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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
May 5, 2012

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Higher Omega-3 Intake Linked to Lower Levels of Alzheimer's Biomarker
U.S. Fares Worse Than Other Developed Nations in Preterm Birth Rate
Reanalyzed Chantix Data Yield Smaller CV Risk, New Controversy
Why Health Literacy Matters
Antimicrobial Resistance in Isolates from Humans and Food Animals
Levofloxacin Approved for Plague
What's the Incidence of Venous Thromboembolism After Knee Arthroscopy?
Disinhibited Attachment Disorder Persists in Young Foster-Care Children
Testosterone Use Escalating in Libido Race
Medical Societies Say Pharmacists Dispensing Without Rx 'Scary'
Sunscreen Advice Called Overkill
Subclinical Hyperthyroidism Raises Risk for Mortality and Cardiac Events
Overdiagnosis of Invasive Breast Cancer with Screening Mammography

MM: We are aware that fish oil may reduce inflammation and our grandmothers always referred to fish as “brain food”. This study indicates the two ideas may find a convergence.
Higher Omega-3 Intake Linked to Lower Levels of Alzheimer's Biomarker
Patients may ask about a study suggesting that increased dietary intake of omega-3s is associated with lower serum levels of amyloid-β (Aβ), an early indicator of Alzheimer disease. The cross-sectional study appears online in Neurology.
Some 1200 people aged 65 and older who were free of dementia answered food-frequency questionnaires and then underwent serum Aβ measurement about a year later. After adjustment for confounders, participants with higher omega-3 intake had lower levels of Aβ42. Other nutrients did not show an association. Participants obtained their omega-3s mainly through salad dressing, fish, poultry, margarine, and nuts.
The authors say their findings suggest "that the potential beneficial effects of [omega-3] intake on AD and cognitive function in the literature might be at least partly explained by an [Aβ]-related mechanism."
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U.S. Fares Worse Than Other Developed Nations in Preterm Birth Rate
Twelve percent of babies born in the U.S. are born preterm (before 37 weeks' gestation), according to a WHO report released Wednesday. In contrast, rates in most European countries, Canada, and Australia range from 7% to 9%.
The higher rate in the U.S. may be explained, in part, by the large numbers of births among teenagers and women aged 35 and older, as well as a high prevalence of twins and triplets implanted after in vitro fertilization (many of whom are delivered early by cesarean section). The WHO report also notes that obesity, diabetes, and hypertension — all common among American women — increase risk for preterm birth.
Other countries that share the 12% rate include Kenya, Turkey, Thailand, Somalia, and Honduras.
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MM: Beware of headlines. They may be misleading. This article stinks of outside influence. Previous studies were larger and longer and found significant long term increased risks of Chantix®. Those studies looked at long term, real life situations. This study is like an isolated lab compared to a multi-center experiment. It simply doesn’t hold up. Last month new interpretations of the Women’s health Initiative (WHI) study said that Premarin® reduced the risk of breast cancer compared to placebo. This type of date simply demonstrates what my father always told me, “that figures don’t lie but liars can figure.”
Reanalyzed Chantix Data Yield Smaller CV Risk, New Controversy
A new meta-analysis criticizes earlier work warning that the smoking-cessation drug varenicline (Chantix) poses increased cardiovascular risks.
The analysis appears in BMJ. It was performed by researchers with no current ties to the drug maker, but one of whom had received a Pfizer investigator-initiated research award.
The new analysis examined the risk of treatment-emergent serious cardiovascular events during 22 randomized placebo-controlled trials comprising over 9200 participants. Events were those defined as occurring within 30 days of stopping treatment (the earlier analysis included events up to 1 year later). Contrary to the earlier findings, the new analysis found a cardiovascular event rate of 0.63% with varenicline and 0.47% with placebo.
Calling the risk estimate of the earlier analysis "inflated," the authors say that, on the contrary, the risk associated with varenicline use "is statistically and clinically insignificant." Sonal Singh, author of the earlier meta-analysis, says he stands by his results and that "people need to look at the data and make up their own minds."
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MM: Apparently there are reasons other than entertainment to listen to our weekly radio show and read these articles. It appears that those who are more familiar with health issues live better and longer than those who are not. So please, keep listening to the radio on Saturday mornings to, The Dr and the Pharmacist on WYLL, 1160 AM at 10am Central time.
BMJ 2012 Mar 15; 344:e1602
Why Health Literacy Matters
Low health literacy was associated with higher all-cause mortality.
Low health literacy is associated with poorer medication adherence, greater use of emergency services, more-frequent hospitalization, and, among elders and patients with heart failure, higher mortality (e.g., JW Gen Med Jun 9 2011). Investigators analyzed the association between functional health literacy — being able to apply reading skills and basic knowledge in a health context — and all-cause mortality among 7857 people (age ≥52) from a random sample of households in England. Participants were administered a four-item test of their comprehension of written instructions for taking aspirin.
Health literacy was determined to be high (i.e., no test errors) in 67% of the cohort, medium (1 error) in 20%, and low (>1 error) in 13%. During a mean follow-up of 5 years, mortality was 6% in the high-literacy group, 9% in the medium-literacy group, and 16% in the low-literacy group. After adjustment for behavioral, demographic, baseline-health, and cognitive variables, all-cause mortality risk was significantly greater in the low-literacy group than in the high-literacy group (hazard ratio, 1.3).
