Stroke Patient Transfer Time; Death Rate After COVID

— Also in TTHealthWatch: alcohol consumption after a cancer diagnosis


TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.

This week's topics include alcohol use among cancer survivors, death after COVID hospitalization and the rate of long COVID, forgoing radiation after breast cancer surgery, and hospital transfer time for stroke patients.

Program notes:

0:40 Transfer of people with strokes

1:40 Older, female, African American longer time

2:40 EMS job

3:00 Safely forgoing radiation in breast cancer treatment

4:00 Luminal A subtype

5:00 Low recurrence seen

6:05 Death rate after COVID

7:05 A fourth readmitted

8:07 Why is long COVID down?

8:40 Alcohol consumption among those with a cancer diagnosis

9:40 Binge and hazardous drinking

10:40 77% non-Hispanic white

11:36 End


Elizabeth: Are adults with a cancer diagnosis drinking alcohol?

Rick: Long COVID symptoms and death after COVID infection.

Elizabeth: When can radiation be safely forgone in breast cancer treatment?

Rick: And the timely transfer of people with stroke to the appropriate hospital.

Elizabeth: That's what we're talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I'm Elizabeth Tracey, a Baltimore-based medical journalist.

Rick: And I'm Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I'm also the dean of the Paul L. Foster School of Medicine.

Elizabeth: Rick, I'm pretty passionate about this notion of getting people who have had a stroke to the right place to receive treatment. I'm hoping that you're okay with starting with that one.

Rick: Absolutely. This is in JAMA and it looks at what's called door-in-door-out times for inter-hospital transfer of patients with stroke. Patients have better outcomes when they receive care at a regional stroke center. When a patient presents to a hospital that doesn't have all the facilities, you want to get them to a reasonable stroke center as quickly as possible. From the time they hit the hospital door at the local hospital to when they get out the door towards the other center should be less than 120 minutes.

This study looked at over 108,000, almost 109,000 patients, who were transferred from over 1,900 different hospitals here in the United States. Of those, about two-thirds had an acute ischemic stroke. The other third had a hemorrhagic stroke. Overall, the median time was 174 minutes. Only about 27% met the criteria -- that is, had the transfer done within 120 minutes.

What things were associated with a longer time were an older individual, being female, being African American or Hispanic. What was associated with a shorter time was if the emergency medicine system personnel notified the hospital ahead of time, went to the patient's house, or wherever they were, thought that there might be a stroke, called ahead to the hospital and said, "Hey, we think we have a stroke." Then the hospital was better at getting them out in 120 minutes. But by the way, the majority of individuals aren't brought in by the EMS team. They are brought in by a local car. This tells us we still have some work to do.

Elizabeth: That was very circumspect there at the end. I would be a little bit more pejorative rating performance. I would also note that there are some people who are really quite a long distance from a regional stroke center.

Rick: This was door-in-door-out and so you're right. If there is a long transport time, that also adds to the delay of treatment. Sometimes a little bit of transportation outside the hospital isn't easy either because they may not have beds.

Elizabeth: It's also sounding to me like this is yet one more thing that we're going to drop into the lap of EMS. Because just like the initiation of different kinds of medications and assessments in the field, it sounds like we're going to be saying, "Hey, guys, can you call ahead?"

Rick: That is one area that we can certainly impact care, but as I mentioned, a third of these individuals didn't arrive by ambulance. They arrived by private vehicles. We still need to work on that group as well.

Elizabeth: Let's turn from here to the New England Journal of Medicine. I said, when can radiation be safely forgone in terms of breast cancer treatment? I would just say that I do a monthly podcast with the head of the Cancer Center at Hopkins and one trend that I see a lot emerging is this notion of modifying radiation treatment with regard to its utility in cancer treatment as a whole. In this case, they were taking a look at, should we use radiotherapy after breast-conserving surgery to reduce the risk of local recurrence of breast cancer? I became educated by this paper because I knew that the algorithm with regard to characterization of breast cancer is actually pretty complicated. This one shows me that it's even more complicated than I knew about.

They did a prospective cohort study looking at women who were at least 55 years of age, had undergone breast-conserving surgery for T1 and 0, small tumor-sized, grade 1 or 2 -- keep going -- luminal A-subtype breast cancer. That is defined as an estrogen receptor positivity of greater than or equal to 1%, progesterone receptor positivity of greater than 20%, negative human epidermal growth factor receptor 2 (HER 2), and a new one for me, the Ki-67 index of less than or equal to 13.25%. That's an immunohistochemical analysis, this Ki-67. What they were looking at was, if we forego radiation in these women, what is our local recurrence in the ipsilateral breast?

After 5 years of enrollment, recurrence was reported in overall 2.3% of the patients. Breast cancer occurred in the contralateral breast in 1.9% of the patients and recurrence of any type in 2.7%. The authors conclude that the incidence of this local recurrence at 5 years is low in this circumstance of omitting radiotherapy, which, of course, has its own set of consequences.

Rick: Well, Elizabeth, you used a couple of medical terms for people that may not be familiar. Ipsilateral breast means the same breast as the initial cancer and contralateral means the other breast. You're absolutely right. We're trying to identify women that are going to have a low risk of recurrence and therefore they're unlikely to benefit from radiation therapy. They'll suffer the side effects, but really not benefit from it.

