Letters
lenged the systematic review process, it did not detract from the methodological rigor. Our group systematically collected literature in the widely recognized categories of CAT and both aggregated (main review) and decomposed (supplementary material) the CAT modality data to provide an “expressive” and “creative” arts approach, respectively. In the commentary by Bradt and Goodill, 1 we are troubled by their confusion related to the moderator analyses and distraught by implications of lack of transparency. Many articles included in the analyses lacked adequate information regarding intervention features especially related to intervention implementation by a certified CAT therapist. However, the articles still could be theoretically and practically divided into 2 categories: intervention sessions directly led and monitored by a CAT therapist or interventions developed by a CAT therapist but not directly led or monitored by a CAT therapist. These definitions were labeled “creative arts therapist” and “no creative arts therapist,” respectively, and were referenced in the review and presented in eTable 1 of our article.5 These definitions were used throughout the analyses and guided interpretation of results. It is unclear how these definitions contradict the meta-regression results or decomposition of the 2 therapeutic monitoring categories found in eTable 3.5 It is difficult to publish all data from a meta-analysis. We applaud JAMA Internal Medicine for allowing us to produce as much supporting data as they did through the published review and online supplements. However, journal space limitations and feasibility in presenting data on 10 separate analyses (5 outcomes × 2 time points) demanded being selective in how best to present those data to the readership. We apologize if we were not able to address a specific concern with the data presented in the main review but welcome the opportunity to share data with any and all researchers. Timothy W. Puetz, PhD, MPH Christopher A. Morley, MPH Matthew P. Herring, PhD Author Affiliations: Office of the Director, National Institutes of Health, Bethesda, Maryland (Puetz); The ArtReach Foundation Inc, Atlanta, Georgia (Morley); Department of Epidemiology, University of Alabama at Birmingham (Herring). Corresponding Author: Timothy W. Puetz, PhD, MPH, Office of the Director, National Institutes of Health, 9000 Rockville Pike, Bethesda, MD 20802 ([email protected]).
Treatment of Nonmelanoma Skin Cancer To the Editor This letter is in response to the recent article by Linos et al.1 As a dermatologic surgeon whose practice is limited to the treatment of nonmelanoma skin cancer (NMSC), a question comes up almost daily from care providers of elderly patients: “My mom is 87, do we really need to treat this?” As the authors mention, although most NMSCs are not life threatening, those of us who manage these diseases are witness to the deep destruction and profound impact on quality of life that they can cause if left untreated. Suspected lesions should always be biopsied because more serious diagnoses such as melanoma or Merkel cell carcinoma are real possibilities, and patients, no matter how old, should be made aware of these conditions. The study does an excellent job of solidifying the safety and efficacy of existing treatments for NMSC. With respect to complications, only 15% of patients responded. These “complications” included minor, temporary symptoms such as numbness and itching, and were not evaluated by the treating physician. There is no reference to complications such as bleeding or infection, presumably because the incidence of these events was low as has been demonstrated previously.2 Statistics are only statistics, and it is impossible for anyone to predict which of our limited–life expectancy patients will be among the 23% who are still alive at 10 years. In that period, a basal cell carcinoma will continue to grow, destroy vital structures, bleed, become infected and ruin the last years of a person’s life. A squamous cell carcinoma can metastasize and become fatal. As dermatologists, we have several options to treat NMSC. Mohs micrographic surgery is a proven approach, particularly for tumors located on the head and neck, with cure rates approaching 100%. While the authors state that this procedure can take 3 hours, the majority of this time is spent with the patient sleeping or sitting in a chair. Lastly, no mention was made as to the fate of those patients who did not undergo treatment. How many of them are regretting their decision? In my office, and those of my colleagues, discussion frequently revolves around the best treatment for a given patient; however, with the safety and efficacy of existing approaches and potential morbitity of these tumors if left untreated, the decision is rarely made to leave a tumor untreated—for cancers only get bigger. Sherrif F. Ibrahim, MD, PhD
Conflict of Interest Disclosures: None reported. Disclaimer: The opinions expressed in this letter are those of the authors and do not necessarily represent the views of the National Institutes of Health.