Comment: Low health literacy is associated with elevated all-cause mortality risk — a finding that, according to the authors, has "implications for the design and delivery of health related services." We don't yet know, however, whether health-literacy screening is feasible in clinical settings or would improve long-term outcomes, including survival.
Paul S. Mueller, MD, MPH, FACP Published in Journal Watch General Medicine April 3, 2012
Citation(s):Bostock S and Steptoe A. Association between low functional health literacy and mortality in older adults: Longitudinal cohort study. BMJ 2012 Mar 15; 344:e1602.
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Emerg Infect Dis 2012 May; 18:741
Antimicrobial Resistance in Isolates from Humans and Food Animals
Prevalence of multidrug resistance in Escherichia coli increased from 7% to 64% during the 5-decade study period and was more frequent in animal than in human isolates.
Antibiotic use is the primary force driving the increase in resistance. To assess changes in resistance rates over time, investigators conducted a retrospective study of Escherichia coli isolates recovered from human and animal specimens submitted between 1950 and 2002 to the E. coli Reference Center and the CDC from public health and veterinary diagnostic laboratories in multiple states. Of 1729 isolates, 983 were from humans and 746 were from cattle, pigs, and chickens. The isolates were tested for susceptibility to 15 antimicrobial drugs.
Overall, 65% of human isolates and 20% of animal isolates were susceptible to all tested drug classes. Multidrug resistance (i.e., resistance to ≥3 antimicrobial classes) was found in >50% of isolates from pigs, cattle, and chickens and in 15% of those from humans. Prevalence of multidrug resistance increased from 7% in isolates from1950–1959 to 64% in those from 2000–2002. Two isolates — both recovered from cattle in 2001 — were resistant to all 15 drugs tested.
In animal-origin E. coli, resistance rates increased for 11 of the 15 antimicrobials during the study period. Gentamicin resistance, found in animal isolates from the 1980s (and in 40% of those collected in 2002), was not seen in human isolates collected before the late 1990s. Like numerous other classes of antimicrobials used to treat human infections, aminoglycosides (including gentamicin) are widely used in food animals.
Comment: As the authors acknowledge, this study is limited by its retrospective design and by the nonrandom collection of samples. Still, the results show a striking, progressive increase in antibiotic resistance during the decades following the introduction of these drugs in humans and animals. The authors note that persistence of resistance to some drugs, such as chloramphenicol, after their withdrawal may reflect cross-resistance conferred by closely related agents.
Mary E. Wilson, MD Published in Journal Watch Infectious Diseases May 2, 2012
Citation(s): Tadesse DA et al. Antimicrobial drug resistance in Escherichia coli from humans and food animals, United States, 1950–2002. Emerg Infect Dis 2012 May; 18:741.
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Levofloxacin Approved for Plague
The FDA has approved the antibiotic levofloxacin (Levaquin) to treat plague and to reduce the risk for acquiring it after exposure.
The drug's approval was based on a laboratory trial of African green monkeys that were infected with the plague bacterium Yersinia pestis. Monkeys were randomized to receive 10 days of levofloxacin or placebo within 6 hours of fever onset. Survival was 94% in the levofloxacin group and 0% in the placebo group.
There are about 10 to 15 cases of plague annually in the U.S., according to the CDC.
CDC info on the Plague: http://www.cdc.gov/ncidod/dvbid/plague/
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J Bone Joint Surg Am 2012 Apr 18; 94:714
What's the Incidence of Venous Thromboembolism After Knee Arthroscopy?
Incidence was 0.40% in this large cohort study.
A million arthroscopic knee procedures are performed annually in the U.S., according to the CDC; pharmacologic prophylaxis to prevent venous thromboembolism (VTE) is not administered routinely after this procedure. In a retrospective study from California's Kaiser Permanente health system, researchers calculated the incidence of symptomatic VTE after 21,000 recent elective knee arthroscopies. Patients with histories of VTE and patients who received prophylaxis were excluded; only 2% of patients met these exclusion criteria.
The 90-day incidence of symptomatic VTE was 0.40%, with cases divided roughly evenly between proximal deep venous thrombosis only and pulmonary embolism; only a few cases involved isolated calf-vein thromboses. VTE risk was above average in people 50 or older (odds ratio, 1.5) and in women who had been prescribed oral contraceptives recently (OR, 2.2).
Comment: Because the incidence of symptomatic VTE after knee arthroscopy is quite low, these authors endorse the American College of Chest Physicians guideline, which states "For patients undergoing knee arthroscopy without a history of prior VTE, we suggest no thromboprophylaxis rather than prophylaxis" (Chest 2012; 141 [Suppl 2]:7S). For patients with histories of VTE (and perhaps patients at high risk for other reasons), pharmacologic prophylaxis seems reasonable.
Allan S. Brett, MD Published in Journal Watch General Medicine April 24, 2012
Citation(s):Maletis GB et al. Incidence of symptomatic venous thromboembolism after elective knee arthroscopy. J Bone Joint Surg Am 2012 Apr 18; 94:714.
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Am J Psychiatry 2012 Mar 8
Disinhibited Attachment Disorder Persists in Young Foster-Care Children
The finding was especially strong in children adopted after age 24 months.
