Wednesday, January 30, 2019

What do recent publications mean for men with localized prostate cancer?

From 2012 to 2018, the U.S. Preventive Services Task Force and the American Academy of Family Physicians recommended not screening for prostate cancer, based on evidence that the then-widespread practice produced no net benefit. As a result, fewer family physicians subsequently screened their patients with the PSA test, and fewer men were diagnosed (or overdiagnosed) with localized prostate cancer. However, the USPSTF's recent change to a more permissive approach to PSA-based screening has increased the likelihood that more men will need to make difficult decisions regarding what to do about a prostate cancer diagnosis.

As I discussed in a previous AFP Community Blog post, surveyed men with newly diagnosed localized prostate cancer expected to gain a whopping 12 years of life expectancy by undergoing surgery or radiation. In fact, two randomized, controlled trials found no gains in prostate cancer-specific or all-cause mortality. After nearly 20 years of follow-up, the U.S. Prostate Cancer Intervention versus Observation Trial (PIVOT) reported in 2017 that radical prostatectomy reduced the likelihood of treatment for asymptomatic, local, or biochemical (PSA) disease progression compared to observation, but caused more urinary incontinence, erectile dysfunction, and limitations in activities of daily living. Similarly, the U.K. Prostate Cancer for Testing and Treatment (ProtecT) trial found that active surveillance was comparable to radiotherapy or prostatectomy, with a slightly greater likelihood of clinical progression and metastatic disease in the active surveillance group.

A 2018 article reviewed the evolving National Comprehensive Cancer Network guidelines for treatment of localized prostate cancer, which recommend incorporating comorbidity-adjusted life expectancy into screening and treatment decisions:

The comorbidity-adjusted life expectancy is particularly important because the number of comorbid diseases is among the most significant predictors of survival after prostate cancer treatment. Prostate cancer is usually slow growing, and the survival benefit of treatment may present only after 10 years. Therefore, patients with low-risk or very low-risk prostate cancer should be treated only if the patient has a comorbidity-adjusted life expectancy of at least 10 years.

An older Swedish randomized trial comparing radical prostatectomy to watchful waiting in men with predominantly clinically-detected (rather than PSA-detected) localized prostate cancer found that radical prostatectomy was associated with less than 3 years of life gained after 23 years of follow-up. Altogether, the evidence suggests that curative treatments may be worthwhile for selected men with symptoms, but that there is little or no benefit to looking for prostate cancer in men who feel well.


This post first appeared on the AFP Community Blog.

Monday, January 21, 2019

When deprescribing is the best medicine

Physicians who care for older adults or others with multiple chronic conditions understand that deprescribing unnecessary or inappropriate therapies is central to providing high-quality care and improving patient safety. An editorial by Drs. Barbara Farrell and Dee Mangin in the January 1 issue of American Family Physician reviewed the health risks associated with polypharmacy (taking five or more chronic medications) and provided a table of resources for each step of the deprescribing process, including several evidence-based guidelines co-written by the authors. AFP's Practice Guidelines department summarized their guideline on deprescribing antipsychotics for dementia and insomnia last year and reviewed how to taper benzodiazepine receptor agonists for insomnia in adults in the January 1 issue.

A 2018 systematic review in the British Journal of General Practice reviewed data from 27 randomized, controlled trials of deprescribing a range of drug classes in adults aged 50 years or older in primary care settings. In 19 studies, at least half of patients in the intervention groups were able to stop their medications completely, and adverse effects were uncommon. However, the risk of "relapse" (needing to resume the drug after completely discontinuing it) ranged from 2 to 80 percent.

