Friday, April 18, 2014

Elegant: Reconstructing lineage hierarchies of the distal lung epithelium using single-cell RNA-seq

 2014 Apr 13. doi: 10.1038/nature13173. [Epub ahead of print]

Reconstructing lineage hierarchies of the distal lung epithelium using single-cell RNA-seq.

Author information

  • 11] Departments of Bioengineering and Applied Physics, Stanford University School of Medicine and Howard Hughes Medical Institute, Stanford, California 94305, USA [2].
  • 21] Department of Biochemistry, Stanford University School of Medicine and Howard Hughes Medical Institute, Stanford, California 94305, USA [2].
  • 3Departments of Bioengineering and Applied Physics, Stanford University School of Medicine and Howard Hughes Medical Institute, Stanford, California 94305, USA.
  • 4Department of Biochemistry, Stanford University School of Medicine and Howard Hughes Medical Institute, Stanford, California 94305, USA.
  • 5Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, California 94305, USA.

Abstract

The mammalian lung is a highly branched network in which the distal regions of the bronchial tree transform during development into a densely packed honeycomb of alveolar air sacs that mediate gas exchange. Although this transformation has been studied by marker expression analysis and fate-mapping, the mechanisms that control the progression of lung progenitors along distinct lineages into mature alveolar cell types are still incompletely known, in part because of the limited number of lineage markers and the effects of ensemble averaging in conventional transcriptome analysis experiments on cell populations. Here we show that single-cell transcriptome analysis circumvents these problems and enables direct measurement of the various cell types and hierarchies in the developing lung. We used microfluidic single-cell RNA sequencing (RNA-seq) on 198 individual cells at four different stages encompassing alveolar differentiation to measure the transcriptional states which define the developmental and cellular hierarchy of the distal mouse lung epithelium. We empirically classified cells into distinct groups by using an unbiased genome-wide approach that did not require a priori knowledge of the underlying cell types or the previous purification of cell populations. The results confirmed the basic outlines of the classical model of epithelial cell-type diversity in the distal lung and led to the discovery of many previously unknown cell-type markers, including transcriptional regulators that discriminate between the different populations. We reconstructed the molecular steps during maturation of bipotential progenitors along both alveolar lineages and elucidated the full life cycle of the alveolar type 2 cell lineage. This single-cell genomics approach is applicable to any developing or mature tissue to robustly delineate molecularly distinct cell types, define progenitors and lineage hierarchies, and identify lineage-specific regulatory factors.

The "CSI" Effect

The CSI Effect: Science ‘As Seen on TV’



"Many medical and medico-legal shows also utilize technology far beyond what is used today—call it creative license. TV investigators receive DNA and lab results within hours, when in reality such things take weeks to months to run. An official autopsy report, complete with toxicology and histology, takes months to complete."

Does Higher Education Actually Prepare You For Your Career?

Does Higher Education Actually Prepare You For Your Career? Depends

Nannystate: Lawmakers consider proposal to ban whole milk at daycares ("They would not be given whole milk unless it was medically required.")

Lawmakers consider proposal to ban whole milk at daycares


If lawmakers have their way, children 2 years old and older would be switched to 1 or 2 percent milk at daycares across Connecticut. They would not be given whole milk unless it was medically required.

From UCSD: The Violent True Believer as a "Lone Wolf" - Psychoanalytic Perspectives on Terrorism

 2014 Apr 2. doi: 10.1002/bsl.2109. [Epub ahead of print]

The Violent True Believer as a "Lone Wolf" - Psychoanalytic Perspectives on Terrorism.

Author information

  • 1Clinical Professor of Psychiatry, University of California, San Diego, School of Medicine; Faculty, San Diego Psychoanalytic Institute; Fellow of the American Academy of Forensic Sciences.

Abstract

The existing research on lone wolf terrorists and case experience are reviewed and interpreted through the lens of psychoanalytic theory. A number of characteristics of the lone wolf are enumerated: a personal grievance and moral outrage; the framing of an ideology; failure to affiliate with an extremist group; dependence on a virtual community found on the Internet; the thwarting of occupational goals; radicalization fueled by changes in thinking and emotion - including cognitive rigidity, clandestine excitement, contempt, and disgust - regardless of the particular ideology; the failure of sexual pair bonding and the sexualization of violence; the nexus of psychopathology and ideology; greater creativity and innovation than terrorist groups; and predatory violence sanctioned by moral (superego) authority. A concluding psychoanalytic formulation is offered. 

