Lung cancer screening in primary care: more pragmatic research needed

The US Preventive Services Task Force, the American Academy of Family Physicians, and the American College of Chest Physicians recommend annual low-dose computed tomography (CT) screening for adults 50 to 80 years of age who have at least a 20 pack-year smoking history and currently smoke or have smoked within the past 15 years. A 2020 meta-analysis of eight randomized controlled trials (summarized in a POEM in American Family Physician) concluded that low-dose CT screening prevents one lung cancer death for every 250 people screened. A 2023 Cochrane for Clinicians article found similar benefits but also noted that for every 10,000 people screened, 363 unnecessary invasive tests are performed. Despite private and public insurance plans fully covering lung cancer screening in the United States, only 10% to 30% of eligible individuals in were receiving it in a recent state-by-state survey.

Barriers to implementing findings from lung cancer screening trials into typical clinical practice include the nonrepresentative nature of research participants (younger, healthier, and less racially and geographically diverse than the target populations) and the superior infrastructure and clinical support available to them. Although an analysis of the National Lung Screening Trial suggested that the eligible people in the United States would experience similar benefits as trial participants, questions about the generalizability of other studies remain.

In a research paper in the January/February 2025 issue of the Journal of the American Board of Family Medicine, Dr. Erin Hirsch and colleagues rated lung cancer screening trials and the nonrandomized Veterans Health Administration Demonstration Project with an established tool that evaluated each study through a primary care lens. Domains included eligibility, recruitment, setting, organization, flexibility of delivery, flexibility of adherence, follow-up, primary outcome, and primary analysis. The investigators scored studies on a 5-point scale, with 1 being completely explanatory and 5 being completely pragmatic. The mean study scores ranged from 2.12 to 3.33, indicating that even the most pragmatic studies fell well short of simulating conditions in community settings.

A lack of pragmatic research may explain why interventions intended to increase lung cancer screening rates have had mostly disappointing results. A systematic review and meta-analysis of intervention studies identified five randomized controlled trials and one prospective observational study. Interventions included patient navigation, outreach calls, and decision aids; control groups received usual care or informational materials. Only two of the studies found statistically significant increases in participation in the intervention group, and a meta-analysis found no difference overall (relative risk = 1.30; 95% CI, 0.74-2.29). A subgroup analysis suggested that multistep interventions targeting multiple barriers may be more effective than single-step ones.

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This post first appeared on the AFP Community Blog.

Food for thought on food as medicine

This month, President Trump nominated Dr. Casey Means, a former ear, nose, and throat surgeon who dropped out of residency and reinvented herself as a wellness influencer and New York Times bestselling author, for Surgeon General. I read Means's book, "Good Energy: The Surprising Connection Between Metabolism and Limitless Health," a few months ago. It discourages intake of processed foods, eschews fad diets, aligns with mainstream nutrition guidance (e.g., Michael Pollan's pithy "eat [real] food, not too much, mostly plants"), and has received positive reviews in publications ranging from NPR to Family Medicine.

My main concern about the book is that it seems aimed mostly at well-off households with the health literacy and leisure time to read self-help books and the disposable income to do most of their shopping at farmer's markets and Whole Foods stores. If Dr. Means ends up being confirmed by the Senate, she should consider writing a sequel ("Great Energy"? "Good Energy for the Budget-Conscious"?) for the 11 million families headed by single parents who often work two or more jobs to get by and have fewer options for buying groceries. For these families, the healthiness of food may not be their top priority. A Pew Research Center survey found that overall, Americans ranked taste as the most important factor in choosing food, followed by cost, then healthiness and convenience. So it isn't enough to tell people what foods are best for their health (or make labels on packaged foods simpler to understand); we also need to make the healthy option the default option.