Patient expectations, medical culture, and organizational constraints can present barriers to deprescribing. A qualitative study of New Zealand primary care physicians in the Annals of Family Medicine described deprescribing as "swimming against the tide." Study participants recommended several practice and system-level interventions to support deprescribing that could also be applied to practices in the U.S.:

- Targeted funding for annual medicines review
- Computer alerts to prompt physicians’ memories
- Computer systems to improve information sharing between prescribers
- Improved access to non-pharmaceutical therapies
- Research to build the evidence base in multimorbidity, education and training
- Ready access to expert advice and user-friendly decision support
- Updating guidelines to include advice on when to consider stopping medicines
- Tools and resources to assist in the communication of risk to patients
- Activating patients to become more involved in medicines management and alert to the possibility that less might be better

Along those lines, the AFP editorial also provided a Table of examples of language that family physicians can use to discuss deprescribing with patients and facilitate shared decision-making.


This post first appeared on the AFP Community Blog.

Thursday, January 17, 2019

Birthday reflections: envisioning my third act

I'm celebrating my 43rd birthday today, and nearly a decade of blogging at Common Sense Family Doctor. Although 2018 was the first year in which I wrote fewer than one post per week (46 total), I haven't slowed my writing output overall, authoring or co-authoring ten journal articles or textbook chapters last year and kicking off 2019 with a new study in the Journal of the American Board of Family Medicine on conversations on Twitter about women and Black men in medicine. I am grateful to my longtime colleague Dr. Ranit Mishori (@ranitmd) for coming up with this novel research idea and inviting me to join the team.

The changing of the calendar prompts me to reflect more on my career arc as a family physician, researcher, educator, and author. I have been thinking of my career thus far as an ongoing series of "acts," each lasting for several years. The first act began in 2004 with a year-long editing and faculty development fellowship at Georgetown, continued through my time as a medical officer at AHRQ, followed by a year working in urgent care, and concluded with my re-joining the family medicine department as a full-time faculty member and associate deputy editor of American Family Physician and earning my Master of Public Health degree from Johns Hopkins.

In the second act, beginning around 2012-2013, I gradually built my outpatient primary care practice in northwest DC (a handful of patients found me first through my blog); developed and enhanced medical school courses and a fellowship program involving population health, health policy and advocacy; and was promoted to professor of family medicine and deputy editor of AFP. To be sure, there have been setbacks along the way, including, recently, the disappointment of not advancing to the interview stage in my application for the open editor position at the Annals of Family Medicine.

2019 feels to me like the start of Act 3, although I can't fully articulate why. Maybe it's because in my 15th year of practice I have clearly entered mid-career. My patients are getting older, and more of them now struggle with chronic diseases and chronic pain and are spending time in various local hospitals. With my paths to editorial leadership of prominent family medicine journals closed off for at least the next decade (barring the unexpected), I have turned my energies toward developing new features such as AFP's Lown Right Care department and, together with collaborators at Lown, Georgetown, and in Louisiana, am working on a systematic review for the first time in years. My public speaking continues to focus on overuse, particularly of screening tests whose benefits are overvalued and harms are underappreciated. My four kids (ages 4 through 12) keep growing, my wife's house calls practice and nonprofit are thriving, and our family has no plans to leave the DC area anytime soon - again, barring the completely unexpected.

Act 3. The curtain rises. What does this next act have in store for me?

Monday, January 7, 2019

Guest Post: How the medical profession can help heal divisions as well as diseases

Richard Gunderman, MD, PhD, Indiana University

Medicine need not be confined to the role of cultural bellwether, a sheep with a bell on its neck that reveals where the whole flock is headed. Along with other professions such as law, clergy and education, medicine can and should play the leadership role of a shepherd, helping our society to develop more thoughtful, balanced and generous approaches to the challenges that face us. After all, the word doctor means teacher, and our culture needs the best instruction we can offer. The dawn of a new year makes the time ripe for such a shift in medicine’s role.

Doctors as teachers

In serving as educators, doctors have many resources to draw on. They are among the best educated groups in our society, having pursued one of our the longest and most intense courses of study. In practice, they regularly participate in moments that help to clarify what life is all about – birth and death, growth and aging, suffering and relief. And they serve as trusted confidantes and counselors to patients and families at some of life’s most meaningful moments.

