abstract: Can online learning adequately prepare medical students to undertake a first female pelvic examination?

 

J Obstet Gynaecol Can. 2012 Mar;34(3):264-8.

Source

Department of Obstetrics and Gynaecology, Queen's University, Kingston ON.

Abstract

Objective:
To determine whether a novel web-based learning module could adequately prepare first-year undergraduate medical students to skilfully perform their first female pelvic examination.

Methods:
First-year Queen's University medical students without prior training or experience in female pelvic examination were recruited for this study. After viewing key segments of the learning module, students were evaluated while performing a pelvic examination on a female volunteer using a standardized assessment checklist (total score = 30 points). Descriptive and comparative statistics were generated.

Results:
Forty-five students participated with a mean age of 24 years (range 20 to 40). The mean score (±SD) on the assessment checklist was 23.9 ± 3.6 points, (range 17 to 30). All study participants received a passing grade of ≥ 50% (15/30 points), and 53.3% (24/45) received an honours grade of ≥ 80% (24/30 points). Of the participants, 88.9% (40/45) agreed that they were well prepared for their first female pelvic examination after viewing the training video. Mean scores were similar for male students (23.9, n = 22) and female students (23.8, n = 23) (P = 0.90, t test). Mean scores were not higher in those who watched key segments of the learning module more than once.

Conclusion:
This learning module viewed immediately prior to a simulated clinic session afforded first-year medical students the necessary knowledge and skills to perform a first female pelvic examination. This was accomplished with as little as one viewing, and could lead to savings in organizational costs and instruction time for medical school curricula.

abstract: Genetic Considerations for a Woman's Annual Gynaecological Examination - Obstet Gynaecol Can.

Obstet Gynaecol Can. 2012 Mar;34(3):276-84.

Genetic Considerations for a Woman's Annual Gynaecological Examination.

Source

Calgary AB.

Abstract

Objective: 
To provide the physician with an overview of common genetic conditions that should be considered during a women's annual gynaecological assessment to determine the patient's risk or to initiate specific testing or referral to another subspecialty service, depending on personal or family history.

Options: 
This genetic information can be used for patient education and possible disease and/or mutation screening or diagnosis.

Outcomes: 
The use of this genetic information may allow improved risk-benefit assessment and management at the annual gynaecological examination.

Evidence:
Studies published in English up to and including May 2010 were retrieved through searches of PubMed and the Cochrane Library, using appropriate controlled vocabulary (gynaecological diagnosis, genetic inheritance) and key words (genetic risk, genetic mutation, inheritance, family history, uterus, ovary, endometrial, vagina, colon, gastric, renal, breast, cardiac, thrombophilia, diabetes, epilepsy, leiomyomata uteri). Other literature sources were identified through searching the web sites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

Values:
The levels of evidence are not adequate for evidence-based recommendations to be made.

Benefits, harms, and costs: 
This committee opinion will enhance the use of new genetic knowledge and its application to the annual gynaecological care of women. Risk management and diagnostic opportunities for genetic gynaecological conditions will be improved. A more complete understanding of genetic conditions may increase anxiety and psychological stress for women and their families.

Sponsors: Society of Obstetricians and Gynaecologists of Canada.

Recommendations 
The levels of evidence are not adequate for evidence-based recommendations to be made.

JNCI Commentary (open access): CYP2D6 Genotype as a Marker for Benefit of Adjuvant Tamoxifen in Postmenopausal Women: Lessons Learned

Blogger's Note: see extensive references including current papers regarding this issue

 "Since 2003, there has been considerable interest and a good degree of credence given to the role of cytochrome P450 2D6 (CYP2D6) genotyping to predict tamoxifen benefit in adjuvant therapy (1–5). This construct was based on the fact that a variety of CYP2D6 polymorphisms lead to reduced CYP2D6 enzyme activity and hence result in lower plasma concentrations of endoxifen, a clinically active metabolite of tamoxifen.....


"In the end, it is crucial to obtain data from randomized trials for clinical demonstration of associations between biomarkers and disease outcomes. To advance breast cancer therapy, laboratory observations that raise hypotheses must be at the very core of what we do; however, it is only after independent validation that they can begin guide clinical practice."

