Category Archives: Thoracic Surgery

Lessons After the Storm: Joplin Surgeon Looks Back

Take emergency weather warnings seriously, prepare a plan to triage and treat mass casualties, and consider how you would work in a worst-case scenario following a major natural disaster. These are some lessons learned by a thoracic surgeon who survived a devastating EF 5 tornado that ripped through his hometown of Joplin, Mo.

The tornado was on the ground for 32 minutes and cut a 6-mile-wide swath through residential and downtown areas. (Photos courtesy Dr. Michael Phillips)

All normal communications were down when Dr. Michael Phillips arrived at his hospital, the Freeman Health System Heart and Vascular Institute. Staff figured out they could communicate via Facebook, Twitter, and texts. There was no water pressure or clean water.  “We were on generator power only, with no ability to identify any patient and no labs or x-rays,” Dr. Phillips said at the annual meeting of the American Association for Thoracic Surgery.

Nearby St. John’s Regional Medical Center, a 360-bed hospital, “was lifted off the ground and moved four inches off its foundation.” There were 183 inpatients at St. John’s when the tornado touched down

Cars were tossed about in front of St. John’s Regional Medical Center in Joplin.

with winds approaching 300 mph on May 22, 2011. More than 70 patients, including 11 on ventilator support, “came to our hospital needing a place to stay, and we were already full. We

have a 250 bed hospital – what do you do from there?”

More than 1,000 patients were treated in the first 24 hours. There were 11 deaths in the first six hours and “I pronounced seven of them,” said Dr. Phillips, a cardiothoracic surgeon at Freeman. There were 161 deaths overall, making the Joplin tornado the deadliest on record since 1950.

“We didn’t sleep. We operated nonstop. We performed 22 operations during that time, 13 of which I performed. It was almost 30 hours before I took a break, the same thing with all the people around me,” Dr. Phillips replied. “I was really blessed by having a wonderful staff around me.”

“There were so many challenges to overcome; it’s really hard to put into words. You have to overcome that initial shock. The layperson doesn’t understand the devastation around them; you do. You have to get your arms around it and move on and deal with the situation at hand.”

A transition zone of less than 100 yards separated “completely normal from complete and total devastation.”

“One can never train enough for such an event. We have to try to be prepared as much as possible. Preparation should include all levels within the health system,” Dr. Phillips said. “Mass triage plans are critical.”

Lessons learned include taking weather warnings seriously.  “We used to blow these off and we pay attention now,” Dr. Phillips said. Take shelter when a siren sounds and review your plans for worst case scenarios.  All this advice applies to other natural disasters – including tsunamis, typhoons, and hurricanes, he said.

“These are all natural disasters that not only take life and create mass casualties, but they also take away our basic essentials of communications, food, clothing, and shelter.”

–Damian McNamara (on Twitter @MedReporter )

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Placing Central Lines and DVTs?

Does the simple act of inserting a central venous catheter induce a hypercoagulable state in patients?

Courtesy Wikimedia Commons/Jsonp/Public domain

Research presented at the Eastern Association for the Surgery of Trauma shows that central venous line insertion significantly decreases clotting time and initial clot formation time and accelerates fibrin cross-linking in both healthy swine and critically ill patients.

The findings indicate that CV catheters induce a systemic hypercoagulable state, probably because of the endothelial injury, which may explain the increased risk for venous thromboembolism associated with central venous lines, said lead author Dr. Mark Ryan, with the University of Miami School of Medicine.

The prospective, observational trial involved eight patients whose blood was drawn from an indwelling peripheral arterial catheter before and 60 minutes after central venous line catheterization and analyzed with thromboelastography (TEG). Ten swine consented to having their blood drawn as well.

The group previously reported that placing a pulmonary artery catheter in critically ill patients and healthy swine significantly decreases the time to initial fibrin formation, thereby inducing a hypercoagulable state.

WENDLING/Elsevier Global Medical News

As in the current study, however, no changes were observed in conventional coagulation parameters, raising questions as to why standard coagulation tests fail to correlate with TEG and whether the prothrombotic state identified by TEG truly indicates an increased risk for deep vein thrombosis, Dr. Ryan said.

