Primecuts: This week in the journals

March 23, 2009

angeloak3.JPGCommentary by David Ecker MD PGY-1 

Faculty  Peer Reviewed

Excitement permeated medical centers throughout the country last Thursday as interns realized a new wave of reinforcements had been named. At Match Day, graduating medical students learned which of the 22,427 first-year residency positions (187 more than last year) they would fill. One-fifth of positions were offered in internal medicine, while family medicine applicants found 101 fewer positions than last year. The National Resident Match Program reported dermatology, neurosurgery, orthopedic surgery, and otolaryngology to be the most competitive specialties. As we offer congratulations, we also offer our gratitude to an energetic generation of physicians dedicated to disease prevention and treatment in hopes of improving our quality of life.

Just as these young adults accept their new role as budding physicians, the NEJM published disturbing results of the Coronary Artery Risk Development in Young Adults (CARDIA) study. This multicenter, prospective study highlights racial and ethnic disparities in health care, and it argues that this inequality leads to increased preventable morbidity and, likely, mortality. Specifically, blacks were nearly 20 times more likely than whites to develop heart failure before 50 years of age. Moreover, the authors identified hypertension, obesity, chronic kidney disease, and depressed systolic function to be present 10-15 years before the onset of clinical heart failure. These potentially modifiable antecedents reiterate the impact proper screening & intervention may have on disease prevention as we strive to eliminate health disparities.

In an effort to be more inclusive, the USPSTF revised their recommendations regarding the use of aspirin for the prevention of cardiovascular disease. This update reflects the increasing trend to include women in cardiovascular research and integrates the results of the Women’s Health Study (WHS) and a new sex-based meta-analysis of aspirin trials. The WHS found that aspirin did not reduce rates of myocardial infarction (MI) nor death but it did reduce stroke risk by 17%.

The USPSTF guideline tells us the 10 year CHD risk percentage above which the benefit of aspirin use in men and in women outweigh the risk (gastrointestinal hemorrhage). This translates to aspirin use in:

Men aged 45-59 with a 10 year CHD risk of greater than/equal to 4%
Men aged 60-69 with a 10 year CHD risk greater than/equal to 9%
Men aged 70-79 with a 10 year CHD risk greater than/equal to 12%

Women aged 55-59 with a 10 year CHD risk of greater than/equal to 3%
Women aged 60-69 with a 10 year CHD risk greater than/equal to 8%
Women aged 70-79 with a 10 year CHD risk greater than/equal to 11%

It should be noted that USPSTF does not recommend aspirin use for cardiovascular disease prevented in women younger than 55 or in men younger than 45 and is inconclusive in those older than 80.

So as not to exclude the male population, we spotlight the New England Journal of Medicne which published the mortality results of two large, randomized prostate-cancer screening trials. In the U.S. Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, the screening group was offered annual digital rectal examination for 4 years and annual PSA testing (>4 ng/mL was considered positive) for 6 years. The European Randomized Study of Screening for Prostate Cancer (ERSPC) trial offered PSA screening an average of once every 4 years with biopsies generally recommended for PSA levels >3 ng/mL. Not surprisingly, both studies showed that screening was associated with a relative increase of about 22% and 70% in the rate of prostate-cancer diagnoses, respectively.

What about mortality? Whereas the PLCO study found that after 7 years of follow-up, the rate of death from prostate cancer did not differ significantly between the two groups, the ERSPC study found that screening decreased the rate of death from prostate cancer by 20%. This translates into an absolute reduction of 7 deaths in 10,000 men screened after 9 years of follow up. This must be compared to the “cost” of screening, which included 17,000 biopsies among men in the 73,000 in the screening group. The accompanying editorial sums it up as: 1410 men would need to be offered screening and an additional 48 would need to be treated to prevent one prostate-cancer death during a 10-year period, assuming the point estimate of ERSPC is correct.

So where does this leave us in guiding our patients? The risk to benefit ratio of screening continues to be the subject of discussion and the USPSTF will likely maintain their position of a shared decision-making approach to PSA screening in men younger than 75 years old and against screening in men age 75 years and older.

Not all news was positive this week, for a survey commissioned by the non-profit National Council on Aging (NCOA) shows many of those with chronic disease are delaying health care due to cost, living in pain, and feeling abandoned by their health care providers. Over half of those surveyed said their health care providers have not asked whether they have help to manage their problems and 45% say that they rarely or never receive referrals to resources such as classes, counselors, dieticians and health educators. The NCOA is calling on health care professionals to connect their patients with effective community self-care programs that include teaching problem-solving, decision-making, and communication skills needed by people with chronic conditions. They report such programs can result in significant improvements in energy, health status, social activities, less fatigue and lower use of the hospital and/or emergency room.

So, as we continue our medical education, we are asked to eliminate healthcare disparities, provide preventative medicine, balance the harms and risks of tailored therapies, as well as ensure patients have the resources and confidence to manage their health outside the clinical setting. How can we not be excited for an additional 44,854 healing hands?

 

Reviewed by Judith Brenner MD, Associate Editor, Clinical Correlations

National Resident Matching Program.  Main Residency Match [Internet].  Updated 2009 Mar 19; cited 2009 Mar 21.  Available from: http://www.nrmp.org/

Bibbins-Domingo K, et al.  Racial Differences in Incident Heart Failure among Yong Adults.  NEJM.  2009 Mar 19; 360(12): 1179-1190.

U.S. Preventative Services Task Force.  Aspirin for the prevention of Cardiovascular Disease: U.S. Preventative Services Task Force Recommendation Statement.  Ann Int Med.  2009 Mar 17; 150(6): 396-404.

Andriole GL, et al.  Mortality Results from a Randomized Prostate-Cancer Screening Trial.  NEJM.  2009 Mar 18; 360(13): 1310-1319.

Schröder FH, et al.  Screening and Prostate-Cancer Mortality in a Randomized European Study.  NEJM.  2009 Mar 18; 360(13): 1320-1328.

National Council on Aging.  Re-forming Healthcare: Americans Speak Out About Chronic Conditions & the Pursuit of Healthier Lives [Internet].  Updated 2009 Mar 18; cited 2009 Mar 21.  Available from: http://www.ncoa.org/index.cfm.

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