Payment Rates May Affect Breast Cancer Treatment

Use of a costly breast cancer therapy called intensity-modulated radiation therapy is strongly influenced by what Medicare will pay for the treatment and where radiation oncologists practice, according to a new study. Researchers analyzed Medicare data for 26,163 women with localized breast cancer who had surgery and radiation therapy between 2001 and 2005. During that time, Medicare billing for the treatment, called IMRT, increased more than 10-fold (from 0.9 percent to 11.2 percent of patients).

The average cost for radiation treatment within the first year after breast cancer diagnosis was $7,179 without IMRT and $15,230 with it. Billing for IMRT was five times higher in regions of the country where the treatment was covered by local Medicare carriers than it was in areas where it was not covered, the researchers said. They also found that billing for IMRT was more common among patients treated in freestanding radiation treatment centers (7.6 percent) than among those treated in hospital-based outpatient clinics (5.4 percent).

The findings "suggest that with respect to breast radiation therapy, much of the variation in cost can be directly attributed to inconsistent treatment definitions and reimbursement rates authorized by Medicare and its intermediaries," concluded Dr. Benjamin D. Smith, of the M.D. Anderson Cancer Center in Houston, and his colleagues. The study is published in the April 29 online edition of in the Journal of the National Cancer Institute.

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New Clues to How Gastric Bypass Surgery Combats Diabetes

Gastric bypass surgery has been known to improve blood sugar control, often sending people with type 2 diabetes into remission, but experts have long wondered exactly how that happens. Now, a new study provides some clues. Circulating amino acids linked with insulin resistance decline dramatically in those who have the bypass surgery, the researchers discovered. They compared 10 obese people with diabetes who had the surgery with 11 who lost weight through dieting. "Something happens after gastric bypass that does not happen as much after the diet-induced weight loss," said Dr. Blandine Laferrere, an associate professor of medicine at St. Luke's Roosevelt Hospital Center and Columbia University, both in New York City.

The surgery, which reduces the stomach to the size of a small pouch, also modifies the junction between the stomach and small intestine. It leads to a dramatic reduction in the level of circulating amino acids that have been linked with diabetes. "The fact that gastric bypass results in the remission of diabetes in the majority of patients is not new," said Laferrere. According to background information in the study, 50 percent to 80 percent of diabetes cases go into remission after the surgery. What doctors have been trying to figure out, she said, is why the bypass surgery is so good at making the diabetes disappear. "The diabetes improves almost immediately, before a significant amount of weight loss occurs," she said. "That points out it is something other than the weight loss."

In the new study, the researchers evaluated biochemical compounds involved in metabolic reactions in the participants. Each group had lost about 20 pounds. The investigators found that the bypass patients had much lower levels of amino acids known as branched-chain amino acids, and the amino acids phenylalanine and tyrosine. "Those changes in the amino acids could be implicated in the mechanism of diabetes remission after gastric bypass," Laferrere said. Experts know the amino acids are linked with insulin resistance partly due to animal studies, she said. "If you supplement the diet of rats with branched-chain amino acids, you can induce more insulin resistance," she explained.

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Chronic Kidney Disease Tied to Heart Problems in Elderly

Chronic kidney disease is common among Americans over 80 years of age and is often linked with heart disease, a new study says. Researchers examined the prevalence of chronic kidney disease in 1,028 octogenarians in four U.S. communities enrolled in the long-term Cardiovascular Health Study All Stars. The prevalence of chronic kidney disease varied from 33 to 51 percent, depending on whether the researchers used blood serum levels of creatinine or cystatin C as markers of the disease.

The findings highlight the fact that using different formulas to assess kidney function in people in their 80s results in different estimates of the chronic kidney disease prevalence in this age group, the investigators said. The study authors noted that no "gold standard" to estimate the prevalence of chronic kidney disease in octogenarians has been developed or validated. However, no matter which formula was used to assess kidney function, chronic kidney disease in octogenarians was associated with cardiovascular disease. Participants with chronic kidney disease were 1.5 to two times more likely than those without chronic kidney disease to have coronary heart disease, heart failure or stroke, according to the report.

