The standard evaluation of patients with syncope has changed little over the years, with considerable continuity between American Family Physician reviews published in 2005, 2011, and this March. But the field received an unexpected jolt last October, when Dr. Paolo Prandoni and colleagues published a cross-sectional study in the New England Journal of Medicine that calculated a surprisingly high prevalence of pulmonary embolism (PE) of 17.3% in patients hospitalized for a first episode of syncope. In this study, 230 of 560 patients at 11 Italian hospitals who did not have a low pretest probability of PE by the Wells rule and negative D-dimer assay underwent computed tomographic pulmonary angiography (CTPA) or ventilation-perfusion lung scans. 97 of these patients had evidence of PE. Overall, the investigators identified PE in 25% of patients with no alternative explanation for syncope and 13% of patients with an alternative explanation.
Algorithms for syncope evaluation focus on identifying cardiac and neurally mediated causes and do not include routine testing for PE. The question raised by the Italian study is if all inpatients with syncope need evaluation, since nearly 1 in 6 patients may have PE. There are good reasons not to jump to this conclusion. First, we don't know if the prevalence of PE in this study was representative of the general population of adults hospitalized for syncope, as it only included patients admitted from emergency departments (and not patients initially evaluated in primary care settings). Second, the study did not determine if PE was the etiology of syncope, as opposed to an incidental finding. This is important because evidence suggests that the enhanced sensitivity of CTPA for detecting small, subsegmental PE is increasing overdiagnosis and overtreatment of clinically insignificant clots. Finally, the absence of a comparison group means that it is not known if the systematic workup for PE improved the patients' prognoses or just added additional cost and risk to the evaluation.
A retrospective cross-sectional study in JAMA Internal Medicine recently used clinical and administrative data from 4 hospitals in Toronto to estimate the prevalence of PE in 1305 patients with a first episode of syncope who were not receiving anticoagulation at the time of admission. 120 of these patients received CTPA, ventilation-perfusion scan, and/or compression ultrasonography, leading to the diagnosis of PE in 18 patients. As opposed to the Italian study, where all persons received at least a D-dimer test, the decision to evaluate for PE was driven by clinical judgment. Nonetheless, of 146 patients in the Toronto study who received any test for PE (presumably those who were most likely to have one), only 12% were positive, and the overall prevalence of PE was a mere 1.4%. The authors concluded that "there is little, if any, justification for routine testing for [venous thromboembolism] in all patients hospitalized for a first episode of syncope."
Based on both studies, I agree that evidence does not support routinely looking for PEs in patients with syncope. In patients with possible signs or symptoms, another clinical decision rule may be used to confidently rule out the diagnosis without resorting to the less sensitive Wells rule or less specific D-dimer test, where a positive result often leads to unnecessary CTPA.
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A slightly different version of this post first appeared on the AFP Community Blog.
Monday, May 29, 2017
Monday, May 22, 2017
Colorectal cancer and falls: too much and too little prevention
One of the paradoxes of the U.S. health care system is that excess and waste often exist side by side with insufficiently provided services. Colorectal cancer screening is a prime example. Previous studies showed that 25% of Medicare recipients undergo repeat screening colonoscopies sooner than necessary, but the Centers of Disease Control and Prevention recently reported that nearly 4 in 10 adults between ages 50 and 75 are not up-to-date on colorectal cancer screening. Last year, I argued that the U.S. Preventive Services Task Force's decision to expand the number of recommended screening options based on inadequate evidence was unlikely to improve this situation.
In an editorial in the May 15th issue of American Family Physician, I and Dr. Jennifer Frost explained why the American Academy of Family Physicians disagreed with the new recommendations, and instead chose not to recommend CT colonography or fecal DNA testing and to also reaffirm its previous stance against screening adults older than 85 years. BMJ journalist Jeanne Lenzer's question about whether the USPSTF remains a voice of caution remains relevant in an era of increasingly elastic evidence letter grades (see "C" for prostate cancer screening).
Another area where there may be too much prevention occurring for too little benefit is screening and treatment for osteoporosis, which Ray Moynihan and colleagues reported that in contrast to the medical literature, community-dwelling older women would prefer to describe as a "risk factor" rather than a "disease." I couldn't agree more; we physicians focus too much on prescribing drugs to treat low bone density and too little on interventions to address the other critical risk factor for hip fractures: falling.
