nuclear medicine grand rounds 10/23/2007 ross mcdougall
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Nuclear Medicine Grand Rounds 10/23/2007
Ross McDougall
• Continuing Medical Education• Assembly Bill 1195• Thyroid cancer
• What do they have in common?
Continuing Medical Education
• Who needs it?• What is involved?
• Does it work?
Continuing Medical Education (CME)
• How many hours of CME are required for all physicians in California?
• An average of 25 Category 1 Continuing Medical Education (CME) hours must be completed per calendar year for each full calendar year licensed.
CME (Category 1)
Courses or programs must be related to one of the following **
patient carecommunity health or public health preventive medicinequality assurance or improvementrisk managementhealth facility standardslegal aspects of clinical medicinebioethics, professional ethicsimprovement of the physician-patient relationship.
CME disclosure attestation
• Best available evidence• Sources and limitations of data• Scientific integrity• Free of commercial bias• Payments• Serve the public interest
–Speaker and organizer have to confirm by dated signature
CME
• We must have evaluation forms completed
• A short digression
California Assembly Bill 1195
• What is it?
–Not what is the California Assembly–But–What is the Bill?
California Assembly Bill 1195
California Assembly Bill 1195 requires continuing medical education activities with patient care components to include curriculum in the subjects of cultural and linguistic competency. The bill requires CME providers to develop standards for this curriculum by July 1, 2006.
California Assembly Bill 1195
• Intent– It is the intent of the legislature to
encourage physicians and surgeons, CME providers in the state of California, and the Accreditation Council for Continuing Medical Education to meet the cultural and linguistic concerns of a diverse patient population through appropriate professional development.
California Assembly Bill 1195
• Definition–Cultural competency is defined as a set
of integrated attitudes, knowledge, and skills that enables health care professionals or organizations to care effectively for patients from diverse cultures, groups, and communities.
California Assembly Bill 1195
• Definition–Linguistic competency is defined as the
ability of a physician or surgeon to provide patients who do not speak English or who have limited ability to speak English, direct communication in the patient’s primary language.
Assembly Bill 1195
• Every CME activity must contain elements of cultural and/or linguistic competency
• This can be–Single activity with a single session–Single activity with multiple sessions
during same time period–Multiple sessions occurring over time
Exempt activities
• Research only• Courses not related to patient care
(leadership)• Courses developed by providers
outside of California
CME and California Assembly Bill 1195
• I do not think CME addresses one very important issue–What?
• I do not think AB1195 addresses one very major cultural problem –Who or what?
• America and in particular California is becoming more culturally diverse
• Implicit in this is diversity of language
• There are differences in incidence of diseases among ethnic groups
• There are differences in outcome in different ethnic groups
• The quality of care can be reduced because of difficulties in communication, language and culture
• How many languages are spoken in the USA?
How many languages?
311 languages–162 indigenous–149 immigrant
Languages spoken in San Francisco
• English 54%• Chinese 18%• Spanish 12%• Tagalog 4%• Russian 2%• Vietnamese 1%• French 1%• Japanese 1%
00
Modern Language Association (Language map)
Disparity based on race and ethnicity
• Cholesterol screening and control• Diabetes screening and control• Blood pressure control• Prostate cancer• Thyroid cancer
–Many more
• Thyroid cancer–cultural and linguistic concerns of a
diverse patient population through appropriate professional development
Incidence rates thyroid cancer (women)
0
5
10
1520
25
30
35
1 2 3 4 5 6 7 8
Rat
e pe
r 100
,000
Series1
Which bar corresponds with which ethnic group?African American, Caucasian, Filipino, Hawaian, Hispanic Vietnamese
Incidence rates thyroid cancer (women)
0
510
1520
2530
35
1 2 3 4 5 6 7 8
Rat
e pe
r 100
,000
Series1
1 Filipino2 Filipino (30-54 yr)3 Filipino (55-69 yr)4 Vietnamese5 Hawaiian6 Hispanic7 White 8 Black
Incidence of thyroid cancer
Haselkorn et al Cancer Epidemiology, Biomarkers Prevention 2003;12:144-150
Why are there differences in incidence of thyroid cancer?
• Estrogen• Diet• Radiation• Genetics• Quality of medical care• Others
Why are there differences in incidence of thyroid cancer?
• Estrogen
Gender differences in thyroid cancer incidence
0
5
10
15
20
1 2 3 4 5
Black Chinese Filipino White Hispanic
Series1
Series2
Estrogen and thyroid cancer
• Estrogen receptors (ER Beta) in vessels of papillary cancer (100%) and follicular cancer (83%)
• Thyroid 2006;16:1215
Estrogen and thyroid cancer
• Estradiol enhances anti-apoptotic signaling pathways
–Cancer J 2005;11:113
Estrogen and thyroid cancer
• Gender differences are found across all ethnic groups therefore this alone cannot account for marked difference in incidence between these groups
Why are there differences in incidence of thyroid cancer?
• Diet–Regions of high iodine intake
• Papillary cancer (also increased incidence)
–Regions of low iodine intake• Follicular cancer
– Anaplastic cancer
Why are there differences in incidence of thyroid cancer?
