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By John Pastor

GAINESVILLE, Fla. -The allure of a new brain surgery technique to relieve the stiffness and shaking caused by Parkinson's disease may lead to unnecessary operations, University of Florida researchers say, but a new screening tool they developed could prevent needless procedures.

Researchers and clinicians affiliated with UF's McKnight Brain Institute described in a recent issue of Neurology the first standardized method to help doctors triage patients who have the best chance to be helped by a promising treatment called deep brain stimulation.

"We all know this can be a dramatic therapy for patients, but we want the right type of patients to get the surgery because they are the only ones who are going to do well with it," said Michael Okun, M.D., co-director of the UF Movement Disorders Center and a neurologist with the College of Medicine. "When you have so many centers doing the operation so rapidly after FDA approval, then you're going to end up with a lot of patients who might not do well with the therapy or who could do worse."

Since the Food and Drug Administration approved the treatment in 2002, about 25,000 patients have received deep brain stimulation to treat tremors and movement problems associated with Parkinson's disease. About a half million Americans have Parkinson's disease, and 50,000 new cases are diagnosed each year, according to the National Institute for Neurological Disorders and Stroke.

The surgery involves the implantation of small electrodes within the thalamus, subthalamus or globus pallidus, all structures deep in the brain. But the surgery only relieves Parkinson's symptoms in a handful of patients who meet an array of requirements, among them good response to the drug levodopa, commonly prescribed to treat Parkinson's disease. Of the first 174 patients referred to the UF Movement Disorders Center for evaluation for deep brain stimulation surgery, only eight would have benefited from the surgery, Okun said.

"Patients have come into our practice who have already received implants who would have never received this therapy if they had been screened properly," Okun said. "Some of them even had diagnoses other than Parkinson's disease. We realized all the doctors sending patients our way were trying to get the best possible care for their patients, but they didn't have the information to evaluate candidates."

As a result, Okun, in collaboration with UF Movement Disorder Center co-directors Kelly Foote, M.D., a neurosurgeon, and Hubert Fernandez, M.D., a neurologist, developed the Florida Surgical Questionnaire for Parkinson's Disease, a five-section triage tool to help general neurologists and health-care professionals who see the vast majority of patients with Parkinson-like symptoms better determine which may benefit from the surgery.

Practitioners can use the assessment to confirm the initial diagnosis of Parkinson's disease and take into account patient characteristics, information about the patient's response to medications and factors that would make surgery inadvisable. It doesn't replace a full interdisciplinary medical examination for Parkinson's disease, Okun says, but it is a starting point.

And there's hope for those whose first-time assessments may not indicate they are appropriate candidates to receive the surgery.

"Maybe a medical optimization score isn't high enough the first time, but a patient can receive therapy so that in six months, or a year, or even later they become a candidate for the surgery," Okun said.

In addition to the patients evaluated for deep brain stimulation procedures at UF, the questionnaire helped accurately pinpoint surgery candidates in a retrospective review of 55 patients at movement disorder medical centers at the University of Kansas and Brown University, and at Beth Israel Deaconess Medical Center, a teaching hospital of Harvard Medical School.

Good candidates for surgery tend to be without any cognitive problems or confusion related to Parkinson's, under 80 and healthy - aside from their Parkinson's symptoms. Generally, their disabling tremors cannot be controlled by medication, but they respond to levodopa, a drug that stimulates the production of the chemical
messenger dopamine in the brain. Levodopa may cause side effects in some patients called on-off fluctuations, and these patients tend to be good candidates, Okun said.

"Ten times as many people who think they want this surgery won't be helped by it," said James Halsey, M.D., a clinical professor of neurology at the University of Alabama at Birmingham School of Medicine.

"This is a useful screening tool for physicians who want to refer patients for deep brain stimulation. Physicians all want their helpless patients to be helped, but this treatment works well for some, doesn't work for many and hurts a few. It (assessment) will also help patients decide whether it's worth it to sit through a waiting list of four to six months, then to travel 200 or 2,000 miles, only to be disappointed."