Finally, as has been suggested by other investigators, pigs may simply have a very different hypercoagulable state than humans do. I selfishly hope so.

–Patrice Wendling

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New Questions on Lung Cancer Screening

Would you allow patients to self-refer for a CT lung cancer screening? Would you screen a never-smoker? What size nodule would trigger a follow-up exam? What is your lower age limit and lower pack-year limit for screening?

These are just a few of the questions tackled during an interactive lung cancer screening session at the recent Radiological Society of North America meeting, and that highlight the uncharted waters physicians face in the wake of the pivotal National Lung Screening Trial.

The NLST demonstrated a 20% reduction in lung cancer mortality when low-dose CT screening was used, compared to chest X-ray, among 53,000 asymptomatic current or former heavy smokers. However, CT produced more than three times the number of positive results and a higher false-positive rate than radiography.

Without a clear plan to manage abnormal findings or a firm handle on cost, policymakers and payors are hesitant to back reimbursement for widespread lung cancer screening. Results of the ongoing NLST cost-effectiveness analysis are expected early next year. Based on already published data, however, a crude back-of-the-envelope estimate puts the incremental cost-effectiveness ratio at $38,000 per life-year gained, NLST investigator Dr. William Black told attendees.

“That actually is a pretty good deal compared to a lot of things we do in medicine, and in fact most people would put the threshold for acceptability somewhere between $50,000 to $100,000 per life-year gained,” he said. “So it certainly is feasible”

Dr. Black pointed out that low-dose CT saved one lung cancer death per 346 persons screened in NLST, which again is very favorable compared to the rate of 1 per 2,000 patients for mammography.

Although the session provided just a small snapshot in time, audience responses suggest there is much work ahead. A full 77% of attendees were not using low-dose CT to screen for lung cancer and 72% reported not being familiar with the recently published National Comprehensive Cancer Network guidelines for lung cancer screening.

One-quarter of the audience had no lower age limit for screening, and 34% said they did not provide either decision support or obtain informed consent.

Dr. Caroline Chiles. Image by Patrice Wendling/Elsevier Global Medical News

Radiologist and NLST collaborator Dr. Caroline Chiles said informed consent in NLST helped prepare patients for the potential risks of a screen, the likelihood of a positive result and that a positive result didn’t mean they had lung cancer.

“It made a huge difference once they got that letter saying they had a positive screen, because at that point you don’t want everyone rushing out to a surgeon to get that nodule resected,” she added.

What attendees and panelists could agree on is the need for smoking cessation to be included in any future lung cancer CT screening program, with 60% of attendees saying they already do so.

Dr. Chiles pointed out that 16.6% of participants in the NELSON lung screening trial quit smoking compared with 3%-7% in the general public, but that participants were less likely to stay non-smokers. She also cited a recent MMWR that found 70% of adult smokers want to quit smoking, but only about half had been advised by a health professional to quit.

“We really have to think of lung cancer screening as being a teachable moment,” she said.

She suggested physicians visit www.smokefree.gov for help in guiding their patients. Dr. Black also noted that the NLST team is working on a lung cancer screening fact sheet for physicians and patients that will be ready in a few weeks and made available on the Internet.

—Patrice Wendling

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Filed under Cardiovascular Medicine, Family Medicine, Health Policy, IMNG, Internal Medicine, Oncology, Physician Reimbursement, Practice Trends, Pulmonary Diseases and Sleep Medicine, Radiology, Surgery, Thoracic Surgery

TAVI Trek Begins

It took just two days after the Nov. 2 FDA approval of the Edwards SAPIEN transcatheter aortic valve for New York-Presbyterian Hospital/Columbia University Medical Center to claim bragging rights as the first center in the United States to implant the device as an FDA-approved standard of care.

The center will be one of four sites to train U.S. doctors in the procedure, and is promising to lead a live demonstration tomorrow (Nov. 9) at the annual Transcatheter Cardiovascular Therapeutics symposium in San Francisco for those eager to get a front row view of transcatheter aortic valve implantation (TAVI).

Courtesy Edwards Lifesciences

The FDA approval also put the U.S. in the rare position of following the footsteps of some 40 countries that have already approved the SAPIEN valve including Latvia, Iran, and Russia. This fact elicited a good laugh at the recent Heart Valve Summit 2011 in Chicago, but also prompted much dialogue about some of the thorny ethical and economical consequences that still lay ahead.