1. 15.↵
   1. Regan MM,
   2. Leyland-Jones B,
   3. Bouzyk M,
   4. et al

   . CYP2D6 genotype and tamoxifen response in postmenopausal women with estrogen-responsive early breast cancer: the Breast International Group 1-98 Trial. J Natl Cancer Inst. 2012;104(6):441-451.
2. 16.↵
   1. Rae JM,
   2. Drury S,
   3. Hayes DF,
   4. et al

   . CYP2D6 and UGT2B7 genotype and risk of recurrence in tamoxifen-treated breast cancer patients. J Natl Cancer Inst. 2012;104(6):452-460.

JNCI - The Challenges of Cancer Vaccines

The Challenges of Cancer Vaccines

open access: British Journal of Cancer - Effects of erythropoietin receptors and erythropoiesis-stimulating agents on disease progression in cancer (safety, adverse events, disease progression, conflicting research.....)

Blogger's Note: note ties to industry
          
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"Erythropoiesis-stimulating agents (ESAs) increase red blood cell (RBC) production in bone marrow by activating the erythropoietin receptor (EpoR) on erythrocytic-progenitor cells. Erythropoiesis-stimulating agents are approved in the United States and Europe for treating anaemia in cancer patients receiving chemotherapy based on randomised, placebo-controlled trials showing that ESAs reduce RBC transfusions.

Erythropoiesis-stimulating agent-safety issues include thromboembolic events and concerns regarding whether ESAs increase disease progression and/or mortality in cancer patients. Several trials have reported an association between ESA use and increased disease progression and/or mortality, whereas other trials in the same tumour types have not provided similar findings.

This review thoroughly examines available evidence regarding whether ESAs affect disease progression. Both clinical-trial data on ESAs and disease progression, and preclinical data on how ESAs could affect tumour growth are summarised. Preclinical topics include (i) whether tumour cells express EpoR and could be directly stimulated to grow by ESA exposure and (ii) whether endothelial cells express EpoR and could be stimulated by ESA exposure to undergo angiogenesis and indirectly promote tumour growth.

Although assessment and definition of disease progression vary across studies, the current clinical data suggest that ESAs may have little effect on disease progression in chemotherapy patients, and preclinical data indicate a direct or indirect effect of ESAs on tumour growth is not strongly supported."

"This review summarised results from clinical and preclinical studies that evaluated whether ESAs affect disease progression. Although there are important limitations on the quality and assessment of disease progression in these studies, the current meta-analyses suggest no overall effect of ESAs on disease progression. Several individual studies have shown a potential trend associating ESA use with increased disease progression. This suggests that ESAs may affect disease progression in particular cancer patient populations (e.g., head and neck cancer patients receiving radiotherapy only) and that additional research is needed to define these populations and how ESAs mediate this effect. Although indirect effects on tumours induced by increased RBC production are theoretically possible, preclinical data to date suggest that tumour cells either do not express EpoR or express low levels of EpoR molecules that are non-functional and/or are not present at the cell surface. Overall, the balance of current evidence does not support an effect of ESAs on either activating EpoR on tumour cells or indirectly stimulating disease progression via angiogenesis. Future clinical trials, meta-analyses, and preclinical research should provide additional data to guide evidence-based use of ESAs in cancer patients."

NIH launches consumer-friendly tips series on complementary health practices, March 6, 2012 News Release - National Institutes of Health (NIH)

Tuesday, March 6, 2012

NCCAM Press Office

NIH launches consumer-friendly tips series on complementary health practices

A new series of monthly health tips, Time to Talk Tips, will provide consumers with easy-to-read information on complementary health practices. The effort is managed by the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health.A resource in NCCAM's Time to Talk campaign, the series highlights specific health topics, such as the safe use of dietary supplements, natural products used for the flu and colds, and mind and body approaches used to manage symptoms of a variety of conditions.
The series will include simple tips, such as: Taking vitamin C regularly does not reduce the likelihood of getting a cold but may improve some cold symptoms, and some dietary supplements may interact with medications (prescription or over-the-counter) or other dietary supplements.

“An increasing number of consumers and patients use the Internet to answer health questions, yet the information they find can be overwhelming and is not always relevant or credible,” said Josephine P. Briggs, M.D., director of NCCAM. “This series will give people evidence-based facts to help them make more informed health care decisions. Health care providers can also provide these tips to their patients who are interested in learning more about complementary health practices.”

