USPSTF 2011 Recommendations for Testicular Cancer Screening

The Buzz: USPSTF 2011 Recommendations Regarding Screening for Testicular Cancer

Citation:

Screening for Testicular Cancer: U.S. Preventive Services Task Force Reaffirmation Recommendation Statement. Annals of Internal Medicine April 5, 2011 Vol 154 p483-6.

Lin K and Sharangpani R. Screening for Testicular Cancer: An Evidence Review for the U.S. Preventive Services Task Force. Annals of Internal Medicine September 21, 2010 Vol 153 396-9.

Summary:

Because of the low incidence and high cure rate of testicular cancer, the USPSTF recommends against routine screening, which includes self exams and clinical exams, in asymptomatic adolescent and adult men (Grade D Recommendation); the benefit would be minimal (if any) and the theoretical risks include the psychological effects of false-positives and harms from diagnostic procedures. Even though patients themselves discover most cases of testicular cancer, there is no evidence that teaching young men to do self-testicular exams would improve health outcomes. The USPSTF instead recommends that clinicians consider testicular cancer in the differential diagnosis when young men present with testicular signs and symptoms. They conclude that prompt assessment and better evaluation of testicular complaints are much more beneficial than widespread screening for early detection.

The American Academy of Family Physicians does not support routine screening, the American Cancer Society does not recommend testicular self-examination, and the American Academy of Pediatrics does not believe in screening for testicular cancer as part of preventive health care.

Commentary:

The USPSTF recommends against screening for testicular cancer in asymptomatic men ages 15-34 years. Instead, more effort should be devoted to prompt assessment and thorough evaluation of adolescent or adult men who present with testicular complaints.

By: Lien Le, MS3, UCSF Medical School

Update on treatment of worsening pharyngitis

The Buzz: There's a new possibility to consider when evaluating patients with worsening pharyngitis
Citation: Avoiding sore throat morbidity and mortality: when is it not "just a sore throat?" American Family Physician January 1, 2011 Vol 83:1 p26-7 
Summary: Fusobacterium necrophorum (Fn) is a newly recognized bacterial cause of sore throat and can result a potentially very serious complication called Lemierre syndrome, or septic thrombophlebitis of the internal jugular vein resulting in metastatic pulmonary infections. Patients typically complain of a sore throat which initially improves after 4-5 days but then worsens with symptoms including rigors, fever, night sweats. Mortality is up to 5% of those affected. Lemierre syndrome occurs most often in those aged 15-30 years. Unfortunately there is no laboratory method for diagnosing Fn infections.

So what's a doc to do? First of all, the article reminds us of the differential diagnosis of worsening sore throat including non-group A strep, untreated group A strep (often due to a false negative rapid strep test which can miss up to 10% of cases), infectious mononucleosis, acute HIV infection, peritonsillar abscess, and Lemierre syndrome. Second, we should remember to consider antibiotic treatment in patients with 3 or more of the following: fever, absence of cough, tender anterior cervical lymph nodes and tonsillar exudate. Penicillin remains the drug of choice for presumed strep infections. It also has activity against Fn. If we suspect Lemiere syndrome (recurrence of sore throat with new rigors or fever), clindamycin can be used in well-appearing patients though ER referral/hospital admission for IV antibiotics should be considered for ill-appearing patients with high fevers, rigors, or unilateral neck swelling.
Commentary: While the data are still being gathered, it's a good idea to keep this info in mind when treating patients with persistent or worsening symptoms. 
By: Spencer Blackman MD

Updated guidelines on management of CA-MRSA infections

The Buzz: Updated guidelines clarify approach to this growing problem
Citation: Clinical Infectious Diseases 2011:52  http://cid.oxfordjournals.org/content/early/2011/01/04/cid.ciq146.full.pdf
Summary: Community acquired methicillin-resistant S. Aures (CA-MRSA) infections continue to be on the rise and knowing the appropriate treatment and prevention guidelines is crucial. The Infections Disease Society of America released updated guidelines for the management of skin and soft tissue infections due to CA-MRSA which include the following key points:
- The primary treatment for cutaneous abscess is immediate incision and drainage.
- Antibiotic treatment should be also used for any of the following: multiple sites of infection, signs of systemic infection (fever, etc), rapidly growing infection, concomitant cellulitis, extremes of age, immunocompromise, significant comorbidities, difficult area to drain (e.g. face, hand, genitalia), lack of response to I&D alone.
- For cellulitis with purulence, antibiotic coverage should include empiric CA-MRSA coverage (Bactrim DS 1-2 po bid, Doxy 100 bid, Clinda 300-450 tid, linezolid). Duration of treament is 5-10 days and should be individualized.
- For cellulitis without purulence, empiric beta-hemolytitc streptococcus coverage should be used (Bactrim, Keflex 500 qid, Clinda) but CA-MRSA coverage is likely not needed.
-The use of rifampin as a single agent or as adjunct therapy is not indicated 


The management of recurrent infections with CA-MRSA was also addressed and included:
- Education around frequent hand washing and good hygiene practices
- Avoid reusing personal grooming items (disposable razors, e.g.) and wash all towels/clothes/linens that come in contact with open wounds.
- Focus cleaning efforts on high-touch surfaces like doorknobs and counter tops.
- Decolonization protocols may also be employed and include twice daily intranasal mupirocin 2% for 5-14 days, bathing with antibacterial soaps (chlorhexadine) for 5-10 days, and dilute bleach baths (1/4 cup bleach to 1/4 tub or 13 gallons water) for 15 min twice weekly for up to 3 months.
- Decolonization of household contacts can be considered.