The Bucharest Early Intervention Project is a longitudinal study comparing 136 infants (baseline age range, 8–31 months) who were randomized to institutionalized or foster care. The children were also compared with 72 typically raised, ethnically matched children living at home (JW Psychiatry Feb 11 2008). Now, researchers report on participants' rates of inhibited and disinhibited reactive attachment disorders, which were comprehensively assessed at baseline, at ages 30, 42, and 54 months, and at age 8 years.
Foster families received specialized social worker care. Analyses included the effect of age at placement in foster homes (before or after age 24 months).
Fostered children who were diagnosed at baseline with inhibited attachment disorder showed marked improvement and were indistinguishable from children living at home after age 30 months; age at placement was not a significant factor. Foster children with disinhibited attachment disorder improved from baseline, but continued to have signs of the disorder, especially if placement occurred after age 24 months. Significantly more signs of attachment disorders were found in the institutionalized group than in the other groups. Lower baseline cognitive ability was associated with worse outcomes.
Comment: These data add to the Bucharest Project's previous findings of adverse effects of maternal deprivation. For parents inquiring about the emotional status of potential foster children or adoptees, these study findings provide some guidance. Children with disinhibited attachment are at high risk for this disorder to persist. By contrast, children without disinhibited attachment disorder who have age-level cognitive development and who are adopted before age 24 months are at low risk for attachment psychopathology.
Barbara Geller, MD Published in Journal Watch Psychiatry April 9, 2012
Citation(s): Smyke AT et al. A randomized controlled trial comparing foster care and institutional care for children with signs of reactive attachment disorder. Am J Psychiatry 2012 Mar 8; [e-pub ahead of print].
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Testosterone Use Escalating in Libido Race
Eli Lilly & Co. and Abbott Laboratories are "helping" 13.8 million American men who have low levels of testosterone. In what may become one of the most sought-after sex enhancement treatments since the introduction of Viagra 14 years ago, new testosterone products from Abbott, Lilly and others are in hot demand. Prescriptions for testosterone replacement therapies have more than doubled since 2006 to 5.6 million. Men are lining up to get injections, gels, and patches to boost their testosterone. One man, 43, a home stager in New York and Chicago stated, "Am I making a deal with the devil? A little bit, but I have to think about my quality of life," Murray said. "It is like I'm in my 20s again." He doesn't have any obvious symptoms of low testosterone levels but simply wants to raise his energy level and give his bodybuilding regime a boost.
Similar to the millions of women who have opted for hormone replacement therapy, men are choosing to get their hormone levels in line. In the U.S., as many as 13.8 million men older than 45 have low levels of testosterone, according to a 2006 study in the International Journal of Clinical Practice. Male testosterone levels begin to decline after age 30 and tend to drop about 1 percent each year, though the level of decline varies. Lower levels can lead to a loss of libido, decrease in bone and muscle mass, and depression.
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MM: I agree with the medical societies that are opposed to this cavalier attitude towards non-physician prescribing. This is a short sighted solution to our nation’s socio-medical economic woes. In the long run patients may suffer more and society will likely pay a larger long term price for mistreatment or mismanagement of medical conditions. From a more selfish perspective, although I give advice as a pharmacist on a daily basis for free, I am offended that this type of legislation would as much as state that my knowledge and advice has no monetary value. It is assumed that consumers would get their advice for free from pharmacists. I find this insulting and offensive. If I choose to give information for free, that’s one thing. If it’s mandated, that’s another. Even when I give out free advice I am subject to professional liability. In contrast, I have not noticed any legislation dictating that free legal advice and legal representation should be mandated. After all, it’s the lawyers who are in government and who are writing the legislation. This is another scam to prevent those in healthcare from being appropriately compensated.
Medical Societies Say Pharmacists Dispensing Without Rx 'Scary'
Think about a patient walking into a pharmacy, self-diagnosing a cough at a kiosk with medical software, and then getting a drug from a pharmacist without a physician's prescription. The FDA is considering this scenario, much to the alarm of the American Medical Association (AMA) and other medical societies, which see the beginnings of an end-run around physician authority.
The FDA has been soliciting opinions on creating a new paradigm for drug approval since February. "Safe use" could mean a pharmacist assessing whether a patient has any condition or risk factor that would contraindicate the use of a particular drug, or helping a patient choose between different drugs. The FDA is also stating that with some medications, an initial visit to a clinician for a prescription would be required, but more automatic refills than usual would be allowed before a follow-up visit.
"Safe-use medications" could benefit many Americans who go untreated or undertreated for their conditions because of the "cost and time required." At the FDA hearing on March 22, two medical societies went on record objecting to the proposal for OTC safe-use drugs.
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Sunscreen Advice Called Overkill
Excess sun can cause skin cancer, but when applied as advised, sunscreen blocks vitamin D, which could cause many more cancers 
by Craig Weatherby
Challenging conventional wisdom about sun exposure and cancer can prove dangerous to a researcher’s career. Like Copernicus, Boston University Professor Michael F. Holick got burned for expressing scientifically accurate views on the sun.