From Stanford U: Characterizing the Relationship Between Free Drug Samples and Prescription Patterns for Acne Vulgaris and Rosacea

 2014 Apr 16. doi: 10.1001/jamadermatol.2013.9715. [Epub ahead of print]

Characterizing the Relationship Between Free Drug Samples and Prescription Patterns for Acne Vulgaris and Rosacea.

Author information

  • 1Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California.
  • 2Stanford Prevention Research Center, Program on Prevention Outcomes and Practices, Stanford University School of Medicine, Stanford, California.
  • 3Department of Dermatology and Pediatrics, Stanford University School of Medicine, Stanford, California.

Abstract

IMPORTANCE Describing the relationship between the availability of free prescription drug samples and dermatologists' prescribing patterns on a national scale can help inform policy guidelines on the use of free samples in a physician's office. 
OBJECTIVES To investigate the relationships between free drug samples and dermatologists' local and national prescribing patterns and between the availability of free drug samples and prescription costs. 
DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study investigating prescribing practices for acne, a common dermatologic condition for which free samples are often available. The settings were, first, the offices of nationally representative dermatologists from the National Disease and Therapeutic Index (an IMS Health Incorporated database) and, second, an academic medical center clinic without samples. Participants were ambulatory patients who received a prescription from a dermatologist for a primary initial diagnosis of acne vulgaris or rosacea in 2010. 
MAIN OUTCOMES AND MEASURES National trends in dermatologist prescribing patterns, the degree of correlation between the availability of free samples and the prescribing of brand-name medications, and the mean cost of acne medications prescribed per office visit nationally and at an academic medical center without samples. 
RESULTS On a national level, the provision of samples with a prescription by dermatologists has been increasing over time, and this increase is correlated (r = 0.92) with the use of the branded generic drugs promoted by these samples. Branded and branded generic drugs comprised most of the prescriptions written nationally (79%), while they represented only 17% at an academic medical center clinic without samples. Because of the increased use of branded and branded generic drugs, the national mean total retail cost of prescriptions at an office visit for acne was conservatively estimated to be 2 times higher (approximately $465 nationally vs $200 at an academic medical center without samples). 
CONCLUSIONS AND RELEVANCE Free drug samples can alter the prescribing habits of physicians away from the use of less expensive generic medications. The benefits of free samples in dermatology must be weighed against potential negative effects on prescribing behavior and prescription costs.

The Politics of Prostate Cancer Screening

 2014 May;41(2):249-255. doi: 10.1016/j.ucl.2014.01.004. Epub 2014 Feb 19.

The Politics of Prostate Cancer Screening.

Author information

  • 1Department of Urologic Surgery, Vanderbilt University, 2525 West End Avenue, Nashville, TN, USA.
  • 2Department of Urologic Surgery, VA Tennessee Valley Geriatric Research, Education, and Clinical Center (GRECC), Vanderbilt University, 2525 West End Avenue, Nashville, TN, USA; Center for Surgical Quality and Outcomes Research, Vanderbilt University, 2525 West End Avenue, Suite 1200, Nashville, TN 37203-1738, USA. Electronic address: david.penson@vanderbilt.edu.

Abstract

The controversial recent recommendation by the United States Preventive Services Task Force (USPSTF) against prostate-specific antigen (PSA)screening for early-stage prostate cancer has caused much debate. Whereas USPSTF recommendations against routine screening mammography in younger women resulted in fierce public outcry and eventual alteration in the language of the recommendation, the same public and political response has not been seen with PSA screening for prostate cancer. It is of paramount importance to ensure improved efficiency and transparency of the USPSTF recommendation process, and resolution of concerns with the current USPSTF recommendation against PSA screening for all ages.

Health promotion: an ethical analysis

 2014 Apr;25(1):19-24. doi: 10.1071/HE13074.

Health promotion: an ethical analysis.