There is good evidence that federal nutrition programs such as the Supplemental Nutrition Assistance Program (SNAP, previously known as "food stamps") and Special Supplemental Nutritional Program for Women, Infants, and Children (WIC) improve health. A Research Letter in JAMA documented increases in food insecurity and days with poor physical health after the end of a temporary pandemic increase to SNAP benefits in March 2023. An Agency for Healthcare Research and Quality evidence synthesis that I previously discussed showed that WIC improves important maternal and child health outcomes. Conversely, a longer-term study suggests that food insecurity in childhood increases cardiovascular risk and obesity in young adulthood, since one is more likely to eat excess food of poor nutritional value if they don't know where their next meal is coming from.

Although I support banning soda purchases from SNAP, eliminating food insecurity by making the program more generous could have an equally beneficial an effect on health. Currently, a four-person household in Pennsylvania must earn less than $62,000 per year to be eligible for SNAP, and the average benefit is $6 per day, or $42 per week. A national program that provided low-income adults with additional vouchers averaging $63 per month for produce purchases (the majority of households were already enrolled in SNAP and/or WIC) led to improvements in food security, diabetes control, weight loss, and blood pressure.

In a recent statement, the U.S. Preventive Services Task Force found insufficient evidence to assess the benefits and harms of screening for food insecurity in health care settings. That doesn't mean that targeted "food as medicine" programs, which should be "understood as complementing and not supplanting existing food and nutrition assistance programs," can't be effective. Ten states have piloted Medicaid managed care projects to address poor nutrition as a health-related social need and use health care dollars to pay for food pharmacies, healthy food vouchers, and medically tailored meals. 

It's worth noting, though, that these promising programs are likely to be defunded if the nearly $1 trillion in Medicaid and SNAP cuts in the recent federal budget bill passed on a party-line vote by the House of Representatives eventually becomes law. Either way, I will continue giving to our local food bank, as the prescription for food insecurity is food, and hungry patients do not make healthy patients.

Fecal immunochemical testing for colorectal cancer is effective and cost-effective

The U.S. is one of only a few countries in the world that relies on colonoscopy as a primary method of screening for colorectal cancer (rather than reserving it for the evaluation of people who test positive on stool-based screenings). I recently wrote a commentary in Medscape about new evidence that supports a continued role for fecal immunochemical testing (FIT) as a colorectal cancer screening test. My article concluded:

When reviewing colorectal cancer screening test choices with patients, family physicians can continue to recommend annual or biennial FIT as a comparable option to colonoscopy. If FIT is selected, we should provide a kit with liquid vial sample collection, if possible, and include a suggested return date in patient instructions. Finally, clinicians in leadership and population health management roles should advocate for cost-effective investments in patient navigation to enhance colorectal cancer screening and diagnostic colonoscopy completion rates, because these initiatives play a crucial role in preventing colorectal cancer deaths.

Exact Sciences, which sells a $600 stool-based screening test that combines FIT with a test for colorectal cancer DNA, would like physicians and patients to believe that its test ("Cologuard") provides superior value to practices and health systems than FIT alone. But an analysis published this week in the Annals of Internal Medicine indicates that it does not. Using data from the original Cologuard diagnostic performance study and a study of a second-generation version (Cologuard Plus), Dr. Hermann Brenner and colleagues at Heidelberg University in German showed that the cost per colorectal cancer detected is 7- to 9-fold higher for Cologuard and Cologuard Plus compared to FIT, depending on what percentage of patients undergo colonoscopy after a positive test result.

Identifying and managing gambling-related harms

The Supreme Court under Chief Justice John Roberts (the Roberts Court) has made several high-profile rulings affecting health care over the past two decades, including its 2012 decision that upheld the Affordable Care Act’s Medicaid expansion but made it optional for states and its 2022 decision that abortion was not a fundamental right protected by the US Constitution.

A less heralded ruling with health implications occurred in 2018, when the Roberts Court held that a prior federal law forbidding states to legalize sports betting was unconstitutional. This decision led to the rapid proliferation of online sports gambling platforms and their ubiquitous television advertisements. No longer do people need to travel to brick and mortar casinos to place bets on players or teams; now they can legally win and lose large sums through a variety of smartphone apps. 68 million Americans, or one in four adults, planned to wager an estimated $15.5 billion on the NCAA Division I basketball tournaments (March Madness) this year.