By: Spencer Blackman MD

Comparing approaches to diabetes screening

The Buzz: ADA guidelines outperform the updated USPSTF approach to screening for diabetes

Citation: A Sheehy et. al. Analysis of Guidelines for Screening Diabetes Mellitus un an Ambulatory Population.  Mayo Clinic Proc. January 2010; 85(1):27-35

Summary: Of the estimated 25 million Americans currently with diabetes, approximately 40% continue to be undiagnosed, and determining the most effective screening method may prevent significant morbidity and mortality. Currently, the American Diabetes Association (ADA) and the US Preventative Services Task Force (USPSTF) have issued vastly different guidelines for screening for diabetes. This retrospective study included 28,842 patients from a large, Midwestern primary care practice, comparing the performance of both approaches to screening. The study found that adhering to USPSTF guidelines would have identified 33% fewer new cases of diabetes, and the authors recommended using the ADA guidelines due to their superior performance. One caveat is the population of patients under 45 who are non-obese with hypertension, for whom the USPSTF recommends screening and the ADA guidelines do not. Study authors point out this is an important group to screen as well.  The study also found that a history of pre-diabetes or polycystic ovarian syndrome conferred the highest risks for developing diabetes.

Commentary: This study suggests we combine USPSTF and ADA guidelines in an effort to identify more cases of diabetes.

By: Maxwell Jen, MSIII & Spencer Blackman, MD

New study assesses risk-reduction of mammography

The Buzz: A novel study from Norway suggests that risk reduction from mammography may be much lower than previously thought.
Citation: M Kalager et. al. Effect of Screening Mammography on Breast-Cancer Mortality in Norway.  N Engl J Med 2010; 363:1203-1210

Summary: Previous observational attempts to quantify the benefit of mammography have relied on historical data for control groups, making it difficult to control for the effect that time (increased breast cancer awareness, better treatment methods, e.g.) may have on improvement in breast cancer survival. Norway has a national public health system which rolled out a program for breast cancer screening (mammography every 2 years for women aged 50-69) and treatment (multidisciplinary treatment teams offered to all women with a new diagnosis of breast cancer) staggered region by region from 1996 to 2005. Using data from 40,075 women, this study compared similar groups in counties where the new program simultaneously was and was not available, thus eliminating possible confounding effects of time.  The study also looked at geographically matched groups from 1986-1995 when the new program was not available. Absolute risk reduction from the combined screening and treatment program in women 50-69 years old was found to be 10%, though it was not possible to say how much of the benefit was from mammography itself.

To address this question, the study included analysis of women aged 70-84 who did not undergo mammography but who were treated by the new teams. In this group, the benefit of the new treatment teams was an 8% reduction in risk.

According to an accompanying editorial, these data suggest that "2500 women would need to be screened over a 10-year period for 1 to avoid death from breast cancer." Moreover, of those 2500, 1000 would be expected to have a false positive on mammography, and 5 to 15 would be wrongly diagnosed and treated. The editor suggests that the decision to initiate or continue screening mammography might be best decided by an informed patient, and that its use should not be a measure of quality in our current health care system.
By: Spencer Blackman MD

Time 2 take ur pill

The Buzz: Text message-based reminder system for OCP use does not seem to improve adherence.
Citation: Hou MY et al. Using daily text-message reminders to improve adherence with oral contraceptives: A randomized controlled trial. Obstet Gynecol 2010 Sep; 116:633.
Summary: Study authors randomized 82 predominantly white, all high-school graduate new or resuming OCP users to to receive daily text-message reminders or no reminders for three cycles. The number of missed pills per cycle was the same in both groups (around 4.5/month). There were no pregnancies in either group.
Commentary: The high rate of missed pills reported in this study suggests that even with advanced reminder systems, many women on OCPs are at higher risk for pregnancy then we might think. OCPs are still a valid option, but this study may aid in shared decision-making around optimal methods.  
By: Spencer Blackman MD

Rosiglitazone (Avandia) and increased risk of CV events

The Buzz: FDA advisory committees recommend removing rosiglitazone
Citation: AAFP News Now, 7/20/2010
Summary: Members of two FDA advisory committees have expressed concerns over the safety of rosiglitazone (Avandia) and have recommended removing the medication from the list of approved drugs. While investigation into the safety of rosiglitazone has been ongoing since 2007, two recent studies from JAMA and the Archives of Internal Medicine
reported significant elevation in CV risk associated with its use. Of note, GlaxoSmithKline, the maker of Avandia, has said that it will record a $2.36 billion legal charge in the second quarter of fiscal year 2010 for settlements related to rosiglitazone.
Commentary: While FDA has yet to make a decision, we should consider getting our patients off rosiglitazone, and certainly not write new prescriptions for it. Pioglitazone (Actos) is considered safer than rosiglitazone, though it should be considered only in patients refractory to or intolerant of first- and second-line therapies.
By: Spencer Blackman MD

UPDATE (9/25/2010): Rosiglitazone has been pulled from the European market, and will only be offered to US patients in whom "every other" diabetes medication has been tried.