So I hope that many patients will read and heed Paula Span's recent New York Times column advising older adults to invest in home modifications that will allow them to move safely around their living spaces as they age. Unfortunately, there aren't nearly enough Certified Aging in Place Specialist (CAPS) contractors to meet national needs. Also, many health insurers that would have no issues paying for a PSA test or screening colonoscopy in a 90 year-old would balk at reimbursing home renovations, even though the latter is much more likely to prevent (rather than cause) a hospitalization.
In an editorial in the May 15th issue of American Family Physician, I and Dr. Jennifer Frost explained why the American Academy of Family Physicians disagreed with the new recommendations, and instead chose not to recommend CT colonography or fecal DNA testing and to also reaffirm its previous stance against screening adults older than 85 years. BMJ journalist Jeanne Lenzer's question about whether the USPSTF remains a voice of caution remains relevant in an era of increasingly elastic evidence letter grades (see "C" for prostate cancer screening).
Another area where there may be too much prevention occurring for too little benefit is screening and treatment for osteoporosis, which Ray Moynihan and colleagues reported that in contrast to the medical literature, community-dwelling older women would prefer to describe as a "risk factor" rather than a "disease." I couldn't agree more; we physicians focus too much on prescribing drugs to treat low bone density and too little on interventions to address the other critical risk factor for hip fractures: falling.
So I hope that many patients will read and heed Paula Span's recent New York Times column advising older adults to invest in home modifications that will allow them to move safely around their living spaces as they age. Unfortunately, there aren't nearly enough Certified Aging in Place Specialist (CAPS) contractors to meet national needs. Also, many health insurers that would have no issues paying for a PSA test or screening colonoscopy in a 90 year-old would balk at reimbursing home renovations, even though the latter is much more likely to prevent (rather than cause) a hospitalization.
Tuesday, May 16, 2017
Fear-mongering in thyroid and breast cancer screening
A large part of practicing primary care consists of providing reassurance to healthy persons. The patient who asks me to look at the mole on her back to make sure it isn't melanoma. The patient who recently recovered from a cold but is still coughing and wants to know that it isn't a sign of something more serious. The patient whose friend's doctor found a lump on his thyroid gland and wants to have his neck checked too.
The last time the U.S. Preventive Services Task Force recommended against screening for thyroid cancer was in 1996. That it took more than 20 years to release an updated recommendation statement (still a "D," or don't do) speaks to how non-controversial the Task Force judged this topic to be. Unfortunately, in the interim many clinicians and patients ignored this advice. In South Korea, a national cancer screening program that began in 1999 encouraged general practitioners to routinely perform thyroid ultrasound scans, resulting in an "epidemic" of new thyroid cancers but no change in thyroid cancer deaths. In the United States, papillary thyroid cancer diagnoses have quadrupled since 1995, again with no change in mortality. In both countries and around the world, physicians are finding and treating thousands of pseudo-cancers that would not have otherwise been found and don't need to be treated. Overdiagnosis begets more overdiagnosis: patients who are "successfully" diagnosed and treated tell friends and relatives to have their necks palpated or scanned for thyroid tumors. And if that feedback cycle wasn't enough, advocacy groups such as the Light of Life Foundation initiated fear-mongering awareness campaigns, as Dr. Gilbert Welch described in an editorial accompanying the USPSTF recommendation:
About a decade ago, public service announcements began to appear encouraging people to have their physicians “check your neck.” The Light of Life Foundation campaign featured actual testimonials of patients describing their positive health behaviors on the day before they were diagnosed with thyroid cancer. The ads used compelling language: “Thyroid cancer doesn’t care how healthy you are. It can happen to anyone. Including you. That’s why it is the fastest growing cancer in the US. Ask your doctor to check your neck. It could save your life.” The campaign’s title—and its main slogan—was “Confidence Kills.” That’s a great public health message: if you feel good, you are about to die.