“Is anyone at the government talking about rationing of care?” asked Dr. Stephen Strelec, an anesthesiologist at University of Pennsylvania Medical Center, at the summit. It’s not just the 92-year-old who says “I want to live,” but the younger patient facing a valve procedure who decides they don’t want to be on anticoagulants and undergo surgery because they can afford this expensive new transcatheter valve in 2 years. “There’s an economic consequence to that decision as well,” he said.

Dr. Robert Bonow, director of the center for cardiovascular innovation at Northwestern, said the issue is being looked at by federal agencies and insurers, but added that it is “one of the biggest hot-button items about this whole technology because it’s not going to be cheap.”

Dr. David Adams, chair of cardiothoracic surgery at Mount Sinai Medical Center, said they’ve already had their share of 90-year-olds wheeled in from the nursing home by family members who read about TAVI in the newspaper and want mom to stay alive.

The suggestion was made that surgeons and interventional cardiologists will have to hone their skills in making the very specific diagnosis of medical futility, and that a board-certified palliative care physician will be one of the most valuable members of the multidisciplinary teams treating these patients.

“Every PARTNER site looking back over their patients can name patients that they wish they didn’t enroll in the trial and done the valve on,” said Dr. Howard Herrmann, director of interventional cardiology and cardiac catheterization at the Hospital of the University of Pennsylvania. “The question is how to recognize them up front.”

Edwards Lifesciences and the FDA are setting up an intensive training program with simulations, an expert review of cases and a proctoring system. Still, the challenge for Edwards and other companies that will follow will be enormous in terms of launching this technology outside the clinical trial setting, said Dr. Adams, co-principal investigator of Medtronic’s CoreValve trial.

“You can not overestimate the amount of company support you’re going to need to do these things safely,” he said. “This is not a new widget you can pick up in one or two tries like a new ring or new stent…It’s a whole new process.”

The European experience, albeit the initial experience, suggests there’s a distinct learning curve to TAVI. A meta-analysis of 12 TAVI trials presented at this summer’s European Society of Cardiology Congress, reported a flattening of mortality curves 8 years after the first human case in 2002, with procedural mortality decreasing from 16.7% in 2004 to 0.0-0.6% in 2010 and 30-day mortality plummeting from 67% to 11% over the same time period. The authors, led by Dr. Pablo Salinas, University Hospital La Paz, Madrid, credit technical improvements in the devices, better patient selection and on-site case proctoring as helping to shorten the learning curve.

—by Patrice Wendling

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Filed under Cardiovascular Medicine, Drug And Device Safety, Geriatric Medicine, Health Policy, Hospice and Palliative Care, Surgery, Thoracic Surgery

Video of the Week: Has the Time Come for Genetic Testing of Early-Stage Lung Cancer?

Researchers have devised and validated an 11-gene expression test that can distinguish patients with stage I or II lung cancer who have a low, intermediate, or high risk for having micrometastatic disease after primary tumor resection that requires adjuvant chemotherapy. Our reporter Mitchel Zoler asked investigator Dr. Johannes Kratz to discuss the need for and strengths of the test.

The multigene assay can outperform conventional risk factors and staging, and may lead to personalized therapies for patients with early-stage nonsquamous non–small cell lung cancer. [Dr. Krause] 

You can read a more detailed analysis of the test and its implications on the  IMNG Oncology Digital Network.

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Coronary Artery Bypass Surgery Gets Better

When it comes to treating blocked coronary arteries, the two major options–coronary artery bypass surgery and coronary artery stenting–have traditionally been in competition. And conventional wisdom held that endovascular coronary artery interventions keeps getting better, with improved stents, while surgical bypass remains fairly stable. After all, surgery is surgery, right?

Well, the simple answer is: Wrong! Surgery has gotten better, too, even over the past decade.

Earlier this month, at the annual meeting of the American Association for Thoracic Surgery,

coronary artery bypass; courtesy Wikimedia Commons

I heard some startling statistics on how much cardiac bypass surgery progressed during the 2000s, numbers that bear repeating and even celebrating.