Author Affiliation: Division of Dermatologic Surgery, University of Rochester Medical Center, Rochester, New York.
1. Bradt J, Goodill S. Creative arts therapies defined. JAMA Intern Med. 2013;173(11):969-970.
Corresponding Author: Sherrif F. Ibrahim, MD, PhD, Division of Dermatologic Surgery, University of Rochester Medical Center, 400 Red Creek Dr, Ste 200, Rochester, NY 14623 ([email protected]).
2. Malchiodi CA. Expressive Therapies. New York, NY: Guilford Press; 2005. 3. McNiff S. Integrating the Arts in Therapy: History, Theory, and Practice. Springfield, IL: Charles C. Thomas Publisher, LTD; 2009.
Conflict of Interest Disclosures: None reported.
4. Rubin JA. Introduction to Art Therapy: Sources & Resources. New York, NY: Taylor & Francis; 2010.
1. Linos E, Parvataneni R, Stuart SE, Boscardin WJ, Landefeld CS, Chren MM. Treatment of nonfatal conditions at the end of life: nonmelanoma skin cancer. JAMA Intern Med. 2013;173(11):1006-1012.
5. Puetz TW, Morley CA, Herring MP. Effects of creative arts therapies on psychological symptoms and quality of life in patients with cancer. JAMA Intern Med. 2013;173(11):960-969.
2. Merritt BG, Lee NY, Brodland DG, Zitelli JA, Cook J. The safety of Mohs surgery: a prospective multicenter cohort study. J Am Acad Dermatol. 2012;67(6):1302-1309.
jamainternalmedicine.com
JAMA Internal Medicine December 9/23, 2013 Volume 173, Number 22
Copyright 2013 American Medical Association. All rights reserved.
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lenged the systematic review process, it did not detract from the methodological rigor. Our group systematically collected literature in the widely recognized categories of CAT and both aggregated (main review) and decomposed (supplementary material) the CAT modality data to provide an “expressive” and “creative” arts approach, respectively. In the commentary by Bradt and Goodill, 1 we are troubled by their confusion related to the moderator analyses and distraught by implications of lack of transparency. Many articles included in the analyses lacked adequate information regarding intervention features especially related to intervention implementation by a certified CAT therapist. However, the articles still could be theoretically and practically divided into 2 categories: intervention sessions directly led and monitored by a CAT therapist or interventions developed by a CAT therapist but not directly led or monitored by a CAT therapist. These definitions were labeled “creative arts therapist” and “no creative arts therapist,” respectively, and were referenced in the review and presented in eTable 1 of our article.5 These definitions were used throughout the analyses and guided interpretation of results. It is unclear how these definitions contradict the meta-regression results or decomposition of the 2 therapeutic monitoring categories found in eTable 3.5 It is difficult to publish all data from a meta-analysis. We applaud JAMA Internal Medicine for allowing us to produce as much supporting data as they did through the published review and online supplements. However, journal space limitations and feasibility in presenting data on 10 separate analyses (5 outcomes × 2 time points) demanded being selective in how best to present those data to the readership. We apologize if we were not able to address a specific concern with the data presented in the main review but welcome the opportunity to share data with any and all researchers. Timothy W. Puetz, PhD, MPH Christopher A. Morley, MPH Matthew P. Herring, PhD Author Affiliations: Office of the Director, National Institutes of Health, Bethesda, Maryland (Puetz); The ArtReach Foundation Inc, Atlanta, Georgia (Morley); Department of Epidemiology, University of Alabama at Birmingham (Herring). Corresponding Author: Timothy W. Puetz, PhD, MPH, Office of the Director, National Institutes of Health, 9000 Rockville Pike, Bethesda, MD 20802 ([email protected]).
