Faculty Peer Reviewed
Hello and welcome to another edition of primecuts! This week we’ll explore studies from the that look at breast cancer screening guidelines, treatment strategies for secondary prevention of myocardial infarction, treatment strategies for alzeimers disease, and the affects of war on health.
In a new practice bulletin published this week, the American College of Obstetrics and Gynecology (ACOG) took another look at the same studies used by the United States Preventive Services Task Force (USPSTF) for breast cancer screening and reinterpreted the evidence.  Using a study by Nelson et al, the USPSTF concluded that because the number needed to treat for 39–49 year old women was 1,904, compared with 1,339 in 50–59 year olds, it would not be cost effective to screen women younger than 50. [2,3] The ACOG sought to define benefit as numbers of years of life gain rather than cost effectiveness, which is why they are now extending the age for screening to as early as 40. Unfortunately, how they exactly defined or calculated the number of years of life gained is not made clear by the article. They do, however, cite that the relative risk reduction of breast cancer mortality for this age group is comparable to older populations (0.85 vs 0.86). Citing a recent study in which combining the clinical breast exam with mammography increased the sensitivity of breast cancer detection from 88.6% to 94.6%, they continue to recommend annual clinical breast examination for women 40 years and older.  They also recommend 1-3yr exams for women from 20-40 despite the potential for false positives and unnecessary invasive diagnostics. Ultimately, the bulletin did not cite new research, so clinicians still have to weigh the risks and benefits of more aggressive screening using the data we have right now.
As the mean age of our population rises, age-related diseases have become an important part of daily medical practice. Alzheimer’s disease in particular poses a difficult challenge, as very few medications exist that decrease morbidity or mortality from the disease. A British trial, currently available only online, examined the use of anti-depressents in Alzheimers patients.  In this multicenter, prospective, and randomized trial, elderly patients with alzheimers and dementia were randomized into 3 arms. The control group received placebo. The remaining patients were divided into treatment with sertraline or treatment with mirtazipine. All were followed with depression testing at 13 and 39 weeks. The main flaw of the study is its lack of power, with only a little over 300 patients evaluated. The severity of depression was not significantly different amongst the control, the mirtazipine group and/or the sertraline group. They did, however, see a significant increase in the number of adverse reactions in the intervention groups (sertraline 46/107, mertazapine 44/108) vs control (29/111). There were no mortality benefits seen with administration of either drug. The study helps clinicians better understand that treating depression in patients with Alzheimers dementia is more complicated than treating those without the disease. This study may help to better frame the risks and benefits of recommending an anti-depressant to these patients and will possibly help direct clinicians to interventions that may be more effective.
Another important question to ask as the population lives longer and longer is, ‘how long should someone be on aspirin for secondary prevention?’. A Lancet article published last week showed that the answer is ‘indefinitely’ if you want to prevent myocardial infarction.  A group of epidemiologists performed a case-control study using the “Health Improvement Network” electronic database and randomly selected 39,533 patients that were started on aspirin for secondary prevention. They followed the charts of these patients starting in 2000 until their first recorded diagnosis of myocardial infarction, cancer, alcohol abuse, age 85, death, or the end of the study period in 2007. The researchers compared outcomes between those on aspirin and recent discontinuers. Those that recently discontinued aspirin had a significantly increased risk of non-fatal myocardial infarction or death from coronary heart disease compared with current users (rate ratio 1.43, 1.12 to 1.84). Though the database is large and the analyses were robust, the main limitation of the study is that it relies on chart review. Nonetheless, the research affirms the importance of lifetime use of aspirin use post MI.
Lastly, we take a look at the affect of today’s sociopolitical climate on health. The New England Journal featured an article this past week looking at a study that followed the work-up of 80 soldiers with chronic/persistent decreased exercise tolerance after returning from serving in Iraq and Afghanistan.  The patients underwent an extensive evaluation involving exercise testing, pulmonary function testing and imaging. Of 49 patients referred for biopsy, 38 were diagnosed with constrictive bronchiolitis, a diagnosis that was not otherwise suspected due to rarity and lack of findings elsewhere. Ultimately, the researchers conclude that there is a strong association between constrictive bronchiolitis and exercise limitation in those who served in the Middle East. They hint that occupational exposure to sulfur mines, incinerated waste, or dust could have contributed to the diagnosis. A year after diagnosis and almost 5 years after returning from deployment, 22 patients surveyed still had significant limitation in climbing 1 flight of stairs, implying the permanence of their debility after coming back from war. This offers a sober reminder of the long-lasting affects of war.
Dr. Vicky Jones is a 3rd year resident at NYU Langone Medical Center
Peer reviewed by Danise Schiliro, MD, contributing editor, Clinical Correlations
Image courtesy of Wikimedia Commons
(1) Practice bulletin no. 122: breast cancer screening. Obstetrics and gynecology [0029-7844] yr:2011 vol:118 iss:2 Pt 1 pg:372 -382. http://journals.lww.com/greenjournal/Citation/2011/08000/Practice_Bulletin_No__122__Breast_Cancer_Screening.40.aspx
(2) Nelson HD, Tyne K, Naik A, Bougatsos C, Chan BK, Humphrey L. Screening for Breast Cancer. Annals of Internal Medicine in November 2009 Ann Intern Med 2009;151:727-737. http://www.annals.org/content/151/10/716.full.pdf+html
(3) Mandelblatt J, Saha S, Teutsch S, Hoerger T, Siu AL, Atkins D, et al. The cost-effectiveness of screening mammography beyond age 65 years: a systematic review for the U.S. Preventive Services Task Force. Cost Work Group ofthe U.S. Preventive ServicesTask Force. Ann Intern Med 2003;139:835–42. http://www.annals.org/content/139/10/835.abstract
(4) Chiarelli AM, Majpruz V, Brown P, Theriault M, Shumak R, Mai V. The contribution of clinical breast examination to the accuracy of breast screening. J Natl Cancer Inst 2009; 101:1236–43. http://jnci.oxfordjournals.org/content/101/18/1236.abstract
(5) Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial. The Lancet, Early Online Publication, 18 July 2011 doi:10.1016/S0140-6736(11)60830-1. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60830-1/abstract
(6) Garcia Rodriguez L A et al. Discontinuation of low dose aspirin and risk of myocardial infarction: case-control study in UK primary care. BMJ 2011; 343:d4094 doi: 10.1136/bmj.d4094 (Published 19 July 2011). http://www.bmj.com/content/343/bmj.d4094
(7) King MS, Eisenberg R, Newman JH, Tolle JJ, Harrell FE Jr, Nian H, Ninan M, Lambright ES, Sheller JR, Johnson JE, Miller RF. Constrictive bronchiolitis in soldiers returning from Iraq and Afghanistan. N Engl J Med. 2011 Jul 21;365(3):222-30. http://www.nejm.org/doi/full/10.1056/NEJMoa1101388