Albert L. Siu

Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement

IMPORTANCE Colorectal cancer is the second leading cause of cancer death in the United States. In 2016, an estimated 134,000 persons will be diagnosed with the disease, and about 49,000 will die from it. Colorectal cancer is most frequently diagnosed among adults aged 65 to 74 years; the median age at death from colorectal cancer is 68 years. OBJECTIVE To update the 2008 US Preventive Services Task Force (USPSTF) recommendation on screening for colorectal cancer. EVIDENCE REVIEW The USPSTF reviewed the evidence on the effectiveness of screening with colonoscopy, flexible sigmoidoscopy, computed tomography colonography, the guaiac-based fecal occult blood test, the fecal immunochemical test, the multitargeted stool DNA test, and the methylated SEPT9 DNA test in reducing the incidence of and mortality from colorectal cancer or all-cause mortality; the harms of these screening tests; and the test performance characteristics of these tests for detecting adenomatous polyps, advanced adenomas based on size, or both, as well as colorectal cancer. The USPSTF also commissioned a comparative modeling study to provide information on optimal starting and stopping ages and screening intervals across the different available screening methods. FINDINGS The USPSTF concludes with high certainty that screening for colorectal cancer in average-risk, asymptomatic adults aged 50 to 75 years is of substantial net benefit. Multiple screening strategies are available to choose from, with different levels of evidence to support their effectiveness, as well as unique advantages and limitations, although there are no empirical data to demonstrate that any of the reviewed strategies provide a greater net benefit. Screening for colorectal cancer is a substantially underused preventive health strategy in the United States. CONCLUSIONS AND RECOMMENDATIONS The USPSTF recommends screening for colorectal cancer starting at age 50 years and continuing until age 75 years (A recommendation). The decision to screen for colorectal cancer in adults aged 76 to 85 years should be an individual one, taking into account the patients overall health and prior screening history (C recommendation).

Aspirin for the Prevention of Cardiovascular Disease: U.S. Preventive Services Task Force Recommendation Statement

DESCRIPTION Update of the 2002 U.S. Preventive Services Task Force (USPSTF) recommendation about the use of aspirin for the prevention of coronary heart disease. METHODS Review of the literature since 2002, focusing on new evidence on the benefits and harms of aspirin for the primary prevention of cardiovascular disease, including myocardial infarction and stroke. The new evidence was reviewed and synthesized according to sex. RECOMMENDATIONS Encourage men age 45 to 79 years to use aspirin when the potential benefit of a reduction in myocardial infarctions outweighs the potential harm of an increase in gastrointestinal hemorrhage. (A recommendation) Encourage women age 55 to 79 years to use aspirin when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. (A recommendation) Evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years or older. (I statement) Do not encourage aspirin use for cardiovascular disease prevention in women younger than 55 years and in men younger than 45 years. (D recommendation).

A Comparison of Pain and Its Treatment in Advanced Dementia and Cognitively Intact Patients with Hip Fracture

Advanced dementia patients may be at substantial risk for undetected or undertreated pain. To examine the treatment of pain following hip fracture, a prospective cohort study was conducted in an academic teaching hospital. Fifty-nine cognitively intact elderly patients with hip fracture and 38 patients with hip fracture and advanced dementia were assessed daily. The cognitively intact patients rated their pain on a numeric scale ranging from 0 (none) to 4 (very severe). Analgesics prescribed and administered were recorded and compared to hip fracture patients with advanced dementia. The advanced dementia patients received one-third the amount of morphine sulfate equivalents as the cognitively intact patients. Forty-four percent of cognitively intact individuals reported severe to very severe pain preoperatively and 42% reported similar pain postoperatively. Half the cognitively intact patients who experienced moderate to very severe pain were prescribed inadequate analgesia for their level of pain. Eighty-three percent of cognitively intact patients and 76% of dementia patients did not receive a standing order for an analgesic agent. These data reveal that a majority of elderly hip fracture patients experienced undertreated pain. The fact that advanced dementia patients received one-third the amount of opioid analgesia as compared to cognitively intact subjects-40% of whom reported severe pain postoperatively-suggests that the majority of dementia patients were in severe pain postoperatively. This study and others suggest that directed interventions to improve pain detection and alter physician prescribing practices in the cognitively impaired are needed.