In 2004, he was forced to resign his professorship of dermatology … simply for suggesting, in a book called The UV Advantage, that exposure to sunlight without sun block for five or 10 minutes a day can be beneficial. His point was that very brief sun exposure generates lots of vitamin D … the hormone-like nutrient needed to strengthen bones and protect against infections and chronic illnesses like diabetes, major cancers, and multiple sclerosis.

We’ve covered the growing body of evidence that vitamin D is critical to health and disease prevention … see the Vitamin D section of our news archive … which includes 10 subsections covering everything from Immunity, Bone, Heart, and Brain Health to Sources, Intakes, Metabolic Health, Pregnancy, and Children.

Earlier this decade, Dr. Holick and fellow vitamin D researchers published findings that deem vitamin D deficiency a public health disaster (Grant WB, Garland CF, Holick MF 2005):

 Now, a clinical study from cloudy Denmark further discredits the anti-sun war waged by official dermatology.

Danish scientists find sunscreen advice blocks vitamin D
According the authors of a study published in the British Journal of Dermatology, people who use the amount and sun protection factor (SPF) of sunscreen recommended by the World Health Organization (WHO) produce little or no vitamin D. Their findings suggest that excessive, obsessive sunscreen use may lead to vitamin D deficiency. Researchers from Copenhagen’s Bispebjerg Hospital recruited 37 healthy volunteers with fair skin (Faurschou A et al. 2012). The volunteers applied sunscreen that met WHO recommendations for thickness and SPF rating, and the Danish team measured the subjects’ blood levels of vitamin D before and after exposure to ultraviolet B (UVB) radiation.
Sunscreen with an SPF of eight was applied at thicknesses – measured as milligrams per square centimeter of skin (mg/cm²) – that ranged from 0.5, 1, 1.5, or 2 mg/cm². Some of the volunteers applied no sunscreen, to serve as controls. Every two to three days, the recruits’ sunscreen-covered skin areas were exposed to UVB radiation equal to three “standard erythema (skin reddening) doses” 20 minutes after sunscreen application. This cycle was repeated four times. The researchers found that the participants who’d applied thinner sunscreen layers produce more vitamin D after their UVB exposure. However, vitamin D levels did not rise significantly in those treated with the thickest layer of sunscreen (2 mg/cm²) … which is the level recommended by the WHO.

