Archive for August, 2011

Feedback after consultation

As many of you know I run a skin cancer business. Doctors essentially lease space from us to conduct their skin cancer practice. They pay us a percentage of their income to perform certain duties including marketing and advertising, recalls and reminders.

Is it acceptable for me to ask patients for feedback on their consultations so that I can work out which are good and which are bad doctors working in our space?

How else can I weed out bad doctors?

Should I weed out bad doctors?

If I have one doctor with great feedback and who builds their practice well and I have a not so good doctor who makes no effort to build their practice  and they both have a spare appointment tomorrow, who should get the one patient that phones?

Should doctors pay a different percentage to me depending on how much effort they make to build their own practice by building relationships? Obviously, I will have to spend much more on advertising and marketing for those doctors that do not make an effort to build their practices.

Should I tell patients that all doctors are independent practitioners and they can takes their chances on who they get?

Very interested in your feedback

Ian

 

 

 

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Calcium plus vitamin D may reduce melanoma risks in some women

Another study on a similar subject:

A combination of calcium and vitamin D may cut the chance of melanoma in half for some women at high risk of developing this life-threatening skin cancer, according to a new study by Stanford University School of Medicine researchers.

Using existing data from a large clinical trial, the study zeroed in on women with a history of non-melanoma skin cancer, as people with this generally non-fatal disease are more likely to develop the more lethal illness — melanoma. The researchers found that women who once had non-melanoma and took the calcium-vitamin D combination developed 57 percent fewer melanomas than women with similar histories who were not given the supplements. Non-melanoma skin cancers, such as basal cell or squamous cell cancers, are the most common forms of skin cancer.

“In preventive medicine, we want to target people most at risk for the disease,” said dermatologist Jean Tang, MD, PhD, lead author of the study. “If you previously had a non-melanoma skin cancer, calcium plus vitamin D might reduce your risk of the more deadly melanoma.”

Tang added a note of caution. The study found that a daily dose of 1,000 mg calcium plus 400 IU of vitamin D doesn’t provide skin cancer protection for everybody. Women without a history of non-melanoma skin cancer who took the supplements did not see any reduction of risk compared with their placebo-group counterparts, according to the research.

The study was published online on June 27 in the Journal of Clinical Oncology.

Vitamin D is well-known for its role in bone growth, but it also affects non-skeletal cells. In many parts of the body, including the skin, vitamin D controls how quickly cells replicate, a process that often goes awry in cancer. Reports from various institutions have suggested that vitamin D is associated with lower risks of colon, breast, prostate and other cancers. Nonetheless, the Institute of Medicine published a report last November saying that more research was needed on vitamin D and calcium, as the evidence was insufficient to prove their having a benefit for conditions other than bone health.

This study is the second to look at the effect of vitamin D supplementation on cancer risk with a randomized, controlled trial.

Tang and colleagues analyzed data from the Women’s Health Initiative, a study that followed 36,000 women ages 50 to 79 for an average of seven years. Half of the women took the daily dose of calcium and vitamin D as part of the experiment; the other half took a placebo pill. The WHI calcium plus vitamin D trial was designed to look at the effects of the supplement on hip fractures and colorectal cancers, but its researchers collected data on many other health issues, including other cancers.

Tang and colleagues took advantage of the large and long-term data set provided by the WHI trial to explore whether vitamin D has a protective effect against skin cancer. “Our results include the first positive cancer-reducing effect seen from the calcium plus vitamin D trial,” said Teresa Fu, MD, a co-author of the study and a recent graduate of the School of Medicine.

The lack of protective effect in women without a history of non-melanoma skin cancer may be due to the amount of vitamin D given to the patients in the WHI trial. “The patients in the Women’s Health Initiative were given vitamin D at a very low dose, based on today’s knowledge — only 400 IU per day,” said David Feldman, MD, professor emeritus of endocrinology and a co-author of the study. Furthermore, patients in the placebo group were allowed to take as much vitamin D as patients that were provided the calcium and vitamin D supplements, so the experimental difference between the two groups was small. In light of that small difference, “it’s somewhat surprising that there was an effect on melanoma risk, and I think many potential benefits of vitamin D may not have been detected,” said Feldman.