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Kids' Eczema, Hay Fever Linked to Allergic Asthma Later

New research finds that adults who suffered from eczema as children especially if they also had hay fever are nine times more likely to have allergic asthma when they're in their 40s. The findings are based on about 1,400 adults who have been followed for five decades as part of Australia's Tasmanian Longitudinal Health Study. The study participants were assessed in 1968, when they were 7 years old, and then again in 2004 when they were about 44 years of age.

"In this study we see that childhood eczema, particularly when hay fever also occurs, is a very strong predictor of who will suffer from allergic asthma in adult life," lead study author Pamela Martin, a University of Melbourne graduate student at the Murdoch Childrens Research Institute, said in a university news release. "The implications of this study are that prevention and rigorous treatment of childhood eczema and hay fever may prevent the persistence and development of asthma."

Allergic asthma is airway obstruction and inflammation that's triggered by inhaled allergens such as dust mites, pet dander, pollen and mold. According to Martin, the study is the first to examine childhood eczema and hay fever and their connection to allergic versus nonallergic asthma. The linkage between childhood illnesses and adult asthma is called the "atopic march." "If successful strategies to stop the 'atopic march' are identified, this could ultimately save lives and health care costs related to asthma management and treatment," Shyamali Dharmage, principal investigator of the Tasmanian Longitudinal Health Study.

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Genome Scans May Reveal Life-Saving Alternatives for Cancer Patients

A 39-year-old woman is referred to Washington University's Siteman Cancer Center in St. Louis with suspected acute myeloid leukemia (AML), a cancer that can be treated relatively simply with medication, or not so simply with a high-risk stem cell transplant, depending on the tumor subtype. But finding out which type of cancer she has proves trickier than expected. While the pathologist sees a type of leukemia known as M3AML, which generally has a good outcome and can be treated with the drug ATRA, the cytogeneticist sees something entirely different.

In his analysis, the woman has a type of leukemia with poor long-term survival that is usually treated with stem cell transplantation a risky therapy that sometimes leads to death. Fortunately, in this case study, documented in the April 20 issue of the Journal of the American Medical Association, the woman's oncologist is aware of a clinical trial and, deferring treatment for six weeks, refers her there so the researchers can do a full scan of her genome and come up with an answer.

Full-genome sequencing involves scanning all the thousand of genes on the human genome to try to find a mistake. It's different from the more common gene testing these days, which looks only for specific DNA that might or might not be responsible for a particular problem. In the St. Louis case, the more in-depth sequencing, done in only seven weeks, uncovered a new genetic "mistake" that showed the woman could be treated with ATRA and not the more-complicated, risky stem cell transplantation.
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Starting HIV Drugs Earlier May Delay AIDS But Not Death

New research suggests that HIV-infected patients are most likely to stay clear of AIDS longer if they start drug therapy when their immune systems are still relatively strong. However, starting treatment earlier, compared to waiting, didn't affect dying from AIDS. "There wasn't a clear benefit in terms of preventing death" by prescribing the drugs before some guidelines suggest, said Dr. Keith Henry, director of HIV clinical research at Hennepin County Medical Center in Minneapolis and co-author of a commentary accompanying the study, published in the April 19 edition of Annals of Internal Medicine.

The issue of when to begin drug treatment is a hot topic in the field of AIDS/HIV medicine. If physicians wait to begin treatment, patients can delay the expense not to mention the side effects of pricey anti-HIV drugs. But such delays may also give the virus a chance to become more powerful and better able to fend off medications. If they're not treated with drugs, HIV-infected people almost always go on to develop AIDS. So when should doctors turn to the drugs? In the U.S., guidelines suggest that HIV-infected patients take them when the level of CD4 cells an important part of the immune system dips below 0.500 X 109 cells per liter (cells/L).