As the authors wrote, “… we demonstrated that the vitamin D serum [blood] level increases in an exponential manner with decreasing thickness of sunscreen layer in response to UVB exposure.” And they drew a reasonable conclusion: “Our results suggest that sunscreen use according to the current recommendations by the WHO may be re-evaluated” (Faurschou A et al. 2012).
Do sunscreens prevent skin cancer?
Epidemiological studies have linked excessive sun exposure to risk of common, relatively non-threatening skin cancers … and sunscreens do seem to prevent these. But there’s little or no evidence that – absent certain melanoma risk factors (see below) – moderate exposure increases the risk of any kind skin cancer … see our sidebar, “Professor Holick on sun exposure and skin cancer.” There’s little evidence that sunscreens prevent the rarest and far more deadly form, called melanoma. But it’s only been a decade since sunscreens began to protect against both kinds of UV radiation, including the UVA type thought to promote melanoma. The melanoma-prevention message has been sun avoidance, especially at midday intensity, but things are not so clear-cut. For example, there are more cases of melanoma in people living at northern latitudes, where the sun is less intense, than among people in southern latitudes.

Several factors other than sun exposure appear related to development of melanoma:

Many researchers, including Dr. Holick, believe that another risk factor might be reliance on UVB-only sunscreens. Until the late 1990s, all sunscreens protected only against UVB sunrays … the form of radiation that reddens the skin and is believed to cause the far more common non-melanoma skin cancers … basal-cell and squamous-cell carcinomas. The use of UVB-only sunscreens led many people to stay in the sun but did not protect them against UVA sunrays, which cause wrinkles, and may cause melanoma. Now, all sunscreens contain screens against UVA and UVB. However, the extent of UVA protection they provide remains uncertain and controversial, so it makes sense to exercise caution. Basal cell carcinoma accounts for more than 90 percent of all skin cancers, is typically slow-growing, and seldom spreads to other parts of the body, while squamous cell carcinoma spreads slightly more often. All skin cancers should be found and treated early because they can invade and destroy nearby tissue.