A report by Andrew W. ElBardissi, a cardiac surgeon at Brigham and Women’s Hospital in Boston, used data collected by the Society of  Thoracic Surgeons on U.S. coronary bypass surgeries done in 2000 and in 2009.

In 2000, more than 136,000 U.S. patients underwent bypass surgery. During the 30 days following surgery, their mortality rate was 2.4%, and 1.6% had a stroke. In 2009, more than 160,000 U.S. patients underwent bypass surgery, with a 30-day mortality of 1.9% and a 1.2% stroke rate.

These changes may sound small, a 0.5% drop in mortality and a 0.4% fall in stroke rate, but in addition to being statistically significant these decreases meant better outcomes for hundreds of patients each year.

With more than 160,000 patients having coronary bypass surgery in 2009, the improvement over the course of 10 years meant that in 2009, 800 fewer patients died following surgery and 640 fewer patients had a stroke compared with the rate 10 years earlier. Well over a thousand patients had a substantially better outcome from their surgery a decade later because of improvements in surgical technique and patient management.  Presumably the numbers were at least as good last year, too, as well as today, next year, and beyond.

These improved outcomes are actually even better because other parts of Dr. ElBardissi’s analysis showed that 2009 patients were sicker than coronary bypass patients treated a decade before. Elective cases fell from 58% of all surgeries in 2000 to 41% in 2009. Balancing this shift was a sharp rise in urgent surgical cases, which jumped from 38% of all bypass cases in 2000 to 54% in 2009. Another measure of how the cases grew more complex was the percent of patients who underwent bypass of their left main coronary artery, the coronary procedure that is riskiest because the left main artery is so critical for supplying blood to heart muscle. Left main bypasses jumped from 23% of the coronary surgery cases in 2000 to 32% in 2009. The 2009 patients also had substantial rises in the prevalence of hypertension, hypercholesterolemia, and chronic obstructive pulmonary disease.

Why did bypass surgery do so much better in 2009, even as patients got sicker? Dr. ElBardissi’s data provide a few likely explanations: In 2009, use of internal mammary artery grafts–the optimal graft vessel–rose from 84% of cases in 2000 to 95% of cases in 2009. And use of helpful medications, including beta blockers, aspirin, and statins, all rose from 2000 to 2009.

—Mitchel Zoler (on Twitter @mitchelzoler)

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Let’s Hear It for the Heart Team

A relatively new, somewhat revolutionary concept appears to be quickly crystallizing for cardiac disease management: the Heart Team. Simply put, the heart team is a collaboration of interventionalist cardiologists and cardiac surgeons (and maybe non-interventionalist cardiologists too) at a single center who work together to combine their endovascular and open-surgical skills in a collaborative and complementary way to give patients optimized treatment that thoughtfully combines the best of both approaches.

The heart team concept has even given birth to a related, new phrase: the hybrid cardiac suite, which is the ultimate collaborative site, a room that accommodates both endovascular and open-surgical procedures under one roof.

Peaceable Kingdom By Edward Hicks/courtesy Wikimedia Commons

It sounds great and makes a lot of sense, but until very recently seemed to be the stuff of dreams, as endovascularists and surgeons traditionally acted as worst enemies, jealously guarding their turf and touting their approach as best.

Those days now may be coming to an end. Get ready to root on the heart team.

When I covered the annual meeting of the American Association for Thoracic Surgery in Philadelphia earlier this month, it seemed like I kept bumping into the heart team idea. There was a report from the PARTNER study, which compared endovascular aortic valve repair to open-surgical repair, and relied on heart teams to run the show. PARTNER, a U.S.study, is also credited with providing fertile ground for the heart team idea to take root in America.

In Europe, the heart team concept got jump-started by the European-based SYNTAX trial, which compared coronary stenting and coronary bypass and relied on a heart team at each participating European center to run the trial. The SYNTAX spirit of cooperation led the major European cardiology and thoracic surgery societies, the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery to last year co-write a new set of guidelines for managing coronary revascularization, and endorsement of heart teams is a key feature of those guidelines. These days, in routine practice at the Thoraxcenter inRotterdam for example, a heart team meets every morning to discuss the pending coronary cases and how they’ll be managed, said heart surgeon A. Pieter Kappetein at the meeting.