Because men were not included in the trial, the researchers cannot be certain whether the protective effect of the supplements would also apply to men with a history of non-melanoma skin cancer. Nonetheless, a 2010 study by Tang demonstrated that elderly men with higher blood levels of vitamin D have fewer non-melanoma skin cancers.

Even in a large study like the WHI, the low frequency of melanomas means that the absolute number of cancers was small. Out of the 36,000 participants, only 176 cases of melanoma were reported. “That just highlights how large a trial needs to be to capture cancer as relatively rare as melanoma,” said Marcia Stefanick, PhD, the Stanford WHI principal investigator and senior author of this study.

“These results spur us to do more studies,” said Tang. She is planning multiple lines of research to examine the potential relationship between vitamin D and cancer prevention, including a study that will compare blood levels of vitamin D with melanoma outcomes. Another line of research will examine the effect of larger doses of vitamin D on the behavior of skin cells in patients with high skin-cancer risk.

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Vitamin D Linked to Skin Cancer

Interesting article. Not necessarily unexpected as those that have a lot of sun exposure have high Vitamin D levels. Multiply the serum levels by approximately 2.5x to get Australia units.

Higher levels of vitamin D, still within the normal  range, are associated with an increased risk of nonmelanoma skin cancer, researchers reported.

In a cohort study, people with higher serum 25-hydroxyvitamin D (25(OH)D) were more likely to develop squamous cell or basal cell carcinoma, according to Melody Eide, MD, and colleagues at Henry Ford Hospital in Detroit.

But other factors – such as increased exposure to sunlight – probably complicate the relationship, Eide and colleagues reported online in Archives of Dermatology.

Ultraviolet B light is known to cause skin cancer, but it also increases cutaneous vitamin D synthesis, the researchers noted, adding that the relationship between vitamin D and skin cancer is complex and studies have yielded conflicting results.

Indeed, some research suggests that vitamin D might reduce the risk of basal cell carcinoma, but other studies have had the opposite outcome.

To help clarify the situation, Eide and colleagues analyzed data, over an average of 9.8 years of follow-up, from 3,223 white members of a health maintenance organization who had a high probability of developing nonmelanoma skin cancer.

The participants had sought counseling for osteoporosis or low bone density between January 1997 and December 2001, and their assessment included levels of serum 25(OH)D, a marker for vitamin D intake and storage.

The researchers used the HMO’s claims database to track incident cases of basal cell and squamous cell carcinoma.

When they were assessed, 2,257 participants did not have a sufficient vitamin D level, where sufficient was defined as at least 30 nanograms of 25(OH)D per milliliter of serum.

All told, the researchers found, 240 patients developed nonmelanoma skin cancer, including 49 with squamous cell carcinoma, 163 with basal cell carcinoma, and 28 with both. Most cases — some 80% — occurred in sites frequently exposed to the sun.

When patients were divided into four groups according to their 25(OH)D levels, there was a trend linking the higher levels and skin cancer risk that was significant atP=0.02.

Compared with the lowest quartile, the highest (less than 19 nanograms per milliliter versus 31 or higher) had an odds ratio for cancer of 1.6 (95% CI 1.1 to 2.3), Eide and colleagues found. Intermediate quartiles also had elevated risks, but they did not reach significance compared with the lowest quartile.

Logistic regression analysis found that having a vitamin D level that was just above the cutoff for deficiency – less than 15 nanograms of 25(OH)D per mL of serum – was associated with an increased risk of nonmelanoma skin cancer. Specifically:

  • For both types combined, the adjusted odds ratio was 1.8 (95% CI 1.1 to 2.9,P<0.05).
  • For squamous cell carcinoma alone, the odds ratio was 1.7, but it did not reach significance with a 95% confidence interval from 0.7 to 4.0.
  • For basal cell carcinoma, the odds ratio was also 1.7 but reached significance at P<0.05 (95% CI 1.00 to 2.9).