The tips accompany topics found in the NCCAM Clinical Digest, a monthly e-newsletter for health care providers that addresses the state of science on complementary health practices for a variety of health conditions. These same topics will also be discussed in monthly Twitter chats (@NCCAM), allowing the public to interact with the center, ask questions, and receive answers in real time.

Nearly 40 percent of Americans use some form of complementary health practice, according to the 2007 National Health Interview Survey. Through its Time to Talk campaign, NCCAM encourages patients and providers to talk about the use of complementary health practices by offering tools and resources—such as wallet cards and tip sheets—that are available for free at nccam.nih.gov/timetotalk.
To learn more about NCCAM's Time to Talk Tips, visit http://nccam.nih.gov/timetotalk.

The mission of the National Center for Complementary and Alternative Medicine (NCCAM) is to define, through rigorous scientific investigation, the usefulness and safety of complementary and alternative medicine interventions and their roles in improving health and health care. For additional information, call NCCAM’s Clearinghouse toll free (in the U.S.) at 1-888-644-6226, or visit the NCCAM Web site at nccam.nih.gov.

About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.

abstract: Palliative Chemotherapy for Malignant Ascites Secondary to Ovarian Cancer

Am J Hosp Palliat Care. 2012

Palliative Chemotherapy for Malignant Ascites Secondary to Ovarian Cancer.

Source

College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL, USA.

Abstract

Although research has shown that palliative chemotherapy is beneficial compared to lack of treatment (Schorge JO, Schaffer JI, Halvorson LM, et al. ed. Williams Gynecology. New York, NY: McGraw Hill Medical; 2008.), other studies show aggressive end-of-life treatment adversely affects quality of life and shortens life span (Arriba L, Fader A, Frasure H, von Gruenigen V. A review of issues surrounding quality of life among women with ovarian cancer. Gynecol Oncol. 2010;119(2):390-396.).

Without a consensus on palliative chemotherapy, underutilization during end of life prevails, and likely will continue without additional research (Barbera L, Elit L, Krzyzanowska M, et al. End of life care for women with gynecologic cancers. Gynecol Oncol. 2010;118(2):196-201.).

This article aims to evaluate and examine existing chemotherapy for palliation of malignant ascites secondary to ovarian cancer and compare commonly used regimens. Agents will be evaluated by their modes of administration. Oral agents include cyclophosphamide and thalidomide, and intraperitoneal vehicles include taxane-based agents, platinum-based agents, antibiotics, and biologic agents. In addition, cost, ethics, and quality of life discussions factor into this review.

Palliative care's goal is to find a balance between life expectancy and symptom relief with minimal adverse effects.

open access: PLoS Medicine: Injectable and Oral Contraceptive Use and Cancers of the Breast, Cervix, Ovary, and Endometrium in Black South African Women: Case–Control Study

Background

Oral contraceptives are known to influence the risk of cancers of the female reproductive system. Evidence regarding the relationship between injectable contraceptives and these cancers is limited, especially in black South Africans, among whom injectable contraceptives are used more commonly than oral contraceptives.

Study Sample

The Johannesburg Cancer Case Control Study is a large ongoing case–control study recruiting self-defined black (not mixed race/ancestry) male and female cancer patients with all cancer types, conducted at the greater Johannesburg public referral hospitals that offer cancer treatment. Female patients recruited from 8 March 1995 to 31 December 2006 were included in the present analysis.

Table 1. Demographic and risk factor characteristics of case and control participants, according to use of hormonal contraceptives.
doi:10.1371/journal.pmed.1001182.t001
Table 2. Frequencies and adjusted odds ratios for breast, cervical, ovarian, and endometrial cancer according to ever/never oral and injectable contraceptive use combinations.
doi:10.1371/journal.pmed.1001182.t002
Figure 2. Odds ratio for ovarian and endometrial cancer in relation to use of hormonal contraceptives, according to duration of use.
Adjusted OR (95% CI) for (A) ovarian cancer and (B) endometrial cancer in relation to use of oral and injectable contraceptives, adjusted for age at diagnosis, year of diagnosis, education, tobacco smoking, alcohol consumption, parity/age at first birth, number of sexual partners, urban/rural residence, and province of birth. Squares represent ORs, and horizontal lines indicate 95% CI. Diamonds represent the ORs and confidence intervals for the group comprising women from all three exposure categories immediately above.
doi:10.1371/journal.pmed.1001182.g002

  
Conclusions

In this study, use of oral and of injectable hormonal contraceptives was associated with a transiently increased risk of breast and cervical cancer and, for long durations of use, with a reduced risk of ovarian and endometrial cancer. The observed effects of injectable and of oral contraceptives on cancer risk in this study did not appear to differ substantially.