Heart teams also got mentioned at the meeting as the new way that patients with ruptured aortic aneurysms are getting managed at selected U.S. sites, as endovascularists and surgeons quickly decide on the best way to treat an emergency aneurysm rupture.

Will U.S.guidelines soon appear that follow the European lead and give a formal nod to heart teams? Yes, said John D. Puskas, chief of cardiac surgery at Emory in Atlanta and a member of the joint American College of Cardiology and Society for Thoracic Surgeons guidelines-writing group that will soon issue their recommendations. “The new guidelines are embargoed, but all of the cardiologists and surgeons who wrote the U.S. guidelines read the European guidelines with interest with respect to the heart team,” he told me.

Will the concept catch on for U.S.practice, after so many years of catheterist-surgeon animosity? Dr. Puskas said yes to that too, citing the changing character of U.S.medical practice as a major factor easing the transition.

“Cardiologists and surgeons are being bought by networks and are becoming salaried. That will lower the barriers that have led to competition. I think we’ll see better collaboration in our specialties than ever before. It gets down to patient-centered decision making.”

—Mitchel Zoler (on Twitter @mitchelzoler)

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Keeping Score on the STS Risk Score

The Society of Thoracic Surgeons has a formula for estimating a patient’s risk of dying following cardiac surgery, the STS Predicted Risk of Mortality score. Some new data reported during the past 2 months suggest that the score doesn’t predict death as well as some experts thought. It looks like when it’s applied to very sick patients, it may produce an overly pessimistic estimate and predict more deaths than patients will actually experience.

"Death's Door" by William Blake; courtesy Wikimedia Commons

A patient’s mortality risk score derives from a list of 30 clinical and demographic inputs, factors like type of surgery, age, sex, hypertension, diabetes, cardiac history, vascular health, hemodynamics, etc. Based on all this, the formula spits out a patient’s probability of dying during the 30 days following the proposed surgery.

The PARTNER trial enrolled patients with severe aortic stenosis to compare a new technique of percutaneous aortic valve replacement with standard open surgical replacement. An initial report on results from the randomized portion of the study occurred last month at the annual meeting of the American College of Cardiology, and some more details on strokes and other neurologic outcomes got reported a few days ago at the American Association for Thoracic Surgery’s annual meeting in Philadelphia.

The patients entered into PARTNER were very, very sick. Their average age was about 83 years, and about 95% had the two highest grades of heart failure, New York Heart Association class III or IV. Their STS risk scores were also high, averaging about 12, which meant these patients had a 12% predicted risk of dying during the 30 days following open surgical replacement of their dysfunctional aortic valve.

These patients “were probably the highest 10% of risk on the STS score,” said Dr. D. Craig Miller, the cardiac surgeon who presented the neurologic data at the AATS meeting. “STS scores have never been validated at this extreme. Never before were enough patients [with scores this high] operated on to validate the STS score ” at this level, Dr. Miller said.

The reality was that the scores broke down. Instead of having a 12% 30-day mortality rate, the patients who underwent open surgery had about an 8% death rate. “We were pleasantly surprised by the low death rates,” at least in comparison to what the STS scores predicted, he said.

The only caveat to this good news was that the less-than-dire outcomes of some patients might have been very specific for the high-level treatment that patients received at the 26 centers that participated in this carefully structured trial. “What would be the results in the real world? That remains unanswered,” Dr. Miller said.

—Mitchel Zoler (on Twitter @mitchelzoler)

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A Conclave for a Complex Valve

Located between the left atrium and the left ventricle of the heart, the left atrioventricular valve was long ago named the “mitral” valve because it is shaped like a mitre, the tall pointed hat worn by all Roman Catholic bishops, including the Pope. When a pope dies, the College of Cardinals meets in a papal conclave to select a new pope. The word “conclave” is Latin for “with a key,” so named because the electors are supposed to be locked in seclusion and not allowed to leave until a new pope is chosen.

Photo credit M.Mazur/www.thepapalvisit.org.uk, via Flickr Creative Commons

With a nod to that history, “conclave” was the name given to the American Association for Thoracic Surgery’s first-ever meeting devoted entirely to surgery of the mitral valve. The 2011 Mitral Conclave drew more than 1,000 attendees from 66 countries to New York last week. Just as a papal conclave involves the most senior members of the church leadership, attendees at the mitral conclave included the world’s leading experts in mitral valve surgery.