Sources: Bastuji-Garin S, Diepgen TL. Cutaneous malignant melanoma, sun exposure, and sunscreen use: epidemiological evidence. Br J Dermatol. 2002 Apr;146 Suppl 61:24-30. Review. Diffey BL. Sunscreens and melanoma: the future looks bright. Br J Dermatol. 2005 Aug;153(2):378-81. Doré JF, Chignol MC. Tanning salons and skin cancer. Photochem Photobiol Sci. 2012 Jan;11(1):30-7. Epub 2011 Aug 15. Review. Faurschou A, Beyer DM, Schmedes A, Bogh MK, Philipsen PA, Wulf HC. The relation between sunscreen layer thickness and vitamin D production after UVB exposure - a randomised clinical trial. Br J Dermatol. 2012 Apr 18. doi: 10.1111/j.1365-2133.2012.11004.x. [Epub ahead of print] Gandini S, Autier P, Boniol M. Reviews on sun exposure and artificial light and melanoma. Prog Biophys Mol Biol. 2011 Dec;107(3):362-6. Epub 2011 Sep 19. Review. Gorham ED, Mohr SB, Garland CF, Chaplin G, Garland FC. Do sunscreens increase risk of melanoma in populations residing at higher latitudes? Ann Epidemiol. 2007 Dec;17(12):956-63. Grant WB, Garland CF, Holick MF. Comparisons of estimated economic burdens due to insufficient solar ultraviolet irradiance and vitamin D and excess solar UV irradiance for the United States. Photochem Photobiol. 2005 Nov-Dec;81(6):1276-86. Green AC, Williams GM, Logan V, Strutton GM. Reduced melanoma after regular sunscreen use: randomized trial follow-up. J Clin Oncol. 2011 Jan 20;29(3):257-63. Epub 2010 Dec 6. Huncharek M, Kupelnick B. Use of topical sunscreens and the risk of malignant melanoma: a meta-analysis of 9067 patients from 11 case-control studies. Am J Public Health. 2002 Jul;92(7):1173-7. Oliveria SA, Saraiya M, Geller AC, Heneghan MK, Jorgensen C. Sun exposure and risk of melanoma. Arch Dis Child. 2006 Feb;91(2):131-8. Epub 2005 Dec 2. Review. Vainio H, Bianchini F. Cancer-preventive effects of sunscreens are uncertain. Scand J Work Environ Health. 2000 Dec;26(6):529-31. Whiteman DC, Whiteman CA, Green AC. Childhood sun exposure as a risk factor for melanoma: a systematic review of epidemiologic studies. Cancer Causes Control. 2001 Jan;12(1):69-82. Review.
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Arch Intern Med 2012 Apr 23
Subclinical Hyperthyroidism Raises Risk for Mortality and Cardiac Events
Risk was particularly high with thyrotropin levels <0.10 mIU/mL.
The results of prospective cohort studies conflict on whether subclinical hyperthyroidism (thyrotropin level <0.45 mIU/L, with normal free thyroxine and triiodothyronine) is associated with elevated incidence of coronary heart disease (CHD) or atrial fibrillation (AF). This meta-analysis combined the results of 10 such studies with 53,000 participants (median age, 59), of whom 2188 (4%) had subclinical hypothyroidism.
During median follow-up of 9 years, in analyses adjusted for age and sex, the risk for those with subclinical hyperthyroidism compared to those who were euthyroid was increased 24% for overall mortality, 29% for CHD mortality and 68% for incident AF. Risks were even higher in those with thyrotropin levels <0.10 mIU/L, and risks did not change substantially after adjustments for other cardiovascular risk factors. The risk attributable to subclinical hyperthyroidism, after accounting for traditional risk factors, was 14.5% for total mortality and 41.5% for incident AF.
Comment: A recent guideline recommends treatment of subclinical hyperthyroidism to prevent cardiac events and osteoporosis, particularly when thyrotropin levels are <0.10 mIU/mL (Thyroid 2011; 21:593). An editorialist agrees with these recommendations, particularly for elderly people with cardiac risks and patients with osteoporosis, but no large randomized trials have evaluated whether treatment results in actual clinical benefit.
Thomas L. Schwenk, MD Published in Journal Watch General Medicine May 3, 2012
Citation(s):Collet T-H et al. Subclinical hyperthyroidism and the risk of coronary heart disease and mortality. Arch Intern Med 2012 Apr 23; [e-pub ahead of print].
Burman KD. What is the clinical importance of subclinical hyperthyroidism? Arch Intern Med 2012 Apr 23; [e-pub ahead of print].
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Ann Intern Med 2012 Apr 3; 156:491
Overdiagnosis of Invasive Breast Cancer with Screening Mammography
Study indicates that overdiagnosis accounts for a significant proportion.
Much attention has been focused on overdiagnosis when screening for prostate cancer, but how common is overdiagnosis with screening mammography? In Norway, a mammography screening program was gradually implemented region by region over a decade, beginning in 1996. Using a complex methodologic approach, researchers compared breast cancer incidence in regions and periods before program initiation with the incidence after initiation of mammography screening to estimate rates of overdiagnosis. Ductal carcinoma in situ was not studied, given its differing clinical course.
Nearly 40,000 cases of invasive breast cancer were diagnosed during the decade. For every 2500 women invited to undergo mammography screening, estimates indicated that 20 cases of clinically important breast cancer were diagnosed and that an additional 6 to 10 cases that would not have become clinically apparent were also diagnosed –– these latter cases represent overdiagnosis.
Comment: Overdiagnosis plays a role in any screening program. This study's methodology makes it difficult to accurately assess whether the risk for overdiagnosis was overestimated. Nonetheless, the study reminds us that mammography screening can identify cases that would have remained clinically silent.
Jamaluddin Moloo, MD, MPH Published in Journal Watch General Medicine April 26, 2012
Citation(s):Kalager M et al. Overdiagnosis of invasive breast cancer due to mammography screening: Results from the Norwegian screening program. Ann Intern Med 2012 Apr 3; 156:491.
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