Medpage: LaCroix A, et al "Health outcomes after stopping conjugated equine estrogens among postmenopausal women with prior hysterectomy: a randomized controlled trial" JAMA 2011; 305: 1305-1314.

Blogger's Note: also see website for video

   ~~~~~~~~~~~~~~~

New WHI Estrogen Analysis Shows Lower Breast Ca Risk

By John Gever, Senior Editor, MedPage Today

Published: April 05, 2011

Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Action Points

• Explain that post-intervention follow-up of the WHI Estrogen-Alone Trial showed that both risks and benefits of unopposed estrogen largely disappeared after therapy stopped.
• Note that while the risk of breast cancer remained decreased for the intervention and post-intervention period combined, the decreased risk during the post-intervention period itself was not statistically significant.

In contrast to other studies of unopposed postmenopausal estrogen therapy, long-term follow-up of Women's Health Initiative (WHI) Estrogen-Alone Trial participants showed a persistent reduction in breast cancer risk, researchers said.

But other benefits and risks associated with use of conjugated equine estrogens (CEE) quickly dissipated after the therapy was stopped, according to Andrea Z. LaCroix, PhD, of Fred Hutchinson Cancer Research Center in Seattle, and colleagues.

"Considering the entire follow-up period, rates of total mortality and the global index of chronic diseases were essentially the same in the conjugated equine estrogen and placebo groups," LaCroix and co-authors wrote in the April 6 issue of the Journal of the American Medical Association.
"Statistically significant age interactions for conjugated equine estrogen use, suggesting greater safety and possible benefit among women in their 50s and potential harm among older women, were observed for coronary heart disease, total MI, colorectal cancer, total mortality, and the global index of chronic diseases," they added.

An editorial in the same issue suggested more caution in interpreting the breast cancer results.

Medical News:Estrogen Benefit in Breast Cancer Affirmed - in Oncology/Hematology, Breast Cancer from MedPage Today

Medical News:Estrogen Benefit in Breast Cancer Affirmed - in Oncology/Hematology, Breast Cancer from MedPage Today

Action Points

• Explain that reduced breast cancer risk with use of estrogen-only hormone therapy after hysterectomy persists long term.
• Point out that the benefit was concentrated largely among low-risk groups, such as those without benign breast disease or a family history of breast cancer.

Commentary: Oestrogen and breast cancer: results from the WHI trial : The Lancet Oncology

 Blogger's Note: this Lancet Oncology article is subscriber based  ($$$)


Commentary

The Lancet Oncology, Early Online Publication, 7 March 2012

Oestrogen and breast cancer: results from the WHI trial

"In The Lancet Oncology , the Women's Health Initiative (WHI) investigators report 1 that receipt of conjugated equine oestrogen for a median of 5·9 years reduced the risk of invasive breast cancer by 23% compared with placebo (151 cases in 5310 women who received oestrogen vs 199 cases in 5429 controls; p=0·02). Women who did develop breast cancer after receipt of oestrogen had significantly reduced breast cancer-specific mortality (six deaths in the oestrogen group vs 16 deaths in controls; p=0·03) and ..."

The Lancet Oncology: Conjugated equine oestrogen and breast cancer incidence and mortality in postmenopausal women with hysterectomy: extended follow-up of the Women's Health Initiative randomised placebo-controlled trial

The Lancet Oncology, Early Online Publication,  

7 March 2012

doi:10.1016/S1470-2045(12)70075-XCite or Link Using DOI

 Feature

The Women's Health Initiative

Women who use the oestrogen-only form of hormone replacement therapy (HRT) appear less likely to develop breast cancer in the longer term, according to new research published in The Lancet Oncology. A follow-up study of over 7500 women from the Women's Health Initiative trial who took oestrogen for about 6 years and then stopped has found that they are over 20% less likely to develop breast cancer and remain significantly less likely to die from the disease than those who never used HRT, a period of nearly 5 years after stopping treatment. The findings are discussed further in a Comment.

 Summary

Background