Abstract

Thinking and practising ethically requires reasoning systematically about the right thing to do. Health promotion ethics - a form of applied ethics - includes analysis of health promotion practice and how this can be ethically justified. Existing frameworks can assist in such evaluation. These acknowledge the moral value of delivering benefits. But benefits need to be weighed against burdens, harms or wrongs, and these should be minimised: they include invading privacy, breaking confidentiality, restraining liberty, undermining self-determination or people's own values, or perpetuating injustice. Thinking about the ethics of health promotion also means recognising health promotion as a normative ideal: a vision of the good society. This ideal society values health, sees citizens as active and includes them in decisions that affect them, and makes the state responsible for providing all of its citizens, no matter how advantaged or disadvantaged, with the conditions and resources they need to be healthy. Ethicists writing about health promotion have focused on this relationship between the citizen and the state. Comparing existing frameworks, theories and the expressed values of practitioners themselves, we can see common patterns. All oppose pursuing an instrumental, individualistic, health-at-all-costs vision of health promotion. And all defend the moral significance of just processes: those that engage with citizens in a transparent, inclusive and open way. In recent years, some Australian governments have sought to delegitimise health promotion, defining it as extraneous to the role of the state. Good evidence is not enough to counter this trend, because it is founded in competing visions of a good society. For this reason, the most pressing agenda for health promotion ethics is to engage with communities, in a procedurally just way, about the role and responsibilities of the citizen and the state in promoting and maintaining good health.

Mesothelioma: "Extrapleural pneumonectomy is associated with greater morbidity and mortality compared with pleurectomy/decortication..."

 2014 Mar 14. pii: S0022-5223(14)00318-3. doi: 10.1016/j.jtcvs.2014.03.011. [Epub ahead of print]

Malignant pleural mesothelioma and the Society of Thoracic Surgeons Database: An analysis of surgical morbidity and mortality.

Author information

  • 1Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif.
  • 2Division of Thoracic Surgery, Department of Surgery, David Geffen School of Medicine at UCLA and West Los Angeles VA Medical Center, Los Angeles, Calif.
  • 3Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Wash.
  • 4Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC.
  • 5Department of Cardiothoracic Surgery, Oregon Heath and Science University, Portland, Ore.
  • 6Section of Cardiac and Thoracic Surgery, Department of Surgery, University of Chicago, Medicine and Biological Sciences, Chicago, Ill. Electronic address: wvignesw@surgery.bsd.uchicago.edu.

Abstract

BACKGROUND:

To date, reported surgical morbidity and mortality for pleurectomy/decortication and extrapleural pneumonectomy performed for malignant pleural mesothelioma primarily represent the experience of a few specialized centers. For comparison, we examined early outcomes of pleurectomy/decortication and extrapleural pneumonectomy from a broader group of centers/surgeons participating in the Society of Thoracic Surgeons-General Thoracic Database.

METHODS:

All patients in the Society of Thoracic Surgeons-General Thoracic Database (version 2.081, representing 2009-2011) who underwent pleurectomy/decortication or extrapleural pneumonectomy for malignant pleural mesothelioma were identified. Patient characteristics, morbidity, mortality, center volume, and procedure were examined using univariable and multivariable analyses.

RESULTS:

A total of 225 patients underwent pleurectomy/decortication (n = 130) or extrapleural pneumonectomy (n = 95) for malignant pleuralmesothelioma at 48 centers. Higher volumes of procedures (≥5/y) were performed at 3 pleurectomy/decortication and 2 extrapleural pneumonectomy centers. Patient characteristics were statistically equivalent between pleurectomy/decortication and extrapleural pneumonectomy groups, except those undergoing extrapleural pneumonectomy were younger (63.2 ± 7.8 years vs 68.3 ± 9.5 years; P < .001) and more likely to have received preoperative chemotherapy (30.1% vs 17.8%; P = .036). Major morbidity was greater after extrapleural pneumonectomy, including acute respiratory distress syndrome (8.4% vs 0.8%; P = .005), reintubation (14.7% vs 2.3%; P = .001), unexpected reoperation (9.5% vs 1.5%; P = .01), and sepsis (4.2% vs 0%; P = .03), as was mortality (10.5% vs 3.1%; P = .03). Multivariate analyses revealed that extrapleural pneumonectomy was an independent predictor of major morbidity or mortality (odds ratio, 6.51; P = .001). Compared with high-volume centers, increased acute respiratory distress syndrome was seen in low-volume centers performing extrapleural pneumonectomy (0% vs 12.5%; P = .05).

CONCLUSIONS:

Extrapleural pneumonectomy is associated with greater morbidity and mortality compared with pleurectomy/decortication when performed by participating surgeons of the Society of Thoracic Surgeons-General Thoracic Database. Effects of center volume require further study.

From Stanford U: Obligate progression precedes lung adenocarcinoma dissemination

 2014 Apr 16. [Epub ahead of print]

Obligate progression precedes lung adenocarcinoma dissemination.

Author information

  • 11Genetics, Stanford University.

Abstract

Despite its clinical importance, very little is known about the natural history and molecular underpinnings of lung cancer dissemination and metastasis. Here we employed a genetically-engineered mouse model of metastatic lung adenocarcinoma in which cancer cells are fluorescently marked to determine whether dissemination is an inherent ability or a major acquired phenotype during lung adenocarcinoma metastasis. We find very little evidence for dissemination from oncogenic Kras-driven hyperplasias or most adenocarcinomas. p53 loss is insufficient to drive dissemination but rather enables rare cancer cells in a small fraction of primary adenocarcinomas to gain alterations that drive dissemination. Molecularcharacterization of disseminated tumors cells indicates that down-regulation of the transcription factor Nkx2-1 precedes dissemination. Finally, we show that metastatic primary tumors possess a highly proliferative sub-population of cells with characteristics matching those of disseminating cells. We propose that dissemination is a major hurdle during the natural course of lung adenocarcinoma metastasis.

The global burden of respiratory disease

 2014 Mar;11(3):404-6. doi: 10.1513/AnnalsATS.201311-405PS.

The global burden of respiratory disease.

Author information

  • 11 Department of Pediatrics, Cell Biology, and Physiology, Washington University in St. Louis, St. Louis, Missouri; and.

Abstract

The Forum of International Respiratory Societies has released a report entitled Respiratory Disease in the World: Realities of Today-Opportunities for Tomorrow. The report identifies five conditions that primarily contribute to the global burden of respiratory disease (asthma, chronic obstructive pulmonary disease, acute respiratory infections, tuberculosis, and lung cancer), and offers an action plan to prevent and treat those diseases. It describes the staggering magnitude of the global burden of lung disease: hundreds of millions of people suffer and four million people die prematurely from respiratory diseases each year. The situation is not hopeless, because most major respiratory illnesses are avoidable. Much of the disease burden can be mitigated by reducing exposure to indoor and outdoor air pollution, restraining tobacco use, and relieving urban overcrowding. Implementation of the strategies described in the Forum of International Respiratory Societies respiratory diseases report would have a profound effect on respiratory health, reduce economic costs, and enhance health equality in the world.

"Economic downturns in the 2000s did not substantially influence the national growth trends for hip and knee arthroplasty in the United States."

 2014 Apr 16;96(8):624-30. doi: 10.2106/JBJS.M.00285.

Impact of the economic downturn on total joint replacement demand in the United States: updated projections to 2021.

Author information

  • 1Exponent, Inc., 3440 Market Street, Suite 600, Philadelphia, PA 19104. E-mail address for S.M. Kurtz: skurtz@exponent.com.
  • 2Exponent, Inc., 149 Commonwealth Drive, Menlo Park, CA 94025.
  • 3University of California San Francisco Department of Orthopaedic Surgery, Institute for Health Policy Studies, 3333 California Street, Suite 265, Box 0936, San Francisco, CA 94118.

Abstract

BACKGROUND:

Few studies have explored the role of the National Health Expenditure and macroeconomics on the utilization of total joint replacement. The economic downturn has raised questions about the sustainability of growth for total joint replacement in the future. Previous projections of total joint replacement demand in the United States were based on data up to 2003 using a statistical methodology that neglected macroeconomic factors, such as the National Health Expenditure.

METHODS:

Data from the Nationwide Inpatient Sample (1993 to 2010) were used with United States Census and National Health Expenditure data to quantify historical trends in total joint replacement rates, including the two economic downturns in the 2000s. Primary and revision hip and knee arthroplasty were identified using codes from the International Classification of Diseases, Ninth Revision, Clinical Modification. Projections in total joint replacement were estimated using a regression model incorporating the growth in population and rate of arthroplasties from 1993 to 2010 as a function of age, sex, race, and census region using the National Health Expenditure as the independent variable. The regression model was used in conjunction with government projections of National Health Expenditure from 2011 to 2021 to estimate future arthroplasty rates in subpopulations of the United States and to derive national estimates.

RESULTS:

The growth trend for the incidence of joint arthroplasty, for the overall United States population as well as for the United States workforce, was insensitive to economic downturns. From 2009 to 2010, the total number of procedures increased by 6.0% for primary total hip arthroplasty, 6.1% for primary total knee arthroplasty, 10.8% for revision total hip arthroplasty, and 13.5% for revision total knee arthroplasty. The National Health Expenditure model projections for primary hip replacement in 2020 were higher than a previously projected model, whereas the current model estimates for total knee arthroplasty were lower.

CONCLUSIONS:

Economic downturns in the 2000s did not substantially influence the national growth trends for hip and knee arthroplasty in the United States. These latest updated projections provide a basis for surgeons, hospitals, payers, and policy makers to plan for the future demand for total joint replacement surgery.

Cass Sunstein: Our Nudge in Chief

Our Nudge in Chief

How, and why, Cass Sunstein believes laws and public policies should help save us from our irrational impulses

From Patty Chevex-Barrios and colleagues: Selective Pathology Fellowships: Diverse, Innovative, and Valuable Subspecialty Training

Julia C. Iezzoni MDApril Ewton MDPatricia Chévez-Barrios MDStephen Moore BALinda M. Thorsen MAWesley Y.Naritoku MD, PhD
From the Department of Pathology, University of Virginia Health System, Charlottesville (Dr Iezzoni); the Department of Pathology and Genomic Medicine, The Methodist Hospital, Houston, Texas (Drs Ewton and Chévez-Barrios); the Accreditation Council for Graduate Medical Education, Chicago, Illinois (Mr Moore and Ms Thorsen); and the Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles (Dr Naritoku).
Context.—Although selective pathology fellowships have a long-standing history of developing trainees with advanced expertise in specific areas of pathology other than those of the American Board of Pathology–certified subspecialties, the widespread interest in this training continues to grow.
Objective.—To describe the historical background and current status of selective pathology fellowships, and to provide examples of 3 programs. In addition, Accreditation Council for Graduate Medical Education (ACGME)–accredited programs and nonaccredited programs in Selective Pathology are compared.
Data Sources.—ACGME data banks and publicly available online materials were used. Program directors of the fellowships examples in this paper provided program-specific information. Additionally, an online survey of the program directors and program coordinators of ACGME-accredited programs and nonaccredited programs in selective pathology was performed.
Conclusions.—There are currently 76 ACGME-accredited selective pathology programs. The programs are distributed between 3 major categories: surgical pathology, focused anatomic pathology, and focused clinical pathology. Although the vast majority of programs are concerned that their funding source may be cut in the next 3 years, most programs will not change the number of fellowship positions in their programs. Program requirements devoted specifically and solely to selective pathology have been developed and are in effect. The value of this training is recognized not only by pathologists, but by clinicians as well, in both academia and private practice. Importantly, the diversity and innovation inherent in selective pathology allow these programs to adeptly address new subspecialty areas and technologic advances in the current and evolving practice of pathology.

Heartbreaking: Texas A&M student dies after mono diagnosis



Texas A&M student dies after mono diagnosis

Thursday, April 17, 2014

Time to End Free Drug Samples

Time to End Free Drug Samples


Deep brain stimulation in the treatment of depression

 2014 Mar;16(1):83-91.

Deep brain stimulation in the treatment of depression.

Author information

  • Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA.

Abstract

Major depressive disorder is a worldwide disease with debilitating effects on a patient's life. Common treatments include pharmacotherapy, psychotherapy, and electroconvulsive therapy. Many patients do not respond to these treatments; this has led to the investigation of alternative therapeutic modalities. Deep brain stimulation (DBS) is one of these modalities. It was first used with success for treating movement disorders and has since been extended to the treatment of psychiatric disorders. Although DBS is still an emerging treatment, promising efficacy and safety have been demonstrated in preliminary trials in patients with treatment-resistant depression (TRD). Further, neuroimaging has played a pivotal role in identifying some DBS targets and remains an important tool for evaluating the mechanism of action of this novel intervention. Preclinical animal studies have broadened knowledge about the possible mechanisms of action of DBS for TRD, Given that DBS involves neurosurgery in patients with severe psychiatric impairment, ethical questions concerning capacity to consent arise; these issues must continue to be carefully considered.

From Duke U: How does family drug treatment court participation affect child welfare outcomes?

 2014 Apr 12. pii: S0145-2134(14)00103-3. doi: 10.1016/j.chiabu.2014.03.010. [Epub ahead of print]

How does family drug treatment court participation affect child welfare outcomes?

Author information

  • 1Center for Child and Family Policy, Duke University, Box 90545, 214 Rubenstein Hall, 302 Towerview Road, Durham, NC 27708, USA.
  • 2Department of Economics, Duke University, USA.

Abstract

Parental substance use is a risk factor for child maltreatment. Family drug treatment courts (FDTCs) have emerged in the United States as a policyoption to treat the underlying condition and promote family preservation. This study examines the effectiveness of FDTCs in North Carolina on child welfare outcomes. Data come from North Carolina records from child protection services, court system, and birth records. Three types of parental participation in a FDTC are considered: referral, enrolling, and completing an FDTC. The sample includes 566 children who were placed into foster care and whose parents participated in a FDTC program. Findings indicate that children of parents who were referred but did not enroll or who enrolled but did not complete had longer stays in foster care than children of completers. Reunification rates for children of completers were also higher. Outcomes for children in the referred and enrolled groups did not differ in the multivariate analyses. While effective substance use treatment services for parents may help preserve families, future research should examine factors for improving participation and completion rates as well as factors involved in scaling programs so that more families are served.

Redistribution of Health Care Costs after the Adoption of Positron Emission Tomography among Medicare Beneficiaries with Non-Small-Cell Lung Cancer, 1998-2005

 2014 Apr;9(4):512-8. doi: 10.1097/JTO.0000000000000102.

Redistribution of Health Care Costs after the Adoption of Positron Emission Tomography among Medicare Beneficiaries with Non-Small-Cell Lung Cancer, 1998-2005.

Author information

  • 1*Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; †Department of Health Policy and Administration, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; ‡Department of Medicine, Duke University School of Medicine, Durham, North Carolina; §Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina; and ‖Department of Radiology, Duke University School of Medicine, Durham, North Carolina.

Abstract

INTRODUCTION:

Treatment patterns and cost implications of increased positron emission tomography imaging use since Medicare approval in 1998 are not well understood. We examined rates of surgery, radiotherapy, and chemotherapy and inpatient and total health care costs between 1998 and 2005 among Medicare beneficiaries with non-small-cell lung cancer.

METHODS:

Patients in this retrospective cohort study were 51,374 Medicare beneficiaries diagnosed with non-small-cell lung cancer between 1996 and 2005. The main outcome measures were receipt of surgical resection, radiotherapy, and chemotherapy and inpatient and total health care costs within 1 year of diagnosis.

RESULTS:

Between 1996-1997 and 2004-2005, the proportion of patients undergoing surgical resection decreased from 29% to 25%, the proportion receiving radiation therapy decreased from 49% to 43%, and inpatient costs decreased from $28,900 to $26,900. The proportion of patients receiving chemotherapy increased from 25% to 40% and total costs increased from $47,300 to $52,200 (p < 0.001 for all comparisons). Changes in use and costs remained after adjustment for shifting demographic characteristics during the study period.

CONCLUSIONS:

Adoption of positron emission tomography between 1998 and 2005 was accompanied by decreases in rates of surgery and radiotherapy and in short-term inpatient costs among Medicare beneficiaries with non-small-cell lung cancer, although there was an increase in chemotherapy and overall costs.