Fear-mongering isn't limited to thyroid cancer, of course. From the 1980s-era American Cancer Society print advertisement that lectured women, "If you haven't had a mammogram, you need more than your breasts examined," promoters of breast cancer screening long used fear to motivate women to undergo screening mammography. In 2015, several advocacy organizations successfully persuaded the U.S. Congress to override the U.S. Preventive Services Task Force's "C" grade (small net benefit) on screening mammography for women aged 40-49 with a "Stop the Guidelines" campaign that included full-page advertisements in major newspapers asking the rhetorical question "Which of our wives, mothers, daughters, and sisters would be be OK to lose?"
The major difference between screening for thyroid and breast cancer is that the latter actually reduces cancer deaths. But women under 50 are less likely to benefit because there is less lethal breast cancer to be found in younger women, and consequently much higher false positive rates that affect more than half of all women receiving annual mammograms from age 40 to 50. And the USPSTF didn't tell clinicians don't screen - more accurately, they said don't screen reflexively, and the message to younger women is not to avoid mammograms, but to talk about the pros and cons with your doctor.
That hasn't stopped a new alliance of radiologists and breast cancer surgeons from targeting the Task Force with a 40not50 campaign which encourages women in their 40s to turn off their brains, eschew shared decision-making, and demand that their doctors start screening them at age 40 because mammograms save lives, and a government-appointed panel (whose 16 members include 7 women) wants to prevent women from seeing their 50th birthdays. Notwithstanding the ulterior motives behind this absurd campaign, it is insulting to women. It says that they can't be trusted to consider the medical evidence, have conversations with their primary care physicians, and make decisions about their healthcare that are right for them.
The last time the U.S. Preventive Services Task Force recommended against screening for thyroid cancer was in 1996. That it took more than 20 years to release an updated recommendation statement (still a "D," or don't do) speaks to how non-controversial the Task Force judged this topic to be. Unfortunately, in the interim many clinicians and patients ignored this advice. In South Korea, a national cancer screening program that began in 1999 encouraged general practitioners to routinely perform thyroid ultrasound scans, resulting in an "epidemic" of new thyroid cancers but no change in thyroid cancer deaths. In the United States, papillary thyroid cancer diagnoses have quadrupled since 1995, again with no change in mortality. In both countries and around the world, physicians are finding and treating thousands of pseudo-cancers that would not have otherwise been found and don't need to be treated. Overdiagnosis begets more overdiagnosis: patients who are "successfully" diagnosed and treated tell friends and relatives to have their necks palpated or scanned for thyroid tumors. And if that feedback cycle wasn't enough, advocacy groups such as the Light of Life Foundation initiated fear-mongering awareness campaigns, as Dr. Gilbert Welch described in an editorial accompanying the USPSTF recommendation:
About a decade ago, public service announcements began to appear encouraging people to have their physicians “check your neck.” The Light of Life Foundation campaign featured actual testimonials of patients describing their positive health behaviors on the day before they were diagnosed with thyroid cancer. The ads used compelling language: “Thyroid cancer doesn’t care how healthy you are. It can happen to anyone. Including you. That’s why it is the fastest growing cancer in the US. Ask your doctor to check your neck. It could save your life.” The campaign’s title—and its main slogan—was “Confidence Kills.” That’s a great public health message: if you feel good, you are about to die.
Fear-mongering isn't limited to thyroid cancer, of course. From the 1980s-era American Cancer Society print advertisement that lectured women, "If you haven't had a mammogram, you need more than your breasts examined," promoters of breast cancer screening long used fear to motivate women to undergo screening mammography. In 2015, several advocacy organizations successfully persuaded the U.S. Congress to override the U.S. Preventive Services Task Force's "C" grade (small net benefit) on screening mammography for women aged 40-49 with a "Stop the Guidelines" campaign that included full-page advertisements in major newspapers asking the rhetorical question "Which of our wives, mothers, daughters, and sisters would be be OK to lose?"
The major difference between screening for thyroid and breast cancer is that the latter actually reduces cancer deaths. But women under 50 are less likely to benefit because there is less lethal breast cancer to be found in younger women, and consequently much higher false positive rates that affect more than half of all women receiving annual mammograms from age 40 to 50. And the USPSTF didn't tell clinicians don't screen - more accurately, they said don't screen reflexively, and the message to younger women is not to avoid mammograms, but to talk about the pros and cons with your doctor.