The findings add “to the limited and conflicting epidemiological investigation regarding the relationship between vitamin D and [nonmelanoma skin cancer],” Eide and colleagues concluded.

They added that, aside from UVB light, the finding might also be confounded by such things as participants’ vitamin D levels over a lifetime and consumption of vitamin D supplements, which they were unable to investigate.

Eide and colleagues also cautioned that the study was conducted at a single institution and that people who seek counseling for osteoporosis risk represent a self-selected group that may not be a representative population

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Tanning website revealed as hoax

Sunny-3 hoax sees skin cancer charity trick tanners with ‘miracle’ cream

Sunny-3, a hoax tanning cream claiming to ‘triple the power of the sun’, has fooled over 14,000 people who have tried to buy it – only to discover that it has been developed by a skincare charity to raise awareness of associated dangers.

Sunny-3’s hoax website set up by a skin charity to raise awareness of the dangers of tanning

Thousands of people have logged onto Sunny-3’s spoof website and tried to buy it since it was launched last week – only to receive an email outlining skin cancer information and revealing the prank.

The trick was designed to highlight the damaging and life-threatening effects of continued sun tanning.

The website lures potential customers by claiming that the cream has taken off in Sweden where people are ‘hosting night tanning parties’.

Customers can also view false videos promoting the products, which are priced at £7.99 or £12.99. Customers are also led into believing that they can order a free sample.

Charity Skcin and advertising firm McCann Worldgroup wanted to raise awareness of soaring rates of the killer – especially in the young, as skin cancer numbers have doubled in the past ten years.

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Atypical Fibroxanthoma (AFX)

Atypical Fibroxanthoma (AFX)

AFX is a tumour that occurs primarily in older individuals after the skin of the head and neck has been damaged significantly by sun exposure and/or therapeutic radiation. Clinically, lesions usually are suggestive of malignancy because they arise rapidly (over just a few weeks or months) in skin in which other skin cancers have been found and treated. When this clinical impression is combined with highly anaplastic pathology, misdiagnosis can result in unnecessary and extensive surgery and radiation.

Histologically, lesions show a highly atypical and pleomorphic cellular appearance, but they typically respond to simple local excision. Clinicopathologic correlation is essential. Factors important to consider are lesion location, patient age, histopathologic appearance, and the observation that the tumour arises from the dermis, not the fat. Many AFX tumours may represent a superficial form of malignant fibrous histiocytoma (MFH) with a much better prognosis. Some cases may represent primary squamous cell carcinoma (SCC) that fails to express keratin.

Sex: Male-to-female ratio is equal.

Age:  In one study, age ranged from 13-95 years with a mean age of 69 years.

History : Typically, the patient presenting with AFX is an older individual (mean age 69 y) with sun-damaged or radiation-damaged skin of the head, neck, and scalp.

Physical:

  • Nodules are red, juicy, and dome shaped and they may be ulcerated. Lesions are usually located on skin that is red, thin, and telangiectatic, indicating previous significant sun or radiation damage. Some nodules are dark enough, due to deposits of haemosiderin, to be confused with a nodular melanoma.
  • Nodules primarily are located on the head and neck and in sun-exposed areas. In addition, lesions have been reported to occur on the trunk, extremities, and in sun-protected areas. The ratio of lesions that occur on the head and neck to lesions that occur in other areas is approximately 4:1.
  • Tumour size increases proportionately with duration of existence but rarely exceeds 3 cm in diameter.
  • Lesion growth typically is rapid, and patients usually seek medical advice within 6 months of onset.
  • In adult cases, skin underlying developing AFX lesions may be considered locally immunosuppressed. Recent reports showed an increased incidence of AFX in patients with AIDS and in patients who are immunosuppressed because of organ transplantation.
  • One case of localized cutaneous metastases has been reported after excision of the primary lesion. This seems to be extremely rare.

Causes

Sun exposure and/or therapeutic radiation that have caused significant skin damage are associated with the development of AFX. The tumour primarily occurs on the head or neck of older individuals.

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