The impact of post-operative pain on outcomes following hip fracture.

&NA; Untreated pain is a major health care issue and very little is known about the treatment of pain and the effect of pain on post‐operative outcomes in older adults. This study was performed to identify the impact of pain on outcomes following hip fracture in older adults. Four hundred and eleven consecutive cognitively intact patients admitted with hip fracture to four New York hospitals were enrolled in a prospective cohort study. Patients were interviewed daily using standardized pain assessments. We used multiple logistic regression and ordinary least squares linear regression to examine the association of post‐operative pain on immediate post‐operative outcomes (duration of stay, physical therapy sessions missed or shortened, ambulation following surgery, and post‐operative complications) and outcomes 6 months following fracture (locomotion, mortality, return to the community, residual pain). Patients with higher pain scores at rest had significantly longer hospital lengths of stay (P=0.03), were significantly more likely to have physical therapy sessions missed or shortened (P=0.002), were significantly less likely to be ambulating by post‐operative day 3 (P<0.001), took significantly longer to ambulate past a bedside chair (P=0.01), and had significantly lower locomotion scores at 6 months (P=0.02). Pain at rest was not significantly associated with post‐operative complications, nursing home placement, survival at 6 months, or residual pain at 6 months. Post‐operative pain is associated with increased hospital length of stay, delayed ambulation, and long‐term functional impairment. Whereas appropriate caution is warranted in administering opioid analgesics to older adults, these data suggest that improved pain control may decrease length of stay, enhance functional recovery, and improve long‐term functional outcomes.

Impacts of Geriatric Evaluation and Management Programs on Defined Outcomes: Overview of the Evidence

Comprehensive geriatric assessment is a technique for multidimensional diagnosis of frail elderly people with the purpose of planning and/or delivering medical, psychosocial, and rehabilitative care. When comprehensive geriatric assessment is coupled with some therapy, then the term geriatric evaluation and management (GEM) will be used. Following a brief history of comprehensive geriatric assessment, we describe the varied patterns of GEM program organization and review the literature of studies examining GEM effectiveness. Program diversity complicates drawing firm conclusions about GEM effects; however, the vast majority of studies report positive, if not uniformly significant, results. Our analysis suggests that much of the variability in findings is due to sample size limitations

Screening for Depression in Adults: US Preventive Services Task Force Recommendation Statement

DESCRIPTION Update of the 2009 US Preventive Services Task Force (USPSTF) recommendation on screening for depression in adults. METHODS The USPSTF reviewed the evidence on the benefits and harms of screening for depression in adult populations, including older adults and pregnant and postpartum women; the accuracy of depression screening instruments; and the benefits and harms of depression treatment in these populations. POPULATION This recommendation applies to adults 18 years and older. RECOMMENDATION The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. (B recommendation).

Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement

The U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without related signs or symptoms. It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment. The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms. Summary of Recommendations and Evidence The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. (B recommendation) The decision to start screening mammography in women prior to age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years. (C recommendation) For women who are at average risk for breast cancer, most of the benefit of mammography results from biennial screening during ages 50 to 74 years. Of all of the age groups, women aged 60 to 69 years are most likely to avoid breast cancer death through mammography screening. While screening mammography in women aged 40 to 49 years may reduce the risk for breast cancer death, the number of deaths averted is smaller than that in older women and the number of false-positive results and unnecessary biopsies is larger. The balance of benefits and harms is likely to improve as women move from their early to late 40s. In addition to false-positive results and unnecessary biopