of how quickly clinicians respond and provide timely care, which can lead to burnout. But asynchronous care can, in some cases, be compensated and increase physician productivity and enhance patient care, according to experts who led a workshop at the Society of General Internal Medicine (SGIM) 2024 Annual Meeting.

Patient portal visits have increased in popularity and use since the COVID-19 pandemic. For primary care clinicians especially, the amount of time spent and the span of requests, from messages with new health concerns to requests for prescription refills, can be daunting.

“Understanding the nuances of these relationships is pivotal in navigating the evolution toward asynchronous care,” said Jennifer Schmidt, MD, an assistant professor of medicine at the Washington University School of Medicine in St. Louis, who co-moderated the workshop.

But patient portals can give clinicians another tool to deliver care beyond conventional office visits or telemedicine appointments, Dr. Schmidt said.

Clinicians can bill insurance if their response to a patient question takes longer than 5 minutes to compose. Responses to messages related to scheduling appointments, refilling prescriptions, or visit follow-ups are not billable.

Some participants at the session said their employers do not have policies that allow compensation for their work in patient portals. Others said their health systems have reported that patients who use portals more frequently have higher satisfaction scores.

Asynchronous care holds promise for extending care beyond traditional constraints, according to Stephen Fuest, MD, an assistant professor of internal medicine at the University of Colorado Anschutz Medical Campus in Aurora, Colorado, and a co-moderator of the workshop.

“By capitalizing on our experiences in designing and implementing systems for portal communication, we can find ways to optimize productivity and alleviate burnout,” Dr. Fuest said.

Dr. Fuest noted that while compensation rates for virtual care are lower than those for in-person, the lack of geographical barriers and time constraints allow clinicians to care for more patients. Asynchronous care also can limit losing patients to follow-up.

BOSTON — Online patient portals have shifted patient expectations of how quickly clinicians respond and provide timely care, which can lead to burnout. But asynchronous care can, in some cases, be compensated and increase physician productivity and enhance patient care, according to experts who led a workshop at the Society of General Internal Medicine (SGIM) 2024 Annual Meeting.

Patient portal visits have increased in popularity and use since the COVID-19 pandemic. For primary care clinicians especially, the amount of time spent and the span of requests, from messages with new health concerns to requests for prescription refills, can be daunting.

“Understanding the nuances of these relationships is pivotal in navigating the evolution toward asynchronous care,” said Jennifer Schmidt, MD, an assistant professor of medicine at the Washington University School of Medicine in St. Louis, who co-moderated the workshop.

But patient portals can give clinicians another tool to deliver care beyond conventional office visits or telemedicine appointments, Dr. Schmidt said.

Clinicians can bill insurance if their response to a patient question takes longer than 5 minutes to compose. Responses to messages related to scheduling appointments, refilling prescriptions, or visit follow-ups are not billable.

Some participants at the session said their employers do not have policies that allow compensation for their work in patient portals. Others said their health systems have reported that patients who use portals more frequently have higher satisfaction scores.

Asynchronous care holds promise for extending care beyond traditional constraints, according to Stephen Fuest, MD, an assistant professor of internal medicine at the University of Colorado Anschutz Medical Campus in Aurora, Colorado, and a co-moderator of the workshop.

“By capitalizing on our experiences in designing and implementing systems for portal communication, we can find ways to optimize productivity and alleviate burnout,” Dr. Fuest said.

Dr. Fuest noted that while compensation rates for virtual care are lower than those for in-person, the lack of geographical barriers and time constraints allow clinicians to care for more patients. Asynchronous care also can limit losing patients to follow-up.

BOSTON — Online patient portals have shifted patient expectations of how quickly clinicians respond and provide timely care, which can lead to burnout. But asynchronous care can, in some cases, be compensated and increase physician productivity and enhance patient care, according to experts who led a workshop at the Society of General Internal Medicine (SGIM) 2024 Annual Meeting.

Patient portal visits have increased in popularity and use since the COVID-19 pandemic. For primary care clinicians especially, the amount of time spent and the span of requests, from messages with new health concerns to requests for prescription refills, can be daunting.

“Understanding the nuances of these relationships is pivotal in navigating the evolution toward asynchronous care,” said Jennifer Schmidt, MD, an assistant professor of medicine at the Washington University School of Medicine in St. Louis, who co-moderated the workshop.

But patient portals can give clinicians another tool to deliver care beyond conventional office visits or telemedicine appointments, Dr. Schmidt said.

Clinicians can bill insurance if their response to a patient question takes longer than 5 minutes to compose. Responses to messages related to scheduling appointments, refilling prescriptions, or visit follow-ups are not billable.

Some participants at the session said their employers do not have policies that allow compensation for their work in patient portals. Others said their health systems have reported that patients who use portals more frequently have higher satisfaction scores.

Asynchronous care holds promise for extending care beyond traditional constraints, according to Stephen Fuest, MD, an assistant professor of internal medicine at the University of Colorado Anschutz Medical Campus in Aurora, Colorado, and a co-moderator of the workshop.

“By capitalizing on our experiences in designing and implementing systems for portal communication, we can find ways to optimize productivity and alleviate burnout,” Dr. Fuest said.

Dr. Fuest noted that while compensation rates for virtual care are lower than those for in-person, the lack of geographical barriers and time constraints allow clinicians to care for more patients. Asynchronous care also can limit losing patients to follow-up.

I don’t write many checks anymore.

When I started my practice in 2000 I wrote a lot. Paychecks for my staff, my rent, insurance, IRA contributions, federal & state withholding, payments on my EMG machine, pretty much everything.

Checks are old. We’ve been using them in some form for roughly 2000 years.

But the online world has changed a lot of that. Now I write maybe 2-3 a month. I could probably do fewer, but haven’t bothered to set those accounts up that way.

I recently was down to my last few checks, so ordered replacements. The minimum order was 600. As I unpacked the box I realized they’re probably the last ones I’ll need, both because checks are gradually passing by and because there are more days behind in my neurology career than ahead.

The checks are a minor thing, but they do make you think. Certainly we’re in the last generation of people who will ever need to use paper checks. Some phrases like “blank check” will likely be with us long after they’re gone (like “dialing a phone”), but the real deal is heading the same way as 8-Track and VHS tapes.

As my 600 checks dwindle down, realistically, so will my career. There is no rewind button on life. I have no desire to leave medicine right now, but the passage of time changes things.

Does that mean I, like my checks, am also getting obsolete?

I hope not. I’d like to think I still have something to offer. I have 30 years of neurology experience behind me, and try to keep up to date on my field. My patients and staff depend on me to bring my best to the office every day.

I hope to stay that way to the end. I’d rather leave voluntarily, still at the top of my game. Even if I end up leaving a few unused checks behind.
 

Dr. Block has a solo neurology practice in Scottsdale, Arizona.

I don’t write many checks anymore.

When I started my practice in 2000 I wrote a lot. Paychecks for my staff, my rent, insurance, IRA contributions, federal & state withholding, payments on my EMG machine, pretty much everything.

Checks are old. We’ve been using them in some form for roughly 2000 years.

But the online world has changed a lot of that. Now I write maybe 2-3 a month. I could probably do fewer, but haven’t bothered to set those accounts up that way.

I recently was down to my last few checks, so ordered replacements. The minimum order was 600. As I unpacked the box I realized they’re probably the last ones I’ll need, both because checks are gradually passing by and because there are more days behind in my neurology career than ahead.

The checks are a minor thing, but they do make you think. Certainly we’re in the last generation of people who will ever need to use paper checks. Some phrases like “blank check” will likely be with us long after they’re gone (like “dialing a phone”), but the real deal is heading the same way as 8-Track and VHS tapes.

As my 600 checks dwindle down, realistically, so will my career. There is no rewind button on life. I have no desire to leave medicine right now, but the passage of time changes things.

Does that mean I, like my checks, am also getting obsolete?

I hope not. I’d like to think I still have something to offer. I have 30 years of neurology experience behind me, and try to keep up to date on my field. My patients and staff depend on me to bring my best to the office every day.

I hope to stay that way to the end. I’d rather leave voluntarily, still at the top of my game. Even if I end up leaving a few unused checks behind.
 

Dr. Block has a solo neurology practice in Scottsdale, Arizona.

I don’t write many checks anymore.

When I started my practice in 2000 I wrote a lot. Paychecks for my staff, my rent, insurance, IRA contributions, federal & state withholding, payments on my EMG machine, pretty much everything.

Checks are old. We’ve been using them in some form for roughly 2000 years.

But the online world has changed a lot of that. Now I write maybe 2-3 a month. I could probably do fewer, but haven’t bothered to set those accounts up that way.

I recently was down to my last few checks, so ordered replacements. The minimum order was 600. As I unpacked the box I realized they’re probably the last ones I’ll need, both because checks are gradually passing by and because there are more days behind in my neurology career than ahead.

The checks are a minor thing, but they do make you think. Certainly we’re in the last generation of people who will ever need to use paper checks. Some phrases like “blank check” will likely be with us long after they’re gone (like “dialing a phone”), but the real deal is heading the same way as 8-Track and VHS tapes.

As my 600 checks dwindle down, realistically, so will my career. There is no rewind button on life. I have no desire to leave medicine right now, but the passage of time changes things.

Does that mean I, like my checks, am also getting obsolete?

I hope not. I’d like to think I still have something to offer. I have 30 years of neurology experience behind me, and try to keep up to date on my field. My patients and staff depend on me to bring my best to the office every day.

I hope to stay that way to the end. I’d rather leave voluntarily, still at the top of my game. Even if I end up leaving a few unused checks behind.
 

Dr. Block has a solo neurology practice in Scottsdale, Arizona.

Each month I set out on an expedition to find a topic for this column. I came across a new book Rebel Health by Susannah Fox that I thought might be a good one. It’s both a treatise on the shortcomings of healthcare and a Baedeker for patients on how to find their way to being better served. Her argument is that many patients’ needs are unmet and their conditions are often invisible to us in mainstream healthcare. We fail to find solutions to help them. Patients would benefit from more open access to their records and more resources to take control of their own health, she argues. A few chapters in, I thought, “Oh, here we go, another diatribe on doctors and how we care most about how to keep patients in their rightful, subordinate place.” The “Rebel” title is provocative and implies patients need to overthrow the status quo. Well, I am part of the establishment. I stopped reading. This book doesn’t apply to me, I thought.

After all, I’m a healthcare progressive, right? My notes and results have been open for years. I encourage shared decision-making and try to empower patients as much as treat them. The idea that I or my colleagues are unwilling to do whatever is necessary to meet our patients’ needs was maddening. We dedicate our lives to it. My young daughter often greets me in the morning by asking if I’ll be working tonight. Most nights, I am — answering patient messages, collaborating with colleagues to help patients, keeping up with medical knowledge. I was angry at what felt like unjust criticism, especially that we’d neglect patients because their problems are not obvious or worse, there is not enough money to be made helping them. Harrumph.

Kaiser Permanente

That’s when I realized the best thing for me was to read the entire book and digest the arguments. I pride myself on being well-read, but I fall into a common trap: the podcasts I listen to, news I consume, and books I read mostly affirm my beliefs. It is a healthy choice to seek dispositive data and contrasting stories rather than always feeding our personal opinions.

Rebel Health was not written by Robespierre. It was penned by a thoughtful, articulate patient advocate with over 20 years experience. She has far more bona fides than I could achieve in two lifetimes. In the book, she reminds us that scientific advances in the last 100 years have made medicine more effective but also disintermediated caregivers, family, and patients. Patients and caregivers can not only help but also offer innovative and customized solutions to their problems. She describes four patient archetypes: seekers, networkers, solvers, and champions, and offers a four-quadrant model to visualize how some patients are unhelped by our current healthcare system. She advocates for frictionless, open access to health data and tries to inspire patients to connect, innovate, and create to fill the voids that exist in healthcare. We have come a long way from the immured system of a decade ago; much of that is the result of patient advocates. But healthcare is still too costly, too fragmented and too many patients unhelped. “Community is a superpower,” she writes. I agree, we should assemble all the heroes in the universe for this challenge.

Fox also tells stories of patients who solved diagnostic dilemmas through their own research and advocacy. I thought of my own contrasting experiences of patients whose DIY care was based on misinformation and how their false confidence led to poorer outcomes for them. I want to share with her readers how physicians feel hurt when patients question our competence or place the opinion of an adversarial Redditor over ours. Physicians are sometimes wrong and often in doubt. Most of us care deeply about our patients regardless of how visible their diagnosis or how easy they are to appease.

We don’t have time to engage back-and-forth on an insignificantly abnormal test they find in their open chart or why B12 and hormone testing would not be helpful for their disease. It’s also not the patients’ fault. Having unfettered access to their data might add work, but it also adds value. They are trying to learn and be active in their care. Physicians are frustrated mostly because we don’t have time to meet these unmet needs. Everyone is trying their best and we all want the same thing: patients to be satisfied and well.

As for learning the skill of being open-minded, an excellent reference is Adam Grant’s Think Again. It’s inspiring and instructive of how we can all be more open, including how to have productive arguments rather than fruitless fights. We live in divisive times. Perhaps if we all put in effort to be open-minded, push down righteous indignation, and advance more honest humility we’d all be a bit better off.

Patients are the primary audience for the Rebel Health book. Yet, as we care about them and we all want to make healthcare better, it is worth reading in its entirety. I told my daughter I don’t have to work tonight because I’ve written my article this month. When she’s a little older, I’ll tell her all about it. To be successful, she’ll have to be as open-minded as she is smart. She can learn both.

I have no conflict of interest in the book.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.

Each month I set out on an expedition to find a topic for this column. I came across a new book Rebel Health by Susannah Fox that I thought might be a good one. It’s both a treatise on the shortcomings of healthcare and a Baedeker for patients on how to find their way to being better served. Her argument is that many patients’ needs are unmet and their conditions are often invisible to us in mainstream healthcare. We fail to find solutions to help them. Patients would benefit from more open access to their records and more resources to take control of their own health, she argues. A few chapters in, I thought, “Oh, here we go, another diatribe on doctors and how we care most about how to keep patients in their rightful, subordinate place.” The “Rebel” title is provocative and implies patients need to overthrow the status quo. Well, I am part of the establishment. I stopped reading. This book doesn’t apply to me, I thought.

After all, I’m a healthcare progressive, right? My notes and results have been open for years. I encourage shared decision-making and try to empower patients as much as treat them. The idea that I or my colleagues are unwilling to do whatever is necessary to meet our patients’ needs was maddening. We dedicate our lives to it. My young daughter often greets me in the morning by asking if I’ll be working tonight. Most nights, I am — answering patient messages, collaborating with colleagues to help patients, keeping up with medical knowledge. I was angry at what felt like unjust criticism, especially that we’d neglect patients because their problems are not obvious or worse, there is not enough money to be made helping them. Harrumph.

Kaiser Permanente

That’s when I realized the best thing for me was to read the entire book and digest the arguments. I pride myself on being well-read, but I fall into a common trap: the podcasts I listen to, news I consume, and books I read mostly affirm my beliefs. It is a healthy choice to seek dispositive data and contrasting stories rather than always feeding our personal opinions.

Rebel Health was not written by Robespierre. It was penned by a thoughtful, articulate patient advocate with over 20 years experience. She has far more bona fides than I could achieve in two lifetimes. In the book, she reminds us that scientific advances in the last 100 years have made medicine more effective but also disintermediated caregivers, family, and patients. Patients and caregivers can not only help but also offer innovative and customized solutions to their problems. She describes four patient archetypes: seekers, networkers, solvers, and champions, and offers a four-quadrant model to visualize how some patients are unhelped by our current healthcare system. She advocates for frictionless, open access to health data and tries to inspire patients to connect, innovate, and create to fill the voids that exist in healthcare. We have come a long way from the immured system of a decade ago; much of that is the result of patient advocates. But healthcare is still too costly, too fragmented and too many patients unhelped. “Community is a superpower,” she writes. I agree, we should assemble all the heroes in the universe for this challenge.

Fox also tells stories of patients who solved diagnostic dilemmas through their own research and advocacy. I thought of my own contrasting experiences of patients whose DIY care was based on misinformation and how their false confidence led to poorer outcomes for them. I want to share with her readers how physicians feel hurt when patients question our competence or place the opinion of an adversarial Redditor over ours. Physicians are sometimes wrong and often in doubt. Most of us care deeply about our patients regardless of how visible their diagnosis or how easy they are to appease.

We don’t have time to engage back-and-forth on an insignificantly abnormal test they find in their open chart or why B12 and hormone testing would not be helpful for their disease. It’s also not the patients’ fault. Having unfettered access to their data might add work, but it also adds value. They are trying to learn and be active in their care. Physicians are frustrated mostly because we don’t have time to meet these unmet needs. Everyone is trying their best and we all want the same thing: patients to be satisfied and well.

As for learning the skill of being open-minded, an excellent reference is Adam Grant’s Think Again. It’s inspiring and instructive of how we can all be more open, including how to have productive arguments rather than fruitless fights. We live in divisive times. Perhaps if we all put in effort to be open-minded, push down righteous indignation, and advance more honest humility we’d all be a bit better off.

Patients are the primary audience for the Rebel Health book. Yet, as we care about them and we all want to make healthcare better, it is worth reading in its entirety. I told my daughter I don’t have to work tonight because I’ve written my article this month. When she’s a little older, I’ll tell her all about it. To be successful, she’ll have to be as open-minded as she is smart. She can learn both.

I have no conflict of interest in the book.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.

Each month I set out on an expedition to find a topic for this column. I came across a new book Rebel Health by Susannah Fox that I thought might be a good one. It’s both a treatise on the shortcomings of healthcare and a Baedeker for patients on how to find their way to being better served. Her argument is that many patients’ needs are unmet and their conditions are often invisible to us in mainstream healthcare. We fail to find solutions to help them. Patients would benefit from more open access to their records and more resources to take control of their own health, she argues. A few chapters in, I thought, “Oh, here we go, another diatribe on doctors and how we care most about how to keep patients in their rightful, subordinate place.” The “Rebel” title is provocative and implies patients need to overthrow the status quo. Well, I am part of the establishment. I stopped reading. This book doesn’t apply to me, I thought.

After all, I’m a healthcare progressive, right? My notes and results have been open for years. I encourage shared decision-making and try to empower patients as much as treat them. The idea that I or my colleagues are unwilling to do whatever is necessary to meet our patients’ needs was maddening. We dedicate our lives to it. My young daughter often greets me in the morning by asking if I’ll be working tonight. Most nights, I am — answering patient messages, collaborating with colleagues to help patients, keeping up with medical knowledge. I was angry at what felt like unjust criticism, especially that we’d neglect patients because their problems are not obvious or worse, there is not enough money to be made helping them. Harrumph.

Kaiser Permanente

That’s when I realized the best thing for me was to read the entire book and digest the arguments. I pride myself on being well-read, but I fall into a common trap: the podcasts I listen to, news I consume, and books I read mostly affirm my beliefs. It is a healthy choice to seek dispositive data and contrasting stories rather than always feeding our personal opinions.

Rebel Health was not written by Robespierre. It was penned by a thoughtful, articulate patient advocate with over 20 years experience. She has far more bona fides than I could achieve in two lifetimes. In the book, she reminds us that scientific advances in the last 100 years have made medicine more effective but also disintermediated caregivers, family, and patients. Patients and caregivers can not only help but also offer innovative and customized solutions to their problems. She describes four patient archetypes: seekers, networkers, solvers, and champions, and offers a four-quadrant model to visualize how some patients are unhelped by our current healthcare system. She advocates for frictionless, open access to health data and tries to inspire patients to connect, innovate, and create to fill the voids that exist in healthcare. We have come a long way from the immured system of a decade ago; much of that is the result of patient advocates. But healthcare is still too costly, too fragmented and too many patients unhelped. “Community is a superpower,” she writes. I agree, we should assemble all the heroes in the universe for this challenge.

Fox also tells stories of patients who solved diagnostic dilemmas through their own research and advocacy. I thought of my own contrasting experiences of patients whose DIY care was based on misinformation and how their false confidence led to poorer outcomes for them. I want to share with her readers how physicians feel hurt when patients question our competence or place the opinion of an adversarial Redditor over ours. Physicians are sometimes wrong and often in doubt. Most of us care deeply about our patients regardless of how visible their diagnosis or how easy they are to appease.

We don’t have time to engage back-and-forth on an insignificantly abnormal test they find in their open chart or why B12 and hormone testing would not be helpful for their disease. It’s also not the patients’ fault. Having unfettered access to their data might add work, but it also adds value. They are trying to learn and be active in their care. Physicians are frustrated mostly because we don’t have time to meet these unmet needs. Everyone is trying their best and we all want the same thing: patients to be satisfied and well.

As for learning the skill of being open-minded, an excellent reference is Adam Grant’s Think Again. It’s inspiring and instructive of how we can all be more open, including how to have productive arguments rather than fruitless fights. We live in divisive times. Perhaps if we all put in effort to be open-minded, push down righteous indignation, and advance more honest humility we’d all be a bit better off.

Patients are the primary audience for the Rebel Health book. Yet, as we care about them and we all want to make healthcare better, it is worth reading in its entirety. I told my daughter I don’t have to work tonight because I’ve written my article this month. When she’s a little older, I’ll tell her all about it. To be successful, she’ll have to be as open-minded as she is smart. She can learn both.

I have no conflict of interest in the book.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at dermnews@mdedge.com.

The first of May is marked as the World Maternal Mental Health Day, a time for patient groups, medical societies, clinicians, and other colleagues who care for women to highlight maternal mental health and to advocate for increased awareness, enhanced access to care, decrease in stigma, and development of the most effective treatments.

In this spirit, and within the context of greater mental health awareness, I wanted to highlight the ironic dichotomy we see in reproductive psychiatry today. Namely, although we have many useful treatments available in the field to treat maternal psychiatric illness, there are barriers to accessing mental healthcare that prevent women from receiving treatment and getting well.

Thinking back on the last few years from the other side of the pandemic, when COVID concerns turned the experience of motherhood on its side in so many ways, we can only acknowledge that it is an important time in the field of reproductive psychiatry. We have seen not only the development of new pharmacologic (neurosteroids) and nonpharmacologic therapies (transcranial magnetic stimulation, cognitive-behaviorial therapy for perinatal depression), but also the focus on new digital apps for perinatal depression that may be scalable and that may help bridge the voids in access to effective treatment from the most rural to the most urban settings.

In a previous column, I wrote about the potential difficulties of identifying at-risk women with postpartum psychiatric illness, particularly within the context of disparate data collection methods and management of data. Hospital systems that favor paper screening methods rather than digital platforms pose special problems. I also noted an even larger concern: namely, once screened, it can be very challenging to engage women with postpartum depression in treatment, and women may ultimately not navigate to care for a variety of reasons. These components are but one part of the so-called “perinatal treatment cascade.” When we look at access to care, patients would ideally move from depression screening as an example and, following endorsement of significant symptoms, would receive a referral, which would result in the patient being seen, followed up, and getting well. But that is not what is happening.

A recent preliminary study published as a short communication in the Archives of Women’s Mental Health highlighted this issue. The authors used the Edinburgh Postnatal Depression Scale (EPDS) to follow symptoms of depression in 145 pregnant women in ob.gyn. services, and found that there were low levels of adherence to psychiatric screenings and referrals in the perinatal period. Another study published in the Journal of Clinical Psychiatry found 30.8% of women with postpartum depression were identified clinically, 15.8% received treatment, and 3.2% achieved remission. That is the gulf, in 2024, that we have not managed to bridge.

The findings show the difficulty women experience accessing perinatal mental health resources. While we’ve known for a long time that the “perinatal treatment cascade” is real, what we don’t understand are the variables in the mix, particularly for patients in marginalized groups. We also do not know where women fall off the curve with regard to accessing care. In my mind, if we’re going to make a difference, we need to know the answer to that question.

Part of the issue is that the research into understanding why women fall off the curve is incomplete. You cannot simply hand a sheet to a woman with an EPDS score of 12 who’s depressed and has a newborn and expect her to navigate to care. What we should really be doing is investing in care navigation for women.

The situation is analogous to diagnosing and treating cardiac abnormalities in a catheterization laboratory. If a patient has a blocked coronary artery and needs a stent, then they need to go to the cath lab. We haven’t yet figured out the process in reproductive psychiatry to optimize the likelihood that patients will be screened and then referred to receive the best available treatment.

Some of our ob.gyn. colleagues have been working to improve access to perinatal mental health services, such as offering on-site services, and offering training and services to patients and providers on screening, assessment, and treatment. At the Center for Women’s Mental Health, we are conducting the Screening and Treatment Enhancement for Postpartum Depression study, which is a universal screening and referral program for women at our center. While some progress is being made, there are still far too many women who are falling through the cracks and not receiving the care they need.

It is both ironic and sad that the growing number of available treatments in reproductive psychiatry are scalable, yet we haven’t figured out how to facilitate access to care. While we should be excited about new treatments, we also need to take the time to understand what the barriers are for at-risk women accessing mental healthcare in the postpartum period.
 

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. STEPS for PPD is funded by the Marriott Foundation. Full disclosure information for Dr. Cohen is available at womensmentalhealth.org. Email Dr. Cohen at obnews@mdedge.com.

The first of May is marked as the World Maternal Mental Health Day, a time for patient groups, medical societies, clinicians, and other colleagues who care for women to highlight maternal mental health and to advocate for increased awareness, enhanced access to care, decrease in stigma, and development of the most effective treatments.

In this spirit, and within the context of greater mental health awareness, I wanted to highlight the ironic dichotomy we see in reproductive psychiatry today. Namely, although we have many useful treatments available in the field to treat maternal psychiatric illness, there are barriers to accessing mental healthcare that prevent women from receiving treatment and getting well.

Thinking back on the last few years from the other side of the pandemic, when COVID concerns turned the experience of motherhood on its side in so many ways, we can only acknowledge that it is an important time in the field of reproductive psychiatry. We have seen not only the development of new pharmacologic (neurosteroids) and nonpharmacologic therapies (transcranial magnetic stimulation, cognitive-behaviorial therapy for perinatal depression), but also the focus on new digital apps for perinatal depression that may be scalable and that may help bridge the voids in access to effective treatment from the most rural to the most urban settings.

In a previous column, I wrote about the potential difficulties of identifying at-risk women with postpartum psychiatric illness, particularly within the context of disparate data collection methods and management of data. Hospital systems that favor paper screening methods rather than digital platforms pose special problems. I also noted an even larger concern: namely, once screened, it can be very challenging to engage women with postpartum depression in treatment, and women may ultimately not navigate to care for a variety of reasons. These components are but one part of the so-called “perinatal treatment cascade.” When we look at access to care, patients would ideally move from depression screening as an example and, following endorsement of significant symptoms, would receive a referral, which would result in the patient being seen, followed up, and getting well. But that is not what is happening.

A recent preliminary study published as a short communication in the Archives of Women’s Mental Health highlighted this issue. The authors used the Edinburgh Postnatal Depression Scale (EPDS) to follow symptoms of depression in 145 pregnant women in ob.gyn. services, and found that there were low levels of adherence to psychiatric screenings and referrals in the perinatal period. Another study published in the Journal of Clinical Psychiatry found 30.8% of women with postpartum depression were identified clinically, 15.8% received treatment, and 3.2% achieved remission. That is the gulf, in 2024, that we have not managed to bridge.

The findings show the difficulty women experience accessing perinatal mental health resources. While we’ve known for a long time that the “perinatal treatment cascade” is real, what we don’t understand are the variables in the mix, particularly for patients in marginalized groups. We also do not know where women fall off the curve with regard to accessing care. In my mind, if we’re going to make a difference, we need to know the answer to that question.

Part of the issue is that the research into understanding why women fall off the curve is incomplete. You cannot simply hand a sheet to a woman with an EPDS score of 12 who’s depressed and has a newborn and expect her to navigate to care. What we should really be doing is investing in care navigation for women.

The situation is analogous to diagnosing and treating cardiac abnormalities in a catheterization laboratory. If a patient has a blocked coronary artery and needs a stent, then they need to go to the cath lab. We haven’t yet figured out the process in reproductive psychiatry to optimize the likelihood that patients will be screened and then referred to receive the best available treatment.

Some of our ob.gyn. colleagues have been working to improve access to perinatal mental health services, such as offering on-site services, and offering training and services to patients and providers on screening, assessment, and treatment. At the Center for Women’s Mental Health, we are conducting the Screening and Treatment Enhancement for Postpartum Depression study, which is a universal screening and referral program for women at our center. While some progress is being made, there are still far too many women who are falling through the cracks and not receiving the care they need.

It is both ironic and sad that the growing number of available treatments in reproductive psychiatry are scalable, yet we haven’t figured out how to facilitate access to care. While we should be excited about new treatments, we also need to take the time to understand what the barriers are for at-risk women accessing mental healthcare in the postpartum period.
 

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. STEPS for PPD is funded by the Marriott Foundation. Full disclosure information for Dr. Cohen is available at womensmentalhealth.org. Email Dr. Cohen at obnews@mdedge.com.

The first of May is marked as the World Maternal Mental Health Day, a time for patient groups, medical societies, clinicians, and other colleagues who care for women to highlight maternal mental health and to advocate for increased awareness, enhanced access to care, decrease in stigma, and development of the most effective treatments.

In this spirit, and within the context of greater mental health awareness, I wanted to highlight the ironic dichotomy we see in reproductive psychiatry today. Namely, although we have many useful treatments available in the field to treat maternal psychiatric illness, there are barriers to accessing mental healthcare that prevent women from receiving treatment and getting well.

Thinking back on the last few years from the other side of the pandemic, when COVID concerns turned the experience of motherhood on its side in so many ways, we can only acknowledge that it is an important time in the field of reproductive psychiatry. We have seen not only the development of new pharmacologic (neurosteroids) and nonpharmacologic therapies (transcranial magnetic stimulation, cognitive-behaviorial therapy for perinatal depression), but also the focus on new digital apps for perinatal depression that may be scalable and that may help bridge the voids in access to effective treatment from the most rural to the most urban settings.

In a previous column, I wrote about the potential difficulties of identifying at-risk women with postpartum psychiatric illness, particularly within the context of disparate data collection methods and management of data. Hospital systems that favor paper screening methods rather than digital platforms pose special problems. I also noted an even larger concern: namely, once screened, it can be very challenging to engage women with postpartum depression in treatment, and women may ultimately not navigate to care for a variety of reasons. These components are but one part of the so-called “perinatal treatment cascade.” When we look at access to care, patients would ideally move from depression screening as an example and, following endorsement of significant symptoms, would receive a referral, which would result in the patient being seen, followed up, and getting well. But that is not what is happening.

A recent preliminary study published as a short communication in the Archives of Women’s Mental Health highlighted this issue. The authors used the Edinburgh Postnatal Depression Scale (EPDS) to follow symptoms of depression in 145 pregnant women in ob.gyn. services, and found that there were low levels of adherence to psychiatric screenings and referrals in the perinatal period. Another study published in the Journal of Clinical Psychiatry found 30.8% of women with postpartum depression were identified clinically, 15.8% received treatment, and 3.2% achieved remission. That is the gulf, in 2024, that we have not managed to bridge.

The findings show the difficulty women experience accessing perinatal mental health resources. While we’ve known for a long time that the “perinatal treatment cascade” is real, what we don’t understand are the variables in the mix, particularly for patients in marginalized groups. We also do not know where women fall off the curve with regard to accessing care. In my mind, if we’re going to make a difference, we need to know the answer to that question.

Part of the issue is that the research into understanding why women fall off the curve is incomplete. You cannot simply hand a sheet to a woman with an EPDS score of 12 who’s depressed and has a newborn and expect her to navigate to care. What we should really be doing is investing in care navigation for women.

The situation is analogous to diagnosing and treating cardiac abnormalities in a catheterization laboratory. If a patient has a blocked coronary artery and needs a stent, then they need to go to the cath lab. We haven’t yet figured out the process in reproductive psychiatry to optimize the likelihood that patients will be screened and then referred to receive the best available treatment.

Some of our ob.gyn. colleagues have been working to improve access to perinatal mental health services, such as offering on-site services, and offering training and services to patients and providers on screening, assessment, and treatment. At the Center for Women’s Mental Health, we are conducting the Screening and Treatment Enhancement for Postpartum Depression study, which is a universal screening and referral program for women at our center. While some progress is being made, there are still far too many women who are falling through the cracks and not receiving the care they need.

It is both ironic and sad that the growing number of available treatments in reproductive psychiatry are scalable, yet we haven’t figured out how to facilitate access to care. While we should be excited about new treatments, we also need to take the time to understand what the barriers are for at-risk women accessing mental healthcare in the postpartum period.
 

Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. STEPS for PPD is funded by the Marriott Foundation. Full disclosure information for Dr. Cohen is available at womensmentalhealth.org. Email Dr. Cohen at obnews@mdedge.com.

PHOENIX — Reimbursement for dermatologic procedures has not maintained a parallel increase with the cost of healthcare delivery, according to new study findings. Medicare cuts, which are expected to continue, have exacerbated this issue even further.

“This ongoing downward trend in inflation-adjusted reimbursement may lead to delayed patient access to quality dermatology surgical care,” said lead study author Lily Park, DO, a resident in the Department of Dermatology, Larkin Community Hospital, Miami. “This trend will lead to reduced access.”

Dr. Park emphasized that reimbursement for Mohs surgery has also been further affected by the multiple surgery reduction rule, which is where Medicare pays less for the second and subsequent procedures performed during the same patient encounter. Reductions may be calculated in several ways, depending on what kind of procedure or service is involved.

“The Mohs surgery community needs to be aware of this financial trend and actively engage with healthcare policymakers to ensure the establishment of a sustainable payment infrastructure,” she said.

Dr. Park presented the study results at the annual meeting of the American College of Mohs Surgery.

The landscape of healthcare economics continues to evolve and has been further complicated by rising inflation. In addition, a 2% cut to the Medicare payment conversion factor was implemented in 2023, followed by a further 3.37% cut in early 2024 — which was cut by half in March 2024, with an additional cut expected this year, she noted. “This has presented more challenges for dermatologic surgeons who are already dealing with the rising healthcare costs.”

However, despite these financial challenges, there is a lack of research on physician reimbursement for dermatologic procedures, including surgery.

Decreased Reimbursement for All Procedures

Dr. Park and colleagues analyzed trends in Medicare reimbursement rates for Mohs micrographic surgery and several other common dermatologic procedures. Beginning with 2007, they calculated the inflation-adjusted values for each year’s non-facility prices for all codes except Current Procedural Terminology (CPT) codes 11102 and 11104. For those two codes, inflation-adjusted prices were based on the prices in 2019, the year when the codes were first introduced. The authors estimated the inflation adjusted value for each year based on the non-facility price for 2007, and the difference between the rate of inflation and the change in physician reimbursement over time was calculated.

The six most commonly performed procedures in 2023, ranked in descending order of frequency, were identified as CPT 17000, used for the removal of actinic keratosis; CPT 11102, used for biopsy of skin; CPT 17110, used for the destruction of benign lesions such as seborrheic keratoses and warts; CPT 17311, used for the destruction of malignant lesions (including Mohs surgery); CPT 11104, which is also related to biopsy of skin; and CPT 10060, used for incision and drainage of abscess.

Their analysis showed that all CPT codes experienced a decline when compared with their inflation-adjusted values. Both Mohs surgery (17311) and benign destruction of premalignant lesions (17000) showed a decrease of 46% in reimbursement during an inflation-adjusted 18-year time span between 2007 and 2024.

When adjusted for inflation, Dr. Park noted, reimbursement for CPT 17311 and 17000 should actually be increased by 42% and 41% in 2024, respectively. The greatest declines in reimbursement were seen during the last 4 years.

“Future legislation, such as H.R.2474, a bill proposing inflation-based updates to physician pay, would aid us in the future if implemented,” said Dr. Park.
 

Dangerous Trend

The finding that payments have declined for many common dermatologic procedures since 2007 “is particularly important given the rising cost of healthcare delivery,” said Jesse M. Lewin, MD, who was asked to comment on the study results. “The administrative burden of electronic medical records, filing, and following up insurance claims has necessitated the employment of more non-physician staff to support these tasks,” he told this news organization.

“Declining reimbursement for Mohs surgery and other cancer-related procedures is a dangerous trend, as the ultimate impact will be the effect it has on quality and accessibility of skin cancer care for patients,” added Dr. Lewin, chief of Mohs micrographic and dermatologic surgery and vice chair of surgical operations at the Icahn School of Medicine at Mount Sinai, New York City. “This is an important study that reinforces physician engagement in healthcare policy and legislation to advocate for our specialty and patients.”

The study was independently supported. Dr. Park and Dr. Lewin, who was not involved with the study, reported no relevant financial relationships.

A version of this article appeared on Medscape.com.

PHOENIX — Reimbursement for dermatologic procedures has not maintained a parallel increase with the cost of healthcare delivery, according to new study findings. Medicare cuts, which are expected to continue, have exacerbated this issue even further.

“This ongoing downward trend in inflation-adjusted reimbursement may lead to delayed patient access to quality dermatology surgical care,” said lead study author Lily Park, DO, a resident in the Department of Dermatology, Larkin Community Hospital, Miami. “This trend will lead to reduced access.”

Dr. Park emphasized that reimbursement for Mohs surgery has also been further affected by the multiple surgery reduction rule, which is where Medicare pays less for the second and subsequent procedures performed during the same patient encounter. Reductions may be calculated in several ways, depending on what kind of procedure or service is involved.

“The Mohs surgery community needs to be aware of this financial trend and actively engage with healthcare policymakers to ensure the establishment of a sustainable payment infrastructure,” she said.

Dr. Park presented the study results at the annual meeting of the American College of Mohs Surgery.

The landscape of healthcare economics continues to evolve and has been further complicated by rising inflation. In addition, a 2% cut to the Medicare payment conversion factor was implemented in 2023, followed by a further 3.37% cut in early 2024 — which was cut by half in March 2024, with an additional cut expected this year, she noted. “This has presented more challenges for dermatologic surgeons who are already dealing with the rising healthcare costs.”

However, despite these financial challenges, there is a lack of research on physician reimbursement for dermatologic procedures, including surgery.

Decreased Reimbursement for All Procedures

Dr. Park and colleagues analyzed trends in Medicare reimbursement rates for Mohs micrographic surgery and several other common dermatologic procedures. Beginning with 2007, they calculated the inflation-adjusted values for each year’s non-facility prices for all codes except Current Procedural Terminology (CPT) codes 11102 and 11104. For those two codes, inflation-adjusted prices were based on the prices in 2019, the year when the codes were first introduced. The authors estimated the inflation adjusted value for each year based on the non-facility price for 2007, and the difference between the rate of inflation and the change in physician reimbursement over time was calculated.

The six most commonly performed procedures in 2023, ranked in descending order of frequency, were identified as CPT 17000, used for the removal of actinic keratosis; CPT 11102, used for biopsy of skin; CPT 17110, used for the destruction of benign lesions such as seborrheic keratoses and warts; CPT 17311, used for the destruction of malignant lesions (including Mohs surgery); CPT 11104, which is also related to biopsy of skin; and CPT 10060, used for incision and drainage of abscess.

Their analysis showed that all CPT codes experienced a decline when compared with their inflation-adjusted values. Both Mohs surgery (17311) and benign destruction of premalignant lesions (17000) showed a decrease of 46% in reimbursement during an inflation-adjusted 18-year time span between 2007 and 2024.

When adjusted for inflation, Dr. Park noted, reimbursement for CPT 17311 and 17000 should actually be increased by 42% and 41% in 2024, respectively. The greatest declines in reimbursement were seen during the last 4 years.

“Future legislation, such as H.R.2474, a bill proposing inflation-based updates to physician pay, would aid us in the future if implemented,” said Dr. Park.
 

Dangerous Trend

The finding that payments have declined for many common dermatologic procedures since 2007 “is particularly important given the rising cost of healthcare delivery,” said Jesse M. Lewin, MD, who was asked to comment on the study results. “The administrative burden of electronic medical records, filing, and following up insurance claims has necessitated the employment of more non-physician staff to support these tasks,” he told this news organization.

“Declining reimbursement for Mohs surgery and other cancer-related procedures is a dangerous trend, as the ultimate impact will be the effect it has on quality and accessibility of skin cancer care for patients,” added Dr. Lewin, chief of Mohs micrographic and dermatologic surgery and vice chair of surgical operations at the Icahn School of Medicine at Mount Sinai, New York City. “This is an important study that reinforces physician engagement in healthcare policy and legislation to advocate for our specialty and patients.”

The study was independently supported. Dr. Park and Dr. Lewin, who was not involved with the study, reported no relevant financial relationships.

A version of this article appeared on Medscape.com.

PHOENIX — Reimbursement for dermatologic procedures has not maintained a parallel increase with the cost of healthcare delivery, according to new study findings. Medicare cuts, which are expected to continue, have exacerbated this issue even further.

“This ongoing downward trend in inflation-adjusted reimbursement may lead to delayed patient access to quality dermatology surgical care,” said lead study author Lily Park, DO, a resident in the Department of Dermatology, Larkin Community Hospital, Miami. “This trend will lead to reduced access.”

Dr. Park emphasized that reimbursement for Mohs surgery has also been further affected by the multiple surgery reduction rule, which is where Medicare pays less for the second and subsequent procedures performed during the same patient encounter. Reductions may be calculated in several ways, depending on what kind of procedure or service is involved.

“The Mohs surgery community needs to be aware of this financial trend and actively engage with healthcare policymakers to ensure the establishment of a sustainable payment infrastructure,” she said.

Dr. Park presented the study results at the annual meeting of the American College of Mohs Surgery.

The landscape of healthcare economics continues to evolve and has been further complicated by rising inflation. In addition, a 2% cut to the Medicare payment conversion factor was implemented in 2023, followed by a further 3.37% cut in early 2024 — which was cut by half in March 2024, with an additional cut expected this year, she noted. “This has presented more challenges for dermatologic surgeons who are already dealing with the rising healthcare costs.”

However, despite these financial challenges, there is a lack of research on physician reimbursement for dermatologic procedures, including surgery.

Decreased Reimbursement for All Procedures

Dr. Park and colleagues analyzed trends in Medicare reimbursement rates for Mohs micrographic surgery and several other common dermatologic procedures. Beginning with 2007, they calculated the inflation-adjusted values for each year’s non-facility prices for all codes except Current Procedural Terminology (CPT) codes 11102 and 11104. For those two codes, inflation-adjusted prices were based on the prices in 2019, the year when the codes were first introduced. The authors estimated the inflation adjusted value for each year based on the non-facility price for 2007, and the difference between the rate of inflation and the change in physician reimbursement over time was calculated.

The six most commonly performed procedures in 2023, ranked in descending order of frequency, were identified as CPT 17000, used for the removal of actinic keratosis; CPT 11102, used for biopsy of skin; CPT 17110, used for the destruction of benign lesions such as seborrheic keratoses and warts; CPT 17311, used for the destruction of malignant lesions (including Mohs surgery); CPT 11104, which is also related to biopsy of skin; and CPT 10060, used for incision and drainage of abscess.

Their analysis showed that all CPT codes experienced a decline when compared with their inflation-adjusted values. Both Mohs surgery (17311) and benign destruction of premalignant lesions (17000) showed a decrease of 46% in reimbursement during an inflation-adjusted 18-year time span between 2007 and 2024.

When adjusted for inflation, Dr. Park noted, reimbursement for CPT 17311 and 17000 should actually be increased by 42% and 41% in 2024, respectively. The greatest declines in reimbursement were seen during the last 4 years.

“Future legislation, such as H.R.2474, a bill proposing inflation-based updates to physician pay, would aid us in the future if implemented,” said Dr. Park.
 

Dangerous Trend

The finding that payments have declined for many common dermatologic procedures since 2007 “is particularly important given the rising cost of healthcare delivery,” said Jesse M. Lewin, MD, who was asked to comment on the study results. “The administrative burden of electronic medical records, filing, and following up insurance claims has necessitated the employment of more non-physician staff to support these tasks,” he told this news organization.

“Declining reimbursement for Mohs surgery and other cancer-related procedures is a dangerous trend, as the ultimate impact will be the effect it has on quality and accessibility of skin cancer care for patients,” added Dr. Lewin, chief of Mohs micrographic and dermatologic surgery and vice chair of surgical operations at the Icahn School of Medicine at Mount Sinai, New York City. “This is an important study that reinforces physician engagement in healthcare policy and legislation to advocate for our specialty and patients.”

The study was independently supported. Dr. Park and Dr. Lewin, who was not involved with the study, reported no relevant financial relationships.

A version of this article appeared on Medscape.com.

In April, the Federal Trade Commission (FTC), by a vote of 3-2, opened a long-anticipated can of worms by approving its final rule that effectively bans employers’ use of all non-compete agreements (with very limited exceptions). The final rule will not go into effect until 120 days after its publication in the Federal Register, which took place on May 7, and numerous legal challenges appear to be on the horizon.

The principal components of the rule are as follows:

• After the effective date, most non-compete agreements (which prevent departing employees from signing with a new employer for a defined period within a specific geographic area) are banned nationwide.
• The rule exempts certain “senior executives,” ie individuals who earn more than $151,164 annually and serve in policy-making positions.
• There is another major exception for non-competes connected with a sale of a business.
• While not explicitly stated, the rule arguably exempts non-profits, tax-exempt hospitals, and other tax-exempt entities.
• Employers must provide verbal and written notice to employees regarding existing agreements, which would be voided under the rule.

The final rule is the latest skirmish in an ongoing, years-long debate. Twelve states have already put non-compete bans in place, according to a recent paper, and they may serve as a harbinger of things to come should the federal ban go into effect. Each state rule varies in its specifics as states respond to local market conditions. While some states ban all non-compete agreements outright, others limit them based on variables, such as income and employment circumstances. Of course, should the federal ban take effect, it will supersede whatever rules the individual states have in place.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

In April, the Federal Trade Commission (FTC), by a vote of 3-2, opened a long-anticipated can of worms by approving its final rule that effectively bans employers’ use of all non-compete agreements (with very limited exceptions). The final rule will not go into effect until 120 days after its publication in the Federal Register, which took place on May 7, and numerous legal challenges appear to be on the horizon.

The principal components of the rule are as follows:

• After the effective date, most non-compete agreements (which prevent departing employees from signing with a new employer for a defined period within a specific geographic area) are banned nationwide.
• The rule exempts certain “senior executives,” ie individuals who earn more than $151,164 annually and serve in policy-making positions.
• There is another major exception for non-competes connected with a sale of a business.
• While not explicitly stated, the rule arguably exempts non-profits, tax-exempt hospitals, and other tax-exempt entities.
• Employers must provide verbal and written notice to employees regarding existing agreements, which would be voided under the rule.

The final rule is the latest skirmish in an ongoing, years-long debate. Twelve states have already put non-compete bans in place, according to a recent paper, and they may serve as a harbinger of things to come should the federal ban go into effect. Each state rule varies in its specifics as states respond to local market conditions. While some states ban all non-compete agreements outright, others limit them based on variables, such as income and employment circumstances. Of course, should the federal ban take effect, it will supersede whatever rules the individual states have in place.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

In April, the Federal Trade Commission (FTC), by a vote of 3-2, opened a long-anticipated can of worms by approving its final rule that effectively bans employers’ use of all non-compete agreements (with very limited exceptions). The final rule will not go into effect until 120 days after its publication in the Federal Register, which took place on May 7, and numerous legal challenges appear to be on the horizon.

The principal components of the rule are as follows:

• After the effective date, most non-compete agreements (which prevent departing employees from signing with a new employer for a defined period within a specific geographic area) are banned nationwide.
• The rule exempts certain “senior executives,” ie individuals who earn more than $151,164 annually and serve in policy-making positions.
• There is another major exception for non-competes connected with a sale of a business.
• While not explicitly stated, the rule arguably exempts non-profits, tax-exempt hospitals, and other tax-exempt entities.
• Employers must provide verbal and written notice to employees regarding existing agreements, which would be voided under the rule.

The final rule is the latest skirmish in an ongoing, years-long debate. Twelve states have already put non-compete bans in place, according to a recent paper, and they may serve as a harbinger of things to come should the federal ban go into effect. Each state rule varies in its specifics as states respond to local market conditions. While some states ban all non-compete agreements outright, others limit them based on variables, such as income and employment circumstances. Of course, should the federal ban take effect, it will supersede whatever rules the individual states have in place.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

Patients with metastatic or advanced cancer treated in practices that have high rates of giving systemic care in the last two weeks of life do not have longer survival rates than patients in practices that have low rates of such care.

This conclusion of a new study published online May 16 in JAMA Oncology may help reassure oncologists that giving systemic anticancer therapy (SACT) at the most advanced stages of cancer will not improve the patient’s life, the authors wrote. It also may encourage them to instead focus more on honest communication with patients about their choices, Maureen E. Canavan, PhD, at the Cancer and Outcomes, Public Policy and Effectiveness Research (COPPER) Center at the Yale School of Medicine in New Haven, Connecticut, and colleagues, wrote in their paper.
 

How Was the Study Conducted?

Researchers used Flatiron Health, a nationwide electronic health records database of academic and community practices throughout the United State. They identified 78,446 adults with advanced or metastatic stages of one of six common cancers (breast, colorectal, urothelial, non–small cell lung cancer [NSCLC], pancreatic and renal cell carcinoma) who were treated at healthcare practices from 2015 to 2019. They then stratified practices into quintiles based on how often the practices treated patients with any systemic therapy, including chemotherapy and immunotherapy, in their last 14 days of life. They compared whether patients in practices with greater use of systemic treatment at very advanced stages had longer overall survival.

What Were the Main Findings?

“We saw that there were absolutely no survival differences between the practices that used more systemic therapy for very advanced cancer than the practices that use less,” said senior author Kerin Adelson, MD, chief quality and value officer at MD Anderson Cancer Center in Houston, Texas. In some cancers, those in the lowest quintile (those with the lowest rates of systemic end-of-life care) lived fewer years compared with those in the highest quintiles. In other cancers, those in the lowest quintiles lived more years than those in the highest quintiles.

“What’s important is that none of those differences, after you control for other factors, was statistically significant,” Dr. Adelson said. “That was the same in every cancer type we looked at.”

An example is seen in advanced urothelial cancer. Those in the first quintile (lowest rates of systemic care at end of life) had an SACT rate range of 4.0-9.1. The SACT rate range in the highest quintile was 19.8-42.6. But the median overall survival (OS) rate for those in the lowest quintile was 12.7 months, not statistically different from the median OS in the highest quintile (11 months.)
 

How Does This Study Add to the Literature?

The American Society of Clinical Oncology (ASCO) and the National Quality Forum (NQF) developed a cancer quality metric to reduce SACT at the end of life. The NQF 0210 is a ratio of patients who get systemic treatment within 14 days of death over all patients who die of cancer. The quality metric has been widely adopted and used in value-based care reporting.

But the metric has been criticized because it focuses only on people who died and not people who lived longer because they benefited from the systemic therapy, the authors wrote.

Dr. Canavan’s team focused on all patients treated in the practice, not just those who died, Dr. Adelson said. This may put that criticism to rest, Dr. Adelson said.

“I personally believed the ASCO and NQF metric was appropriate and the criticisms were off base,” said Otis Brawley, MD, associate director of community outreach and engagement at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University School of Medicine in Baltimore. “Canavan’s study is evidence suggesting the metrics were appropriate.”

This study included not just chemotherapy, as some other studies have, but targeted therapies and immunotherapies as well. Dr. Adelson said some think that the newer drugs might change the prognosis at end of life. But this study shows “even those drugs are not helping patients to survive with very advanced cancer,” she said.

 

Could This Change Practice?

The authors noted that end-of life SACT has been linked with more acute care use, delays in conversations about care goals, late enrollment in hospice, higher costs, and potentially shorter and poorer quality life.

Dr. Adelson said she’s hoping that the knowledge that there’s no survival benefit for use of SACT for patients with advanced solid tumors who are nearing the end of life will lead instead to more conversations about prognosis with patients and transitions to palliative care.

“Palliative care has actually been shown to improve quality of life and, in some studies, even survival,” she said.

“I doubt it will change practice, but it should,” Dr. Brawley said. “The study suggests that doctors and patients have too much hope for chemotherapy as patients’ disease progresses. In the US especially, there is a tendency to believe we have better therapies than we truly do and we have difficulty accepting that the patient is dying. Many patients get third- and fourth-line chemotherapy that is highly likely to increase suffering without realistic hope of prolonging life and especially no hope of prolonging life with good quality.”

Dr. Adelson disclosed ties with AbbVie, Quantum Health, Gilead, ParetoHealth, and Carrum Health. Various coauthors disclosed ties with Roche, AbbVie, Johnson & Johnson, Genentech, the National Comprehensive Cancer Network, and AstraZeneca. The study was funded by Flatiron Health, an independent member of the Roche group. Dr. Brawley reports no relevant financial disclosures.

Patients with metastatic or advanced cancer treated in practices that have high rates of giving systemic care in the last two weeks of life do not have longer survival rates than patients in practices that have low rates of such care.

This conclusion of a new study published online May 16 in JAMA Oncology may help reassure oncologists that giving systemic anticancer therapy (SACT) at the most advanced stages of cancer will not improve the patient’s life, the authors wrote. It also may encourage them to instead focus more on honest communication with patients about their choices, Maureen E. Canavan, PhD, at the Cancer and Outcomes, Public Policy and Effectiveness Research (COPPER) Center at the Yale School of Medicine in New Haven, Connecticut, and colleagues, wrote in their paper.
 

How Was the Study Conducted?

Researchers used Flatiron Health, a nationwide electronic health records database of academic and community practices throughout the United State. They identified 78,446 adults with advanced or metastatic stages of one of six common cancers (breast, colorectal, urothelial, non–small cell lung cancer [NSCLC], pancreatic and renal cell carcinoma) who were treated at healthcare practices from 2015 to 2019. They then stratified practices into quintiles based on how often the practices treated patients with any systemic therapy, including chemotherapy and immunotherapy, in their last 14 days of life. They compared whether patients in practices with greater use of systemic treatment at very advanced stages had longer overall survival.

What Were the Main Findings?

“We saw that there were absolutely no survival differences between the practices that used more systemic therapy for very advanced cancer than the practices that use less,” said senior author Kerin Adelson, MD, chief quality and value officer at MD Anderson Cancer Center in Houston, Texas. In some cancers, those in the lowest quintile (those with the lowest rates of systemic end-of-life care) lived fewer years compared with those in the highest quintiles. In other cancers, those in the lowest quintiles lived more years than those in the highest quintiles.

“What’s important is that none of those differences, after you control for other factors, was statistically significant,” Dr. Adelson said. “That was the same in every cancer type we looked at.”

An example is seen in advanced urothelial cancer. Those in the first quintile (lowest rates of systemic care at end of life) had an SACT rate range of 4.0-9.1. The SACT rate range in the highest quintile was 19.8-42.6. But the median overall survival (OS) rate for those in the lowest quintile was 12.7 months, not statistically different from the median OS in the highest quintile (11 months.)
 

How Does This Study Add to the Literature?

The American Society of Clinical Oncology (ASCO) and the National Quality Forum (NQF) developed a cancer quality metric to reduce SACT at the end of life. The NQF 0210 is a ratio of patients who get systemic treatment within 14 days of death over all patients who die of cancer. The quality metric has been widely adopted and used in value-based care reporting.

But the metric has been criticized because it focuses only on people who died and not people who lived longer because they benefited from the systemic therapy, the authors wrote.

Dr. Canavan’s team focused on all patients treated in the practice, not just those who died, Dr. Adelson said. This may put that criticism to rest, Dr. Adelson said.

“I personally believed the ASCO and NQF metric was appropriate and the criticisms were off base,” said Otis Brawley, MD, associate director of community outreach and engagement at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University School of Medicine in Baltimore. “Canavan’s study is evidence suggesting the metrics were appropriate.”

This study included not just chemotherapy, as some other studies have, but targeted therapies and immunotherapies as well. Dr. Adelson said some think that the newer drugs might change the prognosis at end of life. But this study shows “even those drugs are not helping patients to survive with very advanced cancer,” she said.

 

Could This Change Practice?

The authors noted that end-of life SACT has been linked with more acute care use, delays in conversations about care goals, late enrollment in hospice, higher costs, and potentially shorter and poorer quality life.

Dr. Adelson said she’s hoping that the knowledge that there’s no survival benefit for use of SACT for patients with advanced solid tumors who are nearing the end of life will lead instead to more conversations about prognosis with patients and transitions to palliative care.

“Palliative care has actually been shown to improve quality of life and, in some studies, even survival,” she said.

“I doubt it will change practice, but it should,” Dr. Brawley said. “The study suggests that doctors and patients have too much hope for chemotherapy as patients’ disease progresses. In the US especially, there is a tendency to believe we have better therapies than we truly do and we have difficulty accepting that the patient is dying. Many patients get third- and fourth-line chemotherapy that is highly likely to increase suffering without realistic hope of prolonging life and especially no hope of prolonging life with good quality.”

Dr. Adelson disclosed ties with AbbVie, Quantum Health, Gilead, ParetoHealth, and Carrum Health. Various coauthors disclosed ties with Roche, AbbVie, Johnson & Johnson, Genentech, the National Comprehensive Cancer Network, and AstraZeneca. The study was funded by Flatiron Health, an independent member of the Roche group. Dr. Brawley reports no relevant financial disclosures.

Patients with metastatic or advanced cancer treated in practices that have high rates of giving systemic care in the last two weeks of life do not have longer survival rates than patients in practices that have low rates of such care.

This conclusion of a new study published online May 16 in JAMA Oncology may help reassure oncologists that giving systemic anticancer therapy (SACT) at the most advanced stages of cancer will not improve the patient’s life, the authors wrote. It also may encourage them to instead focus more on honest communication with patients about their choices, Maureen E. Canavan, PhD, at the Cancer and Outcomes, Public Policy and Effectiveness Research (COPPER) Center at the Yale School of Medicine in New Haven, Connecticut, and colleagues, wrote in their paper.
 

How Was the Study Conducted?

Researchers used Flatiron Health, a nationwide electronic health records database of academic and community practices throughout the United State. They identified 78,446 adults with advanced or metastatic stages of one of six common cancers (breast, colorectal, urothelial, non–small cell lung cancer [NSCLC], pancreatic and renal cell carcinoma) who were treated at healthcare practices from 2015 to 2019. They then stratified practices into quintiles based on how often the practices treated patients with any systemic therapy, including chemotherapy and immunotherapy, in their last 14 days of life. They compared whether patients in practices with greater use of systemic treatment at very advanced stages had longer overall survival.

What Were the Main Findings?

“We saw that there were absolutely no survival differences between the practices that used more systemic therapy for very advanced cancer than the practices that use less,” said senior author Kerin Adelson, MD, chief quality and value officer at MD Anderson Cancer Center in Houston, Texas. In some cancers, those in the lowest quintile (those with the lowest rates of systemic end-of-life care) lived fewer years compared with those in the highest quintiles. In other cancers, those in the lowest quintiles lived more years than those in the highest quintiles.

“What’s important is that none of those differences, after you control for other factors, was statistically significant,” Dr. Adelson said. “That was the same in every cancer type we looked at.”

An example is seen in advanced urothelial cancer. Those in the first quintile (lowest rates of systemic care at end of life) had an SACT rate range of 4.0-9.1. The SACT rate range in the highest quintile was 19.8-42.6. But the median overall survival (OS) rate for those in the lowest quintile was 12.7 months, not statistically different from the median OS in the highest quintile (11 months.)
 

How Does This Study Add to the Literature?

The American Society of Clinical Oncology (ASCO) and the National Quality Forum (NQF) developed a cancer quality metric to reduce SACT at the end of life. The NQF 0210 is a ratio of patients who get systemic treatment within 14 days of death over all patients who die of cancer. The quality metric has been widely adopted and used in value-based care reporting.

But the metric has been criticized because it focuses only on people who died and not people who lived longer because they benefited from the systemic therapy, the authors wrote.

Dr. Canavan’s team focused on all patients treated in the practice, not just those who died, Dr. Adelson said. This may put that criticism to rest, Dr. Adelson said.

“I personally believed the ASCO and NQF metric was appropriate and the criticisms were off base,” said Otis Brawley, MD, associate director of community outreach and engagement at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University School of Medicine in Baltimore. “Canavan’s study is evidence suggesting the metrics were appropriate.”

This study included not just chemotherapy, as some other studies have, but targeted therapies and immunotherapies as well. Dr. Adelson said some think that the newer drugs might change the prognosis at end of life. But this study shows “even those drugs are not helping patients to survive with very advanced cancer,” she said.

 

Could This Change Practice?

The authors noted that end-of life SACT has been linked with more acute care use, delays in conversations about care goals, late enrollment in hospice, higher costs, and potentially shorter and poorer quality life.

Dr. Adelson said she’s hoping that the knowledge that there’s no survival benefit for use of SACT for patients with advanced solid tumors who are nearing the end of life will lead instead to more conversations about prognosis with patients and transitions to palliative care.

“Palliative care has actually been shown to improve quality of life and, in some studies, even survival,” she said.

“I doubt it will change practice, but it should,” Dr. Brawley said. “The study suggests that doctors and patients have too much hope for chemotherapy as patients’ disease progresses. In the US especially, there is a tendency to believe we have better therapies than we truly do and we have difficulty accepting that the patient is dying. Many patients get third- and fourth-line chemotherapy that is highly likely to increase suffering without realistic hope of prolonging life and especially no hope of prolonging life with good quality.”

Dr. Adelson disclosed ties with AbbVie, Quantum Health, Gilead, ParetoHealth, and Carrum Health. Various coauthors disclosed ties with Roche, AbbVie, Johnson & Johnson, Genentech, the National Comprehensive Cancer Network, and AstraZeneca. The study was funded by Flatiron Health, an independent member of the Roche group. Dr. Brawley reports no relevant financial disclosures.

The next frontier in cancer detection could be the humble urine test.

Emerging science suggests that the body’s “liquid gold” could be particularly useful for liquid biopsies, offering a convenient, pain-free, and cost-effective way to spot otherwise hard-to-detect cancers.

“The search for cancer biomarkers that can be detected in urine could provide an enormous step forward to decrease cancer patient mortality,” said Kenneth R. Shroyer, MD, PhD, a pathologist at Stony Brook University, Stony Brook, New York, who studies cancer biomarkers.