There were a couple things they used: age over 50, a small tumor, and no metastasis. The other four markers -- three of them we routinely measure: estrogen, progesterone, and HER2. As you mentioned, there is one other cell marker called Ki-67 and that's the only additional one that we can assess who is at low risk and avoid the side effects. I actually think knowing that we can avoid radiation therapy in these women is a very positive finding.

Elizabeth: Me too and I think we're going to further characterize lots of different cancers in this way so that we can avoid the radiation if that's possible.

Rick: Agreed.

Elizabeth: Okay. Now you're going to treat two of them about COVID.

Rick: We're going to talk about death rate after COVID and then we're going to talk about long COVID symptoms. Let's talk first about the death rate. What happens after people get discharged from the hospital when they've had a viral infection and there is still a risk of having a mortal event? To put it in perspective, let's compare it to another viral infection. Let's compare it to the flu, for example.

They looked at almost 900,000 Medicare patients who were discharged from the hospital after either a COVID infection and they compared it with 56,000 people that were discharged from the hospital with the flu. In the first 6 months, the risk of death after being successfully treated was almost 20%. In fact, it was about twice as high than it was with the flu. They looked at 30 days, 60 days, and 6 months and at all points the risk of dying after COVID infection was 2 to 3 fold higher than it was following the flu. Most of that death occurred in the first 30 days. Then they also looked at the hospital readmissions and determined that almost a fourth of those individuals got readmitted to the hospital over the course of 180 days.

Elizabeth: Let's just mention that that's in the BMJ. What about underlying comorbidities?

Rick: What I can say is they matched the patients with flu and COVID, so they had just about the same comorbidities. The readmission rate was the same at 180 days. As you know, they have subsequent infections. They have cardiovascular disease. They have sepsis, pneumonia, and other issues.

Elizabeth: What does Morbidity and Mortality Weekly Report tell us about this?

Rick: Okay. Well, it did not look at the death rate, but it looked at the long COVID rate. They looked over a 1-year period between June of 2022 and June of 2023. There is still a significant number of individuals that have long COVID symptoms, but that prevalence decreased from about 7.5% to 6% just among the overall U.S. population.

Here is what I was surprised at Elizabeth is that the individuals that were most likely to suffer long COVID are people in the middle age. Individuals less than 18 and over 60 are less likely to have long COVID symptoms. Even though the rate decreased somewhat, those that experienced a decline were those under 60 years of age.

Why is the long COVID rate down? Well, because people have been exposed to COVID before, there are probably less virulent strains, and the vaccination rates. We still haven't completely done away with long COVID symptoms.

Elizabeth: Yet one more reason to pay attention to these recommendations that probably all of us need to get a booster in the fall and there is one that's actually matched to the strain that's predominant.

Rick: That's right. There is a new strain out. About 20% of the new COVID infections are a new strain and this vaccine will be available in September.

Elizabeth: Okay. Let's turn to our final one, which is in JAMA Network Open. This was a little bit of a surprise to me. This was looking at alcohol consumption among adults with a cancer diagnosis in the U.S. All of Us Research Program. That's the one that was undertaken by the NIH.

They looked at data from May in 2018 to January of 2022. They were able to identify 15,000+ participants who reported a cancer diagnosis and 1,839 among a subset who underwent treatment within the past year of the baseline survey.

They found that among these 11,800+ cancer survivors, almost 78% were current drinkers; 13% of those folks exceeded moderate drinking, just shy of 24% -- 1 in 5 -- binge drinking, and 38% in hazardous drinking. They defined those all. Moderate is greater than or equal to two drinks, binge greater than or equal to 6 on a single occasion, and hazardous using the criteria called AUDIT-C, which is a score greater than or equal to 3 for women or 4 for men. I think it's a little bit concerning, especially because there are some cancers that are clearly associated with alcohol use.

Rick: Yeah. Think about it for second. In the U.S., we have over 18 million cancer survivors right now. Besides getting treated, they want to say, "What can I do to help prevent cancer in the future?"

This is a modifiable risk. Alcohol is associated with oral cavity cancer, pharyngeal cancer, cancer of the larynx, esophagus, colorectum, liver, and female breast cancer as well. We know that people that continue drinking have worse outcomes. During treatment, they have decreased effectiveness of the chemotherapy. They are more likely to have recurrences. The fact that 40% of individuals that are cancer survivors have hazardous drinking habits means we need to get the message out to them.

Elizabeth: I would also just note that almost 77% of these folks were non-Hispanic White in this study. Almost 76% were diagnosed when the patient was between 18 and 64 years of age, young people who were being diagnosed with these cancers.

Rick: Elizabeth, even though this included a large number of Caucasians and the Hispanics were less likely to drink after a cancer diagnosis than Caucasians, they were more likely to be binge drinkers or hazardous. The message is if you can avoid alcohol, do so. If you do drink, please limit it for women 1 drink or less per day, and for men, no more than 1 or 2 per day.

Elizabeth: On that note then, that's a look at this week's medical headlines from Texas Tech. I'm Elizabeth Tracey.

Rick: And I'm Rick Lange. Y'all listen up and make healthy choices.