By contrast with many observational studies, women in the Women's Health Initiative (WHI) trial who were randomly allocated to receive oestrogen alone had a lower incidence of invasive breast cancer than did those who received placebo. We aimed to assess the influence of oestrogen use on longer term breast cancer incidence and mortality in extended follow-up of this cohort.

Methods

Between 1993 and 1998, the WHI enrolled 10 739  postmenopausal women from 40 US clinical centres into a randomised, double-masked, placebo-controlled trial. Women aged 50—79 years who had undergone hysterectomy and had expected 3-year survival and mammography clearance were randomly allocated by a computerised, permuted block algorithm, stratified by age group and centre, to receive oral conjugated equine oestrogen (0·625 mg per day; n=5310) or matched placebo (n=5429). The trial intervention was terminated early on Feb 29, 2004, because of an adverse effect on stroke. Follow-up continued until planned termination (March 31, 2005). Consent was sought for extended surveillance from the 9786 living participants in active follow-up, of whom 7645 agreed. Using data from this extended follow-up (to Aug 14, 2009), we assessed long-term effects of oestrogen use on invasive breast cancer incidence, tumour characteristics, and mortality. We used Cox regression models to estimate hazard ratios (HRs) in the intention-to-treat population. This study is registered with ClinicalTrials.gov, number NCT00000611.

Findings

After a median follow-up of 11·8 years (IQR 9·1—12·9), the use of oestrogen for a median of 5·9 years (2·5—7·3) was associated with lower incidence of invasive breast cancer (151 cases, 0·27% per year) compared with placebo (199 cases, 0·35% per year; HR 0·77, 95% CI 0·62—0·95; p=0·02) with no difference (p=0·76) between intervention phase (0·79, 0·61—1·02) and post-intervention phase effects (0·75, 0·51—1·09).

In subgroup analyses, we noted breast cancer risk reduction with oestrogen use was concentrated in women without benign breast disease (p=0·01) or a family history of breast cancer (p=0·02). In the oestrogen group, fewer women died from breast cancer (six deaths, 0·009% per year) compared with controls (16 deaths, 0·024% per year; HR 0·37, 95% CI 0·13—0·91; p=0·03). Fewer women in the oestrogen group died from any cause after a breast cancer diagnosis (30 deaths, 0·046% per year) than did controls (50 deaths, 0·076%; HR 0·62, 95% CI 0·39—0·97; p=0·04).

Interpretation

Our findings provide reassurance for women with hysterectomy seeking relief of climacteric symptoms in terms of the effects of oestrogen use for about 5 years on breast cancer incidence and mortality. However, our data do not support use of oestrogen for breast cancer risk reduction because any noted benefit probably does not apply to populations at increased risk of such cancer.

Complete response with pegylated liposomal doxorubicin as a second-line therapy in metastatic ovarian carcinosarcoma: Significance of assessment of the response by FDG-PET 10.1016/j.gynor.2012.02.004 : Gynecologic Oncology Case Reports

".....Furthermore, our case illustrates that the Response Evaluation Criteria in Solid Tumors (RECIST) metric is unreliable in predicting the histopathological treatment response in carcinosarcomas. In our patient, pathological analyses of the tissue removed during the debulking surgery showed more than 75% pathological necrosis, whereas the CT scan revealed stable disease. Furthermore, changes in tumor size evaluated on the CT scan after the treatment with PLD were poorly correlated with the metabolic changes and the tumoral viability (and outcome). A recent study showed that FDG-PET was significantly more accurate than size-based criteria at assessing the histopathological response to neoadjuvant therapy in high-grade, soft-tissue sarcomas (Evilevitch et al., 2008). In our opinion, FDG-PET should be considered as a modality to monitor the treatment response in patients with carcinosarcoma of the ovary.

In conclusion, our case illustrates that PLD might have a role in the treatment of ovarian carcinosarcoma that should be evaluated in future studies. This case also emphasizes the need to monitor the treatment response in these patients with FDG-PET."

Interferon after surgery for women with advanced (Stage II-IV) epithelial ovarian cancer - The Cochrane Library - Lawal - Wiley Online Library

Abstract

This is the protocol for a review and there is no abstract. The objectives are as follows:

To assess the effectiveness and safety of interferon after surgery in the treatment of advanced (stage II-IV) epithelial ovarian cancer.