But unlike a papal conclave, in which participants are required to come to a single decision, mitral conclave speakers exhibited a wide array of opinions, approaches, and surgical techniques for repairing the valve. Since the 1983 publication of a landmark article by Dr. Alain F. Carpentier titled “Cardiac Valve Surgery: The French Correction,” repair rather than replacement of the mitral valve has been the gold standard. But repair is far more complicated, program director Dr. David H. Adams told me.

“Mitral valve repair is one of the most interesting and creative operations we do in adult cardiac surgery. Since a typical mitral valve dysfunction is associated with multiple associated valve lesions, a successful repair must utilize techniques that address each of the lesions. It’s not surprising that experts have come up with different ways of repairing the same lesion.”

 Current valvular heart disease guidelines from the American College of Cardiology /American Heart Association, and the European Society of Cardiology are based largely on expert opinion rather than evidence from clinical trials. Going forward, studies will need to focus on specific mitral valve etiologic and lesion subgroups, he said.

Mitral Conclave logo courtesy of Dr. David H. Adams

 “Given the complexity of mitral valve disease and the breadth of cardiac surgery, we need specialty meetings where experts can share their experience. Here in New York for 2 days, we’ve seen every major school in the field of mitral valve repair covered. But I think the top surgeons are agreeing more than they’re disagreeing.”

When I asked Dr. Adams about the naming of the meeting as a “conclave” rather than a simple “symposium” or “conference,” he mentioned the link to the bishop’s mitre. But he added, “A ‘conclave’ is a meeting of high importance.”

–Miriam E. Tucker (on twitter @miriametucker)

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Seeing Red: Heart Disease and Women

The Red Dress Campaign has caught women’s attention regarding the very real dangers of cardiovascular disease, but a new study shows they may not be taking the message to heart.

Photo courtesy of The Heart Truth®, NHLBI, NIH

The study, presented at the recent American College of Cardiology meeting, found that the overall incidence of acute MI decreased among 315,246 patients admitted to New Jersey hospitals 1986-2007. The decrease was significant among both men and women, but was more prominent among men.

The incidence of acute MI fell from 598 to 311 per 100,000 men and from 321 to 197 per 100,000 women, according to cardiologist Dr. Liliana Cohen and her colleagues at the Robert Wood Johnson Medical School in New Brunswick, N.J. They also identified a growing gap in the rates of left heart catheterization and percutaneous coronary intervention between men and women.

The rates of catheterization increased fivefold in women and threefold in men over the 22-year study period, but the likelihood of catheterization remained lower for women. Moreover, the difference among male and female cath patients going on to receive PCI increased from 2.2% in 1986 to 9.4% in 2007.

Finally, both in-hospital and 1-year mortality remained higher among women, and failed to show a significant decrease after 2002 – the year the National Heart Lung and Blood Institute launched the Red Dress campaign.

“Although awareness of cardiovascular disease in women has increased in the general population, there has been much less translation of this into clinical practice,” Dr. Cohen told me.

This may be due to women presenting later because they doubt an MI can happen to them or that physicians still are not treating women as aggressively as they treat men, she said. It also may relate to the fact that women have more difficult cardiac anatomy, so that once they receive cardiac cath, PCI remains difficult.

Photo courtesy of The Heart Truth®, NHLBI, NIH

Dr. Cohen suggests that in its next phase, the campaign needs to continue to focus on public health awareness, but also on research into how to translate public awareness into clinical practice by focusing on physicians and into newer techniques of PCI for the smaller blood vessels in women.

Quibble if you will about the generalizability of data from a single state or the potential impact of a single PR campaign, but it’s hard to ignore these disappointing outcomes.

I once heard a bold and blistering guest lecture at a cancer meeting by Nancy Goodman Brinker, founder and CEO of Susan G. Komen for the Cure, who told several thousand — mostly male — oncologists that a survival rate topping 90% for early stage breast cancer simply wasn’t good enough.  Truer words were never spoken.

— Patrice Wendling

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