Expanded access to sports gambling has fueled a rise in the number of people affected by gambling disorder. Previously known as pathologic gambling, gambling disorder manifests as “impaired control over gambling, gambling taking precedence over other life interests, and the continuation or escalation of gambling despite negative consequences.” Young males are the demographic group most likely to have gambling disorder, and comorbid alcohol use disorder and depression are common. Although prevalence estimates in North America are low (1.5% of women, 2.7% of men), hazardous gambling—risky or compulsive gambling behavior that does not meet criteria for gambling disorder—is thought to be far more common, particularly in older adults with more leisure time.

A recent article in the BMJ summarized a National Institute for Health and Care Excellence (NICE) guideline on identification and management of gambling-related harms. Based on expert opinion and low-certainty evidence, NICE recommends that clinicians ask direct questions about gambling in patients with mental health concerns, alcohol or substance use disorders, housing or financial insecurity, justice involvement, and certain higher-risk professions (eg, active-duty military, veterans, sports professionals, people working in the gambling or financial industries). People with gambling disorder are at increased risk for self-harm and suicide attempts. Effective treatments include referral to self-help groups such as Gamblers Anonymous, group or individual cognitive behavioral therapy, motivational interviewing, and naltrexone. Psychology Today maintains a national directory of therapists with training in CBT for gambling disorder.

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This post first appeared on the AFP Community Blog.

Migraine headaches: diagnostic and treatment tips

A patient with a history of headaches is brought by ambulance to the emergency department for the abrupt onset of weakness and decreased sensation in their left arm and leg. A code stroke is called. Are these symptoms of an acute stroke or a stroke mimic, such as a hemiplegic migraine?

A retrospective analysis of characteristics of 15 consecutive years of code stroke cases at a hospital in Barcelona, Spain, found that patients who were ultimately diagnosed with migraine headache with aura (1.1%) were more likely to be younger, female, and have fewer vascular risk factors than patients with ischemic strokes. In addition, an initial NIH Stroke Scale of greater than 6 (odds ratio = 3.74) and a fibrinogen level of greater than 400 mg/dL (odds ratio = 2.98) distinguished strokes from migraine headaches.

An article on acute migraine headaches in the April 2025 issue of American Family Physician reviewed current treatment strategies for acute migraine headaches, which “account for … 3.6 million primary care visits annually and are the fifth most common reason for emergency department visits” in the United States. The POUND mnemonic (ie, pulsatile quality, one-day duration, unilateral headache, nausea or vomiting, disabling intensity) can help clinicians make the diagnosis of migraine in primary care, and the Migraine Disability Assessment (MIDAS) quantifies headache severity. Scores that indicate MIDAS grades III and IV should prompt clinicians to consider targeted migraine medications rather than simple analgesics.

Although several drug classes are effective for acute migraine, a 2024 systematic review and network meta-analysis of 137 randomized controlled trials (summarized in a POEM in the April 2025 issue of AFP) found that triptans produced greater pain relief at 2 hours and less use of rescue drugs in the first 2 to 24 hours than the newer and more expensive medications ubrogepant, rimegepant, and lasmiditan.

Clinical practice guidelines on the management of episodic migraine headache, including the 2023 US Veterans Affairs/Department of Defense guideline, preferentially recommend triptans for most patients. In March, the American College of Physicians released a pharmacologic treatment guideline that recommends adding a triptan in nonpregnant adults with moderate to severe migraines who have not responded to a nonsteroidal anti-inflammatory drug or acetaminophen. Triptans can cause vasospasm, so they are contraindicated in patients with coronary artery disease, cardiovascular disease, and peripheral artery disease and should not be used in combination with ergot alkaloids.

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This post first appeared on the AFP Community Blog.