Popular culture has reflected an erosion of the doctor as teacher and role model. In the 1960s and 70s, television doctors such as Dr. Kildare and Marcus Welby epitomized virtues such as dedication and compassion. Then along came “M.A.S.H.” and “St. Elsewhere,” which adopted a more irreverent attitude toward medicine and the people who practice it. By 2004’s “House,” which ran for eight seasons, the doctor had degenerated into a clever but deeply misanthropic opioid addict.

First, do no harm

As a physician and educator, I think that, for medicine to help heal our culture, doctors must embrace their role as advocates for principles that have long represented the core of the healing professions. Although “Primum non nocere, or ”First, do no harm,“ does not appear in the writings of the "father of medicine” Hippocrates, it is often cited as medicine’s first principle. And the idea that doctors should avoid harm is part of the modified Hippocratic Oath that most doctors take when they graduate from medical school.

This principle does not imply that doctors should never harm. After all, no surgeon could ever operate and no oncologist could ever administer chemotherapy if they rigorously adhered to it. It means instead that risks and harms must always be balanced against benefits, and that where the balance is too uncertain or unfavorable, it is better to do nothing. More broadly speaking, we should avoid saying things or acting in ways that cause needless injury.

What would “Do no harm” look like in our popular culture? First, it would mean eschewing personal attacks, which seek to label people as unworthy, disgusting, or evil. In public discourse, our goal should be to understand different points of view, to educate one another, and to take the interests of others into account in arriving at decisions. Physicians are expected to take good care of even patients they find disagreeable, and this an outlook sorely deficient in the U.S. today.

Get the whole story

A second habit deeply ingrained over the course of medical training is to recognize that there are usually more than two sides to any question. Suppose a patient complains of pain in the right lower quadrant of the abdomen, a classic symptom of appendicitis. Only poor physicians would confine their attention to the question, “Is it appendicitis or not?” The real issue at hand is to determine what is causing the pain and what needs to be done about it.

In popular culture, complex matters are often reduced to highly simplified dichotomies, in which the two sides are portrayed as sporting white and black hats. It seems as though all Americans need to know is whether a person is a Democrat or Republican, a conservative or a liberal, or a reader of The Washington Post or The Wall Street Journal. In fact, however, making good choices requires an understanding far deeper than which side of a political divide a person is on.

Good doctors learn quickly that a cursory inspection can be deeply misleading, as a story once told by a colleague reveals. An elderly, disheveled, incoherent woman was brought to the emergency room with a broken arm. The staff took her for a homeless person. Later, however, she started to make sense, and provided her phone number. When her family came to pick her up, they arrived in a chauffeured limousine. In this as in so many cases, what first met the eye turned out to be quite deceptive.

Put service before self

To become really good doctors, medical students need to learn something: Patients do not exist to provide careers to physicians; instead, physicians exist to care for patients. Like other professionals, doctors need to put the interests of their patients first. The overarching goal is not to advance the physician’s career, to generate more income, or to secure the business interests of a medical practice or hospital. The goal is to care well for the patient.

The founders of the U.S. knew that human beings are not angels, but they also believed that people can look beyond narrow self-interest and do what is best for others and the larger whole. They knew that serving a purpose beyond self is one of the surest ways to find meaning and purpose in life, and that those who contribute the most often lead the fullest lives. They bet their own lives on the proposition that Americans could answer the call of their better selves.

By serving as exemplars of what a life of service looks like in communities across the country, doctors and other professionals can remind Americans of all ages what human beings at their best are really capable of. To look out only for number one is to lose hope in neighbors, communities and society. To get to know others, to take an interest in their stories, and to reach out and serve when they need help and support is one of the signs of a hopeful, thriving culture.

The idea of medicine as a cultural beacon of goodness may seem profoundly counter-cultural. Our appetite seems much greater for stories of doctors whose financial or sexual misconduct has disgraced themselves and the profession. Yet for the professions to play a role in reshaping our habits of mind and heart, their members must act courageously, not waiting until the cultural winds have shifted but letting their better voices speak even when no one else seems to be listening.The Conversation


This article is republished from The Conversation under a Creative Commons license. Read the original article.