• Diet–Low intake of phytoestrogens (isoflavin)
• Odds ratio 1.6 – 1.9
–Low intake of carotenoids• Odds ratio 1.3 – 1.6
Haselkorn et al Cancer Epidemiology, Biomarkers Prevention 2003;12:144-150
Diet and thyroid cancer
• Isoflavin–Anti-estrogen–Antioxidant– Inhibit growth of estrogen dependent
cancers
• Carotenoid–Antioxidant
Cartenoids
• 40 carbon atoms• Yellow to orange (red) color• Efficient free-radical scavengers, and
they enhance the vertebrate immune system
Why are there differences in incidence of thyroid cancer?
• Radiation–What is known about radiation and
thyroid cancer?• Medical• Atomic bomb• Atomic power-plant• Occupational
Radiation and the thyroid
• As part of the Pacific Proving Grounds the Bikini Atoll was the site of more than 20 nuclear weapon tests between 1946 and 1958, including the first test of a practical dry fuel hydrogen bomb in 1952.
Radiation and thyroid cancer
• Can we blame atomic bombs for the disparate incidence of thyroid cancer in different ethnic groups?
• If not is there another reason for radiation being an etiological factor?
Radiation and thyroid cancer
• More than 10 dental X-rays gave OR = 3.5, 95% CI = 1.6-7.6
• Eur J Canc Prev 1997
• There was a 2-fold significantly increased risk of thyroid cancer in those exposed to dental X-rays (OR=2.1; 95% CI: 1.4–3.1) (p= 0.001). There was a dose-response relationship which showed an increasing trend in risk with increasing number of dental X-rays (p-trend <0.0001).
• Memon (Williams) Eur Thyroid Ass Meeting, Leipzig 2007
Radiation and the thyroid
• CT dose to patients with cystic fibrosis–The mean doses delivered to the four
most strongly exposed organs (lungs, breasts, bone marrow, and thyroid gland) were 18.6, 16.9, 5.2, and 3.5 mGy, respectively
– Chest 2007;132:1233-1238
Radiation and health
• Patient radiation doses from 64 slice cardiac gated CT are appreciably higher than in routine body CT examinations.
• The female breast, which could receive a radiation dose 10-30 times that received from mammography screening
– Brit J Radiol 2007;80:534-544
Radiation and health
• Cardiac CT –Organ doses ranged from 42 to 91 mSv
for the lungs and 50 to 80 mSv for the female breast.
– Lifetime cancer risk estimates for standard cardiac scans varied from 1 in 143 for a 20-year-old woman to 1 in 3261 for an 80-year-old man.
– Jama 2007;298:317-323
Other potential sources of radiation
• Any suggestions?
Kung TM, Ng WL, Gibson JB. Volcanoes and carcinoma of the thyroid: a possible association. Arch Env Health 1981; 36: 265-7
Radon 222Polonium 210and other radio-nuclides
Why are there differences in incidence of thyroid cancer?
• Genetics–Regions with high incidence of thyroid
cancer tend to be homogeneous–However–No single gene has been incriminated in
cancer arising from follicular cells–This also applies to familial cancers of
follicular cells
Why are there differences in incidence of thyroid cancer?
• Quality of medical care–Lower rate of thyroid cancer in African
Americans may be caused by lax detection.• Those diagnosed
– were more likely to be insured– Live in wealthier areas (ZIP codes)
• Luc et al American Academy of Otolaryngology-Head and Neck Surgery Foundation’s Annual Meeting 2007
Other factors
• Ethnic difference with no apparent etiological cause
The bigger questions about CME
• What is its value?
Arguments for mandatory CME
• Continuing education is necessary• Every physician will receive education• Physicians will address their educational
needs• Education can influence practice• Isolation is reduced• Performance of poor physician is improved
» Donen CMAJ 1998;158:1044
Arguments against mandatory CME
• Physicians should be responsible for their own education
• All that is guaranteed is attendance• Principles of adult learning are violated• Performance of poor physician is not
improved• No evidence it improves practice• It is expensive and time consuming
» Donen CMAJ 1998;158:1044
Nuclear Medicine Grand Rounds 10/23/2007Summary
• Continuing Medical Education• Assembly Bill 1195• Cultural diversity in medicine• Language diversity in medicine
–Thyroid cancer as an example of cultural and language diversity
Age Adjusted Thyroid Cancer Rates by Race/Ethnicity 1999-2003
4.8
2.65
5.64
3.09
14.03
10.05
17.87
12.71
0 5 10 15 20
White, NH
Black, NH
Asian, NH
Hispanic
Males FemalesRate per 100,000 age-adjusted to the 2000 US standard populations
Annual Age-adjusted Thyroid Cancer Incidence Rates for Males and Females
Massachusetts vs SEER 1984-2003
0
2
4
6
8
10
12
14
16
18
20
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Year
Rate
per
100
,000
MA Males MA FemalesSEER Males SEER Females
Rates are age-adjusted to the 2000 U.S. Standard Population