UF researchers discover racial disparities in oral cancer treatment and survival

By Lindy McCollum-Brounley GAINESVILLE, Fla. - Black men battling oral and pharyngeal cancer in Florida don't live as long as their white counterparts and are less likely to undergo the surgery necessary to optimally treat the disease, a University of Florida study reveals. "What we found is that African-American males in Florida died 44 percent earlier than did white males, and were also more likely to receive only radiation therapy and not surgery than were whites," said Scott Tomar, D.M.D., Dr. P.H., an associate professor in the division of public health services and research at UF's College of Dentistry. The study, published in this month's edition of Cancer Causes and Control, is one of the nation's first state-specific reports of racial disparities in treatment and survival of the deadly disease. On average, black men in the study died a year sooner after diagnosis than white men - a finding consistent with national data showing that white men are twice as likely as black men to survive five years after diagnosis, Tomar said. "Our study is unique in that it looks at state-specific data for oral and pharyngeal cancer treatment and mortality," Tomar said. "This eliminates a great amount of regional variation in the data. Previous studies that have attempted to look at issues of racial disparities have used samples of people from around the country, and they mixed geographic differences with racial differences, making it difficult to understand what might be happening differently for blacks than for whites." Nearly 30,000 people are diagnosed with oral cancer in the United States every year, according to the National Cancer Institute. Although the number of cancer cases in general has steadily declined during the past 10 years, black men historically have been disproportionately represented in the number of new cases, and their survival rates are dismal compared with those of white men and of women of both races. Florida was of particular interest to Tomar because of its disproportionate burden of oral and pharyngeal cancers - it has one of the highest incidence rates in the country and the fifth highest mortality rate. So high, in fact, that Floridians suffer more than double the number of deaths caused by oral and pharyngeal cancers than that of the top four states combined, Tomar said. "Clearly, oral cancer is a major issue in this state," Tomar said. UF researchers wanted to know how Florida stacked up on the issue of racial disparities in treatment and survival of oral cancers. To find out, they examined data gathered by the Florida Cancer Data System on oral and pharyngeal cancer diagnosis, treatment and mortality for more than 27,000 Floridians between 1988 and 1998. The researchers compared data only on black and white patients; individuals of other races were excluded from the study sample. The study's final sample size of 21,481 people included 19,331 white men and women and 2,150 black men and women. Analysis of the data revealed twice as many cases of oral and pharyngeal cancers diagnosed in men as in women. Most occurred in people 51 to 74 with the median age was 65 - although blacks were significantly younger and poorer than whites at the time of diagnosis. Anatomic location of the cancer differed greatly between whites and blacks; more than half of the black patients were diagnosed with aggressive pharyngeal cancers compared with about 39 percent of whites. The study's most compelling evidence: The cancers among blacks were twice as likely to have spread by the time of diagnosis. However, regardless of tumor location or whether the cancer had metastasized, blacks consistently were less likely to undergo surgery than were whites. Differences in survival rates were even more striking, with blacks having a median survival time of 360 days compared with 649 days for whites. Although the incidence rate for both black and white men became nearly equal over the study's 10-year period, the disparity in survival time did not significantly change. Although the study did not associate cancer incidence with causes, Tomar said established risk factors for the development of oral and pharyngeal cancers include tobacco and alcohol use. National Cancer Institute statistics show more than 80 percent of all oral cancers occur in cigarette smokers. Add alcohol use into the mix and the risk for oral cancer increases to 15 times that of non-users of tobacco and alcohol. "As far as the differences in incidence between black and white males, there is some evidence that it may be due to difference in these behavioral risk factors like use of tobacco and alcohol," Tomar said. "On the other hand, the patterns of use of some of these substances, nationally as well as here in Florida, really wouldn't explain the huge differences in incidence seen historically." Alice M. Horowitz, an education specialist with the National Institutes of Health's National Institute of Dental and Craniofacial Research, said, "Educating the public about the risk factors of oral cancers and teaching them to ask for oral cancer exams is key to the prevention and early diagnosis of oral and pharyngeal cancers. Clearly, we need to do a better job of training health-care providers of all types to do oral examinations, and we need the public to become educated enough to demand them." Tomar said he agrees that public education would go a long way in the fight against oral and pharyngeal cancers because early detection can result in cure rates as high as 90 percent. However, he said he also wants to determine why Floridians experience such enormous racial differences in treatment and survival regardless of how early or at what stage the oral cancer is detected. "There is this difference in how people are treated and that contributes to the huge racial disparity in survival. Unfortunately, we just don't know why there are those differences." Tomar said. "Our next line of investigation is to begin to tease out some of the answers."