Treatment of Nonmelanoma Skin Cancer To the Editor This letter is in response to the recent article by Linos et al.1 As a dermatologic surgeon whose practice is limited to the treatment of nonmelanoma skin cancer (NMSC), a question comes up almost daily from care providers of elderly patients: “My mom is 87, do we really need to treat this?” As the authors mention, although most NMSCs are not life threatening, those of us who manage these diseases are witness to the deep destruction and profound impact on quality of life that they can cause if left untreated. Suspected lesions should always be biopsied because more serious diagnoses such as melanoma or Merkel cell carcinoma are real possibilities, and patients, no matter how old, should be made aware of these conditions. The study does an excellent job of solidifying the safety and efficacy of existing treatments for NMSC. With respect to complications, only 15% of patients responded. These “complications” included minor, temporary symptoms such as numbness and itching, and were not evaluated by the treating physician. There is no reference to complications such as bleeding or infection, presumably because the incidence of these events was low as has been demonstrated previously.2 Statistics are only statistics, and it is impossible for anyone to predict which of our limited–life expectancy patients will be among the 23% who are still alive at 10 years. In that period, a basal cell carcinoma will continue to grow, destroy vital structures, bleed, become infected and ruin the last years of a person’s life. A squamous cell carcinoma can metastasize and become fatal. As dermatologists, we have several options to treat NMSC. Mohs micrographic surgery is a proven approach, particularly for tumors located on the head and neck, with cure rates approaching 100%. While the authors state that this procedure can take 3 hours, the majority of this time is spent with the patient sleeping or sitting in a chair. Lastly, no mention was made as to the fate of those patients who did not undergo treatment. How many of them are regretting their decision? In my office, and those of my colleagues, discussion frequently revolves around the best treatment for a given patient; however, with the safety and efficacy of existing approaches and potential morbitity of these tumors if left untreated, the decision is rarely made to leave a tumor untreated—for cancers only get bigger. Sherrif F. Ibrahim, MD, PhD
Conflict of Interest Disclosures: None reported. Disclaimer: The opinions expressed in this letter are those of the authors and do not necessarily represent the views of the National Institutes of Health.
Author Affiliation: Division of Dermatologic Surgery, University of Rochester Medical Center, Rochester, New York.
1. Bradt J, Goodill S. Creative arts therapies defined. JAMA Intern Med. 2013;173(11):969-970.
Corresponding Author: Sherrif F. Ibrahim, MD, PhD, Division of Dermatologic Surgery, University of Rochester Medical Center, 400 Red Creek Dr, Ste 200, Rochester, NY 14623 ([email protected]).
2. Malchiodi CA. Expressive Therapies. New York, NY: Guilford Press; 2005. 3. McNiff S. Integrating the Arts in Therapy: History, Theory, and Practice. Springfield, IL: Charles C. Thomas Publisher, LTD; 2009.
Conflict of Interest Disclosures: None reported.
4. Rubin JA. Introduction to Art Therapy: Sources & Resources. New York, NY: Taylor & Francis; 2010.
1. Linos E, Parvataneni R, Stuart SE, Boscardin WJ, Landefeld CS, Chren MM. Treatment of nonfatal conditions at the end of life: nonmelanoma skin cancer. JAMA Intern Med. 2013;173(11):1006-1012.
5. Puetz TW, Morley CA, Herring MP. Effects of creative arts therapies on psychological symptoms and quality of life in patients with cancer. JAMA Intern Med. 2013;173(11):960-969.
2. Merritt BG, Lee NY, Brodland DG, Zitelli JA, Cook J. The safety of Mohs surgery: a prospective multicenter cohort study. J Am Acad Dermatol. 2012;67(6):1302-1309.
jamainternalmedicine.com
JAMA Internal Medicine December 9/23, 2013 Volume 173, Number 22
Copyright 2013 American Medical Association. All rights reserved.
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2095