Physicians have long known that urine can reveal a lot about our health — that’s why urinalysis has been part of medicine for 6000 years. Urine tests can detect diabetes, pregnancy, drug use, and urinary or kidney conditions.

But other conditions leave clues in urine, too, and cancer may be one of the most promising. “Urine testing could detect biomarkers of early-stage cancers, not only from local but also distant sites,” Dr. Shroyer said. It could also help flag recurrence in cancer survivors who have undergone treatment.

Granted, cancer biomarkers in urine are not nearly as widely studied as those in the blood, Dr. Shroyer noted. But a new wave of urine tests suggests research is gaining pace.

“The recent availability of high-throughput screening technologies has enabled researchers to investigate cancer from a top-down, comprehensive approach,” said Pak Kin Wong, PhD, professor of mechanical engineering, biomedical engineering, and surgery at The Pennsylvania State University. “We are starting to understand the rich information that can be obtained from urine.”

Urine is mostly water (about 95%) and urea, a metabolic byproduct that imparts that signature yellow color (about 2%). The other 3% is a mix of waste products, minerals, and other compounds the kidneys removed from the blood. Even in trace amounts, these substances say a lot.

Among them are “exfoliated cancer cells, cell-free DNA, hormones, and the urine microbiota — the collection of microbes in our urinary tract system,” Dr. Wong said.

“It is highly promising to be one of the major biological fluids used for screening, diagnosis, prognosis, and monitoring treatment efficiency in the era of precision medicine,” Dr. Wong said.

How Urine Testing Could Reveal Cancer

Still, as exciting as the prospect is, there’s a lot to consider in the hunt for cancer biomarkers in urine. These biomarkers must be able to pass through the renal nephrons (filtering units), remain stable in urine, and have high-level sensitivity, Dr. Shroyer said. They should also have high specificity for cancer vs benign conditions and be expressed at early stages, before the primary tumor has spread.

“At this stage, few circulating biomarkers have been found that are both sensitive and specific for early-stage disease,” said Dr. Shroyer.

But there are a few promising examples under investigation in humans:

Prostate cancer. Researchers at the University of Michigan have developed a urine test that detects high-grade prostate cancer more accurately than existing tests, including PHI, SelectMDx, 4Kscore, EPI, MPS, and IsoPSA.

The MyProstateScore 2.0 (MPS2) test, which looks for 18 genes associated with high-grade tumors, could reduce unnecessary biopsies in men with elevated prostate-specific antigen levels, according to a paper published in JAMA Oncology.

It makes sense. The prostate gland secretes fluid that becomes part of the semen, traces of which enter urine. After a digital rectal exam, even more prostate fluid enters the urine. If a patient has prostate cancer, genetic material from the cancer cells will infiltrate the urine.

In the MPS2 test, researchers used polymerase chain reaction (PCR) testing in urine. “The technology used for COVID PCR is essentially the same as the PCR used to detect transcripts associated with high-grade prostate cancer in urine,” said study author Arul Chinnaiyan, MD, PhD, director of the Michigan Center for Translational Pathology at the University of Michigan, Ann Arbor. “In the case of the MPS2 test, we are doing PCR on 18 genes simultaneously on urine samples.”

A statistical model uses levels of that genetic material to predict the risk for high-grade disease, helping doctors decide what to do next. At 95% sensitivity, the MPS2 model could eliminate 35%-45% of unnecessary biopsies, compared with 15%-30% for the other tests, and reduce repeat biopsies by 46%-51%, compared with 9%-21% for the other tests.

Head and neck cancer. In a paper published in JCI Insight, researchers described a test that finds ultra-short fragments of DNA in urine to enable early detection of head and neck cancers caused by human papillomavirus.

“Our data show that a relatively small volume of urine (30-60 mL) gives overall detection results comparable to a tube of blood,” said study author Muneesh Tewari, MD, PhD, professor of hematology and oncology at the University of Michigan .

A larger volume of urine could potentially “make cancer detection even more sensitive than blood,” Dr. Tewari said, “allowing cancers to be detected at the earliest stages when they are more curable.”

The team used a technique called droplet digital PCR to detect DNA fragments that are “ultra-short” (less than 50 base pairs long) and usually missed by conventional PCR testing. This transrenal cell-free tumor DNA, which travels from the tumor into the bloodstream, is broken down small enough to pass through the kidneys and into the urine. But the fragments are still long enough to carry information about the tumor’s genetic signature.

This test could spot cancer before a tumor grows big enough — about a centimeter wide and carrying a billion cells — to spot on a CT scan or other imaging test. “When we are instead detecting fragments of DNA released from a tumor,” said Dr. Tewari, “our testing methods are very sensitive and can detect DNA in urine that came from just 5-10 cells in a tumor that died and released their DNA into the blood, which then made its way into the urine.”

Pancreatic cancer. Pancreatic ductal adenocarcinoma is one of the deadliest cancers, largely because it is diagnosed so late. A urine panel now in clinical trials could help doctors diagnose the cancer before it has spread so more people can have the tumor surgically removed, improving prognosis.

Using enzyme-linked immunosorbent assay test, a common lab method that detects antibodies and other proteins, the team measured expression levels for three genes (LYVE1, REG1B, and TFF1) in urine samples collected from people up to 5 years before they were diagnosed with pancreatic cancer. The researchers combined this result with patients’ urinary creatinine levels, a common component of existing urinalysis, and their age to develop a risk score.

This score performed similarly to an existing blood test, CA19-9, in predicting patients’ risk for pancreatic cancer up to 1 year before diagnosis. When combined with CA19-9, the urinary panel helped spot cancer up to 2 years before diagnosis.

According to a paper in the International Journal of Cancer, “the urine panel and affiliated PancRISK are currently being validated in a prospective clinical study (UroPanc).” If all goes well, they could be implemented in clinical practice in a few years as a “noninvasive stratification tool” to identify patients for further testing, speeding up diagnosis, and saving lives.

Limitations and Promises

Each cancer type is different, and more research is needed to map out which substances in urine predict which cancers and to develop tests for mass adoption. “There are medical and technological hurdles to the large-scale implementation of urine analysis for complex diseases such as cancer,” said Dr. Wong.

One possibility: Scientists and clinicians could collaborate and use artificial intelligence techniques to combine urine test results with other data.

“It is likely that future diagnostics may combine urine with other biological samples such as feces and saliva, among others,” said Dr. Wong. “This is especially true when novel data science and machine learning techniques can integrate comprehensive data from patients that span genetic, proteomic, metabolic, microbiomic, and even behavioral data to evaluate a patient’s condition.”

One thing that excites Dr. Tewari about urine-based cancer testing: “We think it could be especially impactful for patients living in rural areas or other areas with less access to healthcare services,” he said.
 

A version of this article appeared on Medscape.com.

The next frontier in cancer detection could be the humble urine test.

Emerging science suggests that the body’s “liquid gold” could be particularly useful for liquid biopsies, offering a convenient, pain-free, and cost-effective way to spot otherwise hard-to-detect cancers.

“The search for cancer biomarkers that can be detected in urine could provide an enormous step forward to decrease cancer patient mortality,” said Kenneth R. Shroyer, MD, PhD, a pathologist at Stony Brook University, Stony Brook, New York, who studies cancer biomarkers.

Physicians have long known that urine can reveal a lot about our health — that’s why urinalysis has been part of medicine for 6000 years. Urine tests can detect diabetes, pregnancy, drug use, and urinary or kidney conditions.

But other conditions leave clues in urine, too, and cancer may be one of the most promising. “Urine testing could detect biomarkers of early-stage cancers, not only from local but also distant sites,” Dr. Shroyer said. It could also help flag recurrence in cancer survivors who have undergone treatment.

Granted, cancer biomarkers in urine are not nearly as widely studied as those in the blood, Dr. Shroyer noted. But a new wave of urine tests suggests research is gaining pace.

“The recent availability of high-throughput screening technologies has enabled researchers to investigate cancer from a top-down, comprehensive approach,” said Pak Kin Wong, PhD, professor of mechanical engineering, biomedical engineering, and surgery at The Pennsylvania State University. “We are starting to understand the rich information that can be obtained from urine.”

Urine is mostly water (about 95%) and urea, a metabolic byproduct that imparts that signature yellow color (about 2%). The other 3% is a mix of waste products, minerals, and other compounds the kidneys removed from the blood. Even in trace amounts, these substances say a lot.

Among them are “exfoliated cancer cells, cell-free DNA, hormones, and the urine microbiota — the collection of microbes in our urinary tract system,” Dr. Wong said.

“It is highly promising to be one of the major biological fluids used for screening, diagnosis, prognosis, and monitoring treatment efficiency in the era of precision medicine,” Dr. Wong said.

How Urine Testing Could Reveal Cancer

Still, as exciting as the prospect is, there’s a lot to consider in the hunt for cancer biomarkers in urine. These biomarkers must be able to pass through the renal nephrons (filtering units), remain stable in urine, and have high-level sensitivity, Dr. Shroyer said. They should also have high specificity for cancer vs benign conditions and be expressed at early stages, before the primary tumor has spread.

“At this stage, few circulating biomarkers have been found that are both sensitive and specific for early-stage disease,” said Dr. Shroyer.

But there are a few promising examples under investigation in humans:

Prostate cancer. Researchers at the University of Michigan have developed a urine test that detects high-grade prostate cancer more accurately than existing tests, including PHI, SelectMDx, 4Kscore, EPI, MPS, and IsoPSA.

The MyProstateScore 2.0 (MPS2) test, which looks for 18 genes associated with high-grade tumors, could reduce unnecessary biopsies in men with elevated prostate-specific antigen levels, according to a paper published in JAMA Oncology.

It makes sense. The prostate gland secretes fluid that becomes part of the semen, traces of which enter urine. After a digital rectal exam, even more prostate fluid enters the urine. If a patient has prostate cancer, genetic material from the cancer cells will infiltrate the urine.

In the MPS2 test, researchers used polymerase chain reaction (PCR) testing in urine. “The technology used for COVID PCR is essentially the same as the PCR used to detect transcripts associated with high-grade prostate cancer in urine,” said study author Arul Chinnaiyan, MD, PhD, director of the Michigan Center for Translational Pathology at the University of Michigan, Ann Arbor. “In the case of the MPS2 test, we are doing PCR on 18 genes simultaneously on urine samples.”

A statistical model uses levels of that genetic material to predict the risk for high-grade disease, helping doctors decide what to do next. At 95% sensitivity, the MPS2 model could eliminate 35%-45% of unnecessary biopsies, compared with 15%-30% for the other tests, and reduce repeat biopsies by 46%-51%, compared with 9%-21% for the other tests.