In Europe, the guideline number is frequently lower meaning a weaker immune system at under 0.350 X 109 cells/L.In the new study, researchers examined how patients did when they began drug therapy with their CD4 cells at a variety of levels. The study authors examined the medical records of almost 21,000 HIV-infected patients who sought treatment in HIV clinics in Europe and through the Veterans Health Administration system in the United States. The researchers found that the death rate was about the same regardless of whether patients began treatment when their CD4 levels dipped under 0.500 X 109 cells/L or if they waited until their immune systems deteriorated more and reached below the level of 0.350 X 109 cells/L.

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Do Immune System Ills Help Drive Type 2 Diabetes?

New research suggests that the development of insulin resistance and type 2 diabetes may be linked to an immune system reaction gone awry. "The main point of this study is trying to shift the emphasis in thinking of type 2 diabetes as a purely metabolic disease, and instead emphasize the role of the immune system in type 2," said study co-author Dr. Daniel Winer, an endocrine pathologist at Toronto General Hospital in Canada. When the research began, Winer was a postdoctoral fellow at Stanford University in California. The researchers have identified immune system antibodies in people who are obese and insulin-resistant that aren't present in people who are obese without insulin resistance. They also tested a drug that modifies the immune system in mice fed a fatty diet, and found that the medication could help maintain normal blood sugar levels.

The findings were published online April 17 in the journal Nature Medicine. Funding for the study was provided by the U.S. National Institutes of Health. Nearly 26 million Americans have diabetes, according to the U.S. Centers for Disease Control and Prevention. Between 90 percent and 95 percent of these cases are type 2 diabetes, where the body doesn't use insulin efficiently, so the pancreas must make increasing amounts of insulin. Eventually, the pancreas stops making enough insulin to meet the increased demand. The less common form of the disease, type 1 diabetes, occurs when the immune system mistakenly destroys the insulin-producing beta cells in the pancreas. This type of diabetes is considered an autoimmune disease, and isn't linked to how much a person weighs.

Although the causes of type 2 haven't been clear, it's known that the disease runs in families, suggesting a genetic component. Also, while type 2 is strongly linked to increased weight, not everyone who is overweight gets type 2 diabetes. And, that's what got the researchers searching for another factor. Winer explained that excess weight has been linked to inflammation, which can cause the immune system to react. As visceral fat (abdominal fat) expands, it eventually runs out of room, explained Winer. At that point, the fat cells may become stressed and inflamed, and eventually the cells die. When that happens, immune system cells known as macrophages come to sweep up the mess.

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Nervous System Imbalance May Cause Fatigue in Breast Cancer Survivors
The persistent fatigue and exhaustion plaguing some breast cancer survivors after successful treatment stems from a tug of war between the "fight-or-flight" and "resting" parts of the autonomic nervous system, with the former working overtime and the other unable to rein it in, a new study suggests. Researchers from Ohio State University split 109 women who had completed breast cancer treatment up to two years earlier into two groups those who did and didn't report long-term fatigue and tested their blood for a baseline level of norepinephrine, a stress hormone. Participants were then asked to give a five-minute speech and do a series of verbal math problems, both tasks aimed at increasing their stress levels.

As expected, further blood tests showed that levels of norepinephrine associated with the "fight-or-flight" sympathetic nervous system rose in both groups after the stressful experience, researchers said. However, breast cancer survivors who experienced persistent fatigue had higher levels than those who weren't chronically tired. The study, released online in advance of publication in an upcoming print issue of the journal Psychoneuroendocrinology, was partially funded by the U.S. National Institutes of Health and the American Cancer Society.

The findings are the most recent from a 30-year-long study about the effects of stress on the human body. The researchers used earlier data from a larger ongoing study looking at whether yoga can ward off continuing fatigue in breast cancer patients. "We're not sure if the fatigue is stress-induced. But certainly cancer is an extremely stressful life event," said study author Christopher Fagundes, a postdoctoral fellow at Ohio State University's Institute of Behavioral Medicine Research. "So those stressors might be contributing to those autonomic system changes."
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