For family medicine workforce, HHS reorganization plan receives a failing grade

Match Day on March 21, 2025 unfolded similarly to the National Resident Matching Program in previous years. My program successfully recruited a full class of 13 future interns from medical schools across the country, but family medicine as a whole, despite the typically rosy American Academy of Family Physicians news story, didn't even come close, with 15% of slots unfilled and a quarter of programs needing to enter the Supplemental Offer and Acceptance Program (SOAP, previously known as the "Scramble"). The sub-headline from a Medscape news article said it all: "Anesthesiology Still Hot, Family Medicine Is Not."

Before becoming a core faculty member at the Lancaster General Hospital Family Medicine Residency Program, I spent more than 15 years teaching in Georgetown's family medicine department. Part of my job was to encourage students' interest in primary care careers and mentor those who chose to enter family medicine. Out of a typical graduating class of 200 students, our largest family-medicine bound group was 15 (7.5%) and the smallest was 6 (3%). Most years, two or three times as many students matched into Anesthesiology or Orthopedic Surgery.

While I'm grateful for subspecialists who alleviate pain, rescue patients who are unable to breathe on their own, manage complicated fractures, and replace worn-out hips and knees, the gap between the number of family doctors we need and the number we have keeps getting wider. The number of visits to primary care physicians fell by 43% from 2010 to 2021 despite 7.4% growth in the U.S. population, and a near-doubling in outpatient visits to advanced practice providers (the majority of whom work in medical subspecialties) wasn't enough to make up for this deficit. Challenges in accessing timely primary care affect not only private practices and health systems, but also the publicly funded Veterans Affairs system.

How can we train more family physicians? A recent study in Family Medicine found that contrary to conventional wisdom, more graduating students switch in to family medicine from another specialty than switch out of it after intending on family medicine upon matriculation. (I'm an example of this pattern, having intended to become a pediatrician when I started medical school.) Although this doesn't diminish the importance of nurturing students who (like my wife) declare their interest in family medicine starting on day one, it seems to make representation on admissions committees less critical. Other proposals include streamlining pathways for international medical graduates to enter residency programs in fields with physician shortages.

A report funded by the Milbank Memorial Fund highlighted five states - Virginia, Rhode Island, Connecticut, Oklahoma, and California - that are or will be setting spending targets for primary care as a percentage of their overall health care spend in order to increase their supply of clinicians and give practices more of the resources they need to improve health outcomes. This is, to put it mildly, easier said than done, starting with how to define primary care, estimate the health care dollars flowing into it, and determine the optimal percentage of those dollars. And if you build it, will they come?

We can hope and pray that some combination of interventions in premed programs, medical school, residency, and financial compensation will build the primary care infrastructure that America needs and prevent our health outcomes from getting much worse than they already are. But we need more research to design and implement these efforts. Dr. Rochelle Walensky, who directed the Centers for Disease Control and Prevention (CDC) from 2021 to 2023, calls the current state of affairs an "evidence emergency":

There is no more urgent research need than addressing the health of the workforce that is charged primarily with caring for the people of its nation. And yet, there is neither a funding stream nor a cohesive research community to do so. An investment in the evaluation of initiatives to strengthen the physician workforce is critical, and such research should not be conducted in silos. Data must be shared and evidence compiled and then directly interpreted and acted on for program and policy decision making.

Foundations such as Milbank, the Kaiser Family Foundation, and the Commonwealth Fund can't support this work by themselves. This is where the federal government must step up. But the Trump administration's radical shrinking and restructuring of the Department of Health and Human Services (HHS), which decimated the workforces and research grant-issuing functions of the better-known National Institutes of Health and the CDC, has also vanished the agency responsible for supporting health services research. According to HHS, the Agency for Healthcare Research and Quality will be merged into an "Office of Strategy," and the Health Services and Resources Administration (HRSA), which supports the backbone of federally qualified health centers that provide primary care to 1 in 11 Americans, will be consolidated into RFK Jr.'s "Administration for a Healthy America." To use a professional football analogy, it's as if the general manager of the team with the league's worst record used their premium draft picks to select a bunch of recreational players who wouldn't have been drafted by any other team in the first place. Instant analysis: a failing grade for HHS.