Head and neck cancer. In a paper published in JCI Insight, researchers described a test that finds ultra-short fragments of DNA in urine to enable early detection of head and neck cancers caused by human papillomavirus.

“Our data show that a relatively small volume of urine (30-60 mL) gives overall detection results comparable to a tube of blood,” said study author Muneesh Tewari, MD, PhD, professor of hematology and oncology at the University of Michigan .

A larger volume of urine could potentially “make cancer detection even more sensitive than blood,” Dr. Tewari said, “allowing cancers to be detected at the earliest stages when they are more curable.”

The team used a technique called droplet digital PCR to detect DNA fragments that are “ultra-short” (less than 50 base pairs long) and usually missed by conventional PCR testing. This transrenal cell-free tumor DNA, which travels from the tumor into the bloodstream, is broken down small enough to pass through the kidneys and into the urine. But the fragments are still long enough to carry information about the tumor’s genetic signature.

This test could spot cancer before a tumor grows big enough — about a centimeter wide and carrying a billion cells — to spot on a CT scan or other imaging test. “When we are instead detecting fragments of DNA released from a tumor,” said Dr. Tewari, “our testing methods are very sensitive and can detect DNA in urine that came from just 5-10 cells in a tumor that died and released their DNA into the blood, which then made its way into the urine.”

Pancreatic cancer. Pancreatic ductal adenocarcinoma is one of the deadliest cancers, largely because it is diagnosed so late. A urine panel now in clinical trials could help doctors diagnose the cancer before it has spread so more people can have the tumor surgically removed, improving prognosis.

Using enzyme-linked immunosorbent assay test, a common lab method that detects antibodies and other proteins, the team measured expression levels for three genes (LYVE1, REG1B, and TFF1) in urine samples collected from people up to 5 years before they were diagnosed with pancreatic cancer. The researchers combined this result with patients’ urinary creatinine levels, a common component of existing urinalysis, and their age to develop a risk score.

This score performed similarly to an existing blood test, CA19-9, in predicting patients’ risk for pancreatic cancer up to 1 year before diagnosis. When combined with CA19-9, the urinary panel helped spot cancer up to 2 years before diagnosis.

According to a paper in the International Journal of Cancer, “the urine panel and affiliated PancRISK are currently being validated in a prospective clinical study (UroPanc).” If all goes well, they could be implemented in clinical practice in a few years as a “noninvasive stratification tool” to identify patients for further testing, speeding up diagnosis, and saving lives.

Limitations and Promises

Each cancer type is different, and more research is needed to map out which substances in urine predict which cancers and to develop tests for mass adoption. “There are medical and technological hurdles to the large-scale implementation of urine analysis for complex diseases such as cancer,” said Dr. Wong.

One possibility: Scientists and clinicians could collaborate and use artificial intelligence techniques to combine urine test results with other data.

“It is likely that future diagnostics may combine urine with other biological samples such as feces and saliva, among others,” said Dr. Wong. “This is especially true when novel data science and machine learning techniques can integrate comprehensive data from patients that span genetic, proteomic, metabolic, microbiomic, and even behavioral data to evaluate a patient’s condition.”

One thing that excites Dr. Tewari about urine-based cancer testing: “We think it could be especially impactful for patients living in rural areas or other areas with less access to healthcare services,” he said.
 

A version of this article appeared on Medscape.com.

The next frontier in cancer detection could be the humble urine test.

Emerging science suggests that the body’s “liquid gold” could be particularly useful for liquid biopsies, offering a convenient, pain-free, and cost-effective way to spot otherwise hard-to-detect cancers.

“The search for cancer biomarkers that can be detected in urine could provide an enormous step forward to decrease cancer patient mortality,” said Kenneth R. Shroyer, MD, PhD, a pathologist at Stony Brook University, Stony Brook, New York, who studies cancer biomarkers.

Physicians have long known that urine can reveal a lot about our health — that’s why urinalysis has been part of medicine for 6000 years. Urine tests can detect diabetes, pregnancy, drug use, and urinary or kidney conditions.

But other conditions leave clues in urine, too, and cancer may be one of the most promising. “Urine testing could detect biomarkers of early-stage cancers, not only from local but also distant sites,” Dr. Shroyer said. It could also help flag recurrence in cancer survivors who have undergone treatment.

Granted, cancer biomarkers in urine are not nearly as widely studied as those in the blood, Dr. Shroyer noted. But a new wave of urine tests suggests research is gaining pace.

“The recent availability of high-throughput screening technologies has enabled researchers to investigate cancer from a top-down, comprehensive approach,” said Pak Kin Wong, PhD, professor of mechanical engineering, biomedical engineering, and surgery at The Pennsylvania State University. “We are starting to understand the rich information that can be obtained from urine.”

Urine is mostly water (about 95%) and urea, a metabolic byproduct that imparts that signature yellow color (about 2%). The other 3% is a mix of waste products, minerals, and other compounds the kidneys removed from the blood. Even in trace amounts, these substances say a lot.

Among them are “exfoliated cancer cells, cell-free DNA, hormones, and the urine microbiota — the collection of microbes in our urinary tract system,” Dr. Wong said.

“It is highly promising to be one of the major biological fluids used for screening, diagnosis, prognosis, and monitoring treatment efficiency in the era of precision medicine,” Dr. Wong said.

How Urine Testing Could Reveal Cancer

Still, as exciting as the prospect is, there’s a lot to consider in the hunt for cancer biomarkers in urine. These biomarkers must be able to pass through the renal nephrons (filtering units), remain stable in urine, and have high-level sensitivity, Dr. Shroyer said. They should also have high specificity for cancer vs benign conditions and be expressed at early stages, before the primary tumor has spread.

“At this stage, few circulating biomarkers have been found that are both sensitive and specific for early-stage disease,” said Dr. Shroyer.

But there are a few promising examples under investigation in humans:

Prostate cancer. Researchers at the University of Michigan have developed a urine test that detects high-grade prostate cancer more accurately than existing tests, including PHI, SelectMDx, 4Kscore, EPI, MPS, and IsoPSA.

The MyProstateScore 2.0 (MPS2) test, which looks for 18 genes associated with high-grade tumors, could reduce unnecessary biopsies in men with elevated prostate-specific antigen levels, according to a paper published in JAMA Oncology.

It makes sense. The prostate gland secretes fluid that becomes part of the semen, traces of which enter urine. After a digital rectal exam, even more prostate fluid enters the urine. If a patient has prostate cancer, genetic material from the cancer cells will infiltrate the urine.

In the MPS2 test, researchers used polymerase chain reaction (PCR) testing in urine. “The technology used for COVID PCR is essentially the same as the PCR used to detect transcripts associated with high-grade prostate cancer in urine,” said study author Arul Chinnaiyan, MD, PhD, director of the Michigan Center for Translational Pathology at the University of Michigan, Ann Arbor. “In the case of the MPS2 test, we are doing PCR on 18 genes simultaneously on urine samples.”

A statistical model uses levels of that genetic material to predict the risk for high-grade disease, helping doctors decide what to do next. At 95% sensitivity, the MPS2 model could eliminate 35%-45% of unnecessary biopsies, compared with 15%-30% for the other tests, and reduce repeat biopsies by 46%-51%, compared with 9%-21% for the other tests.

Head and neck cancer. In a paper published in JCI Insight, researchers described a test that finds ultra-short fragments of DNA in urine to enable early detection of head and neck cancers caused by human papillomavirus.

“Our data show that a relatively small volume of urine (30-60 mL) gives overall detection results comparable to a tube of blood,” said study author Muneesh Tewari, MD, PhD, professor of hematology and oncology at the University of Michigan .

A larger volume of urine could potentially “make cancer detection even more sensitive than blood,” Dr. Tewari said, “allowing cancers to be detected at the earliest stages when they are more curable.”

The team used a technique called droplet digital PCR to detect DNA fragments that are “ultra-short” (less than 50 base pairs long) and usually missed by conventional PCR testing. This transrenal cell-free tumor DNA, which travels from the tumor into the bloodstream, is broken down small enough to pass through the kidneys and into the urine. But the fragments are still long enough to carry information about the tumor’s genetic signature.

This test could spot cancer before a tumor grows big enough — about a centimeter wide and carrying a billion cells — to spot on a CT scan or other imaging test. “When we are instead detecting fragments of DNA released from a tumor,” said Dr. Tewari, “our testing methods are very sensitive and can detect DNA in urine that came from just 5-10 cells in a tumor that died and released their DNA into the blood, which then made its way into the urine.”

Pancreatic cancer. Pancreatic ductal adenocarcinoma is one of the deadliest cancers, largely because it is diagnosed so late. A urine panel now in clinical trials could help doctors diagnose the cancer before it has spread so more people can have the tumor surgically removed, improving prognosis.

Using enzyme-linked immunosorbent assay test, a common lab method that detects antibodies and other proteins, the team measured expression levels for three genes (LYVE1, REG1B, and TFF1) in urine samples collected from people up to 5 years before they were diagnosed with pancreatic cancer. The researchers combined this result with patients’ urinary creatinine levels, a common component of existing urinalysis, and their age to develop a risk score.

This score performed similarly to an existing blood test, CA19-9, in predicting patients’ risk for pancreatic cancer up to 1 year before diagnosis. When combined with CA19-9, the urinary panel helped spot cancer up to 2 years before diagnosis.

According to a paper in the International Journal of Cancer, “the urine panel and affiliated PancRISK are currently being validated in a prospective clinical study (UroPanc).” If all goes well, they could be implemented in clinical practice in a few years as a “noninvasive stratification tool” to identify patients for further testing, speeding up diagnosis, and saving lives.

Limitations and Promises

Each cancer type is different, and more research is needed to map out which substances in urine predict which cancers and to develop tests for mass adoption. “There are medical and technological hurdles to the large-scale implementation of urine analysis for complex diseases such as cancer,” said Dr. Wong.

One possibility: Scientists and clinicians could collaborate and use artificial intelligence techniques to combine urine test results with other data.

“It is likely that future diagnostics may combine urine with other biological samples such as feces and saliva, among others,” said Dr. Wong. “This is especially true when novel data science and machine learning techniques can integrate comprehensive data from patients that span genetic, proteomic, metabolic, microbiomic, and even behavioral data to evaluate a patient’s condition.”

One thing that excites Dr. Tewari about urine-based cancer testing: “We think it could be especially impactful for patients living in rural areas or other areas with less access to healthcare services,” he said.
 

A version of this article appeared on Medscape.com.