That hasn't stopped a new alliance of radiologists and breast cancer surgeons from targeting the Task Force with a 40not50 campaign which encourages women in their 40s to turn off their brains, eschew shared decision-making, and demand that their doctors start screening them at age 40 because mammograms save lives, and a government-appointed panel (whose 16 members include 7 women) wants to prevent women from seeing their 50th birthdays. Notwithstanding the ulterior motives behind this absurd campaign, it is insulting to women. It says that they can't be trusted to consider the medical evidence, have conversations with their primary care physicians, and make decisions about their healthcare that are right for them.
Sunday, May 7, 2017
American Family Physician translates research for practice
Over the next few months, I'll have more to say about the recent announcement that my longtime mentor Jay Siwek, MD, editor of American Family Physician since 1988 and the only family physician in the journal's 67-year history to hold that position, will be stepping down in January after 30 years at the helm. In the meantime, this post highlights three ways AFP currently translates research for primary care practice: the Top 20 research studies articles, Pro-Con editorials, and Journal Club.
**
The May 1 issue of American Family Physician features the latest installment of the "Top 20 Research Studies" series of articles that Drs. Mark Ebell and Roland Grad have been writing annually since 2012. What sets this particular set of study summaries apart from other journals' "best of the year" studies lists? Dr. Jay Siwek explains in his editor's note:
Medical journals occasionally publish an article summarizing the best studies in a certain field from the previous year; however, those articles are limited by being one person's idiosyncratic collection of a handful of studies. In contrast, this article by Drs. Ebell and Roland Grad is validated in two ways: (1) the source material (POEMs) was derived from a systematic review of thousands of articles using a rigorous criterion-based process, and (2) these “best of the best” summaries were rated by thousands of Canadian primary care physicians for relevance and benefits to practice.
The research studies from 2016 rated most primary care relevant, valid, patient-oriented, and practice changing include patient-oriented evidence that matters (POEMs) on hypertension; respiratory conditions; musculoskeletal conditions; diabetes mellitus and obesity; and miscellaneous items. The complete POEMs are available in AFP's Evidence-Based Medicine toolkit. Also, Canadian Medical Association members identified four important guidelines published in 2016: the U.S. Preventive Services Task Force (USPSTF) on screening for colorectal cancer and interventions for tobacco cessation in adults; the American College of Physicians on management of chronic insomnia; and the Centers for Disease Control and Prevention on opioid prescribing for chronic pain.
During Dr. Ebell's past membership on the USPSTF, the panel voted to recommend one-time screening for hepatitis C virus (HCV) in every adult born between 1945 and 1965 (also known as birth cohort screening). On the other hand, as a member of the Canadian Task Force on Preventive Health Care, Dr. Grad recently developed a recommendation against screening for HCV in asymptomatic adults without risk factors, including baby boomers. AFP previously presented both sides of this complicated debate in a pair of editorials that outlined the case for birth cohort screening and the case against it (which I wrote). You can find other Pro-Con editorials on controversial family medicine topics in this online collection.
Finally, readers should be aware that essential concepts from AFP Journal Club, a popular journal feature that analyzed key research studies from 2007 to 2015, have been incorporated into our EBM toolkit. This annotated collection of evidence-based medicine pointers provides useful information for clinicians, teachers, and learners at all levels.
**
This post originally appeared on the AFP Community Blog.
**
The May 1 issue of American Family Physician features the latest installment of the "Top 20 Research Studies" series of articles that Drs. Mark Ebell and Roland Grad have been writing annually since 2012. What sets this particular set of study summaries apart from other journals' "best of the year" studies lists? Dr. Jay Siwek explains in his editor's note:
Medical journals occasionally publish an article summarizing the best studies in a certain field from the previous year; however, those articles are limited by being one person's idiosyncratic collection of a handful of studies. In contrast, this article by Drs. Ebell and Roland Grad is validated in two ways: (1) the source material (POEMs) was derived from a systematic review of thousands of articles using a rigorous criterion-based process, and (2) these “best of the best” summaries were rated by thousands of Canadian primary care physicians for relevance and benefits to practice.
The research studies from 2016 rated most primary care relevant, valid, patient-oriented, and practice changing include patient-oriented evidence that matters (POEMs) on hypertension; respiratory conditions; musculoskeletal conditions; diabetes mellitus and obesity; and miscellaneous items. The complete POEMs are available in AFP's Evidence-Based Medicine toolkit. Also, Canadian Medical Association members identified four important guidelines published in 2016: the U.S. Preventive Services Task Force (USPSTF) on screening for colorectal cancer and interventions for tobacco cessation in adults; the American College of Physicians on management of chronic insomnia; and the Centers for Disease Control and Prevention on opioid prescribing for chronic pain.
During Dr. Ebell's past membership on the USPSTF, the panel voted to recommend one-time screening for hepatitis C virus (HCV) in every adult born between 1945 and 1965 (also known as birth cohort screening). On the other hand, as a member of the Canadian Task Force on Preventive Health Care, Dr. Grad recently developed a recommendation against screening for HCV in asymptomatic adults without risk factors, including baby boomers. AFP previously presented both sides of this complicated debate in a pair of editorials that outlined the case for birth cohort screening and the case against it (which I wrote). You can find other Pro-Con editorials on controversial family medicine topics in this online collection.
Finally, readers should be aware that essential concepts from AFP Journal Club, a popular journal feature that analyzed key research studies from 2007 to 2015, have been incorporated into our EBM toolkit. This annotated collection of evidence-based medicine pointers provides useful information for clinicians, teachers, and learners at all levels.
**
This post originally appeared on the AFP Community Blog.
Monday, May 1, 2017
Every screening test is a calculated gamble
When I was last in Las Vegas to attend the International Consumer Electronics Show, I stayed at one of the city's many combination hotel and casinos, with a layout designed to funnel guests and other visitors through the gaming floor to get practically anywhere. While walking past a row of pulsating slot machines in the lobby one morning, I remembered the title of a terrific New York Times editorial I read a few years ago, "You Have to Gamble On Your Health."
In this editorial, Dr. H. Gilbert Welch (whom I've lauded before for his work on the subject of overdiagnosis) explained why even though most people who receive screening tests for cancer think that they are playing it safe, every test has tradeoffs. Just as a gambler rarely hits the jackpot in Vegas, a patient who undergoes cancer screening is rarely the lucky one whose life is extended from the test, and much more likely to figuratively lose his or her shirt. Common harms of screening include false positive results, risks associated with subsequent diagnostic procedures, and possible unnecessary treatment (and associated side effects) for "cancer" that looks dangerous under the microscope but is actually destined to never cause health problems.
The good news is that for a few very well-studied screening tests such as mammography, an informed patient can assess the odds of all of these outcomes based on scientific data and decide whether screening is a better choice for her than no screening. A mammography screening decision aid by Dr. Jill Jin that appeared in JAMA did a great job of illustrating these tradeoffs, and may help to explain why one prominent health journalist announced that she had decided to forego mammography because she believed that "the numbers are in my favor."
Yes, every screening test is a gamble, but I give credit to my fellow physicians for providing increasingly sophisticated support for these tough decisions that you'd never get in Vegas.
**
This post first appeared on Common Sense Family Doctor on January 6, 2015.
 |
| Courtesy of www.lasvegas.com |
In this editorial, Dr. H. Gilbert Welch (whom I've lauded before for his work on the subject of overdiagnosis) explained why even though most people who receive screening tests for cancer think that they are playing it safe, every test has tradeoffs. Just as a gambler rarely hits the jackpot in Vegas, a patient who undergoes cancer screening is rarely the lucky one whose life is extended from the test, and much more likely to figuratively lose his or her shirt. Common harms of screening include false positive results, risks associated with subsequent diagnostic procedures, and possible unnecessary treatment (and associated side effects) for "cancer" that looks dangerous under the microscope but is actually destined to never cause health problems.
 |
| Courtesy of www.lasvegas.com |
The good news is that for a few very well-studied screening tests such as mammography, an informed patient can assess the odds of all of these outcomes based on scientific data and decide whether screening is a better choice for her than no screening. A mammography screening decision aid by Dr. Jill Jin that appeared in JAMA did a great job of illustrating these tradeoffs, and may help to explain why one prominent health journalist announced that she had decided to forego mammography because she believed that "the numbers are in my favor."
Yes, every screening test is a gamble, but I give credit to my fellow physicians for providing increasingly sophisticated support for these tough decisions that you'd never get in Vegas.
**
This post first appeared on Common Sense Family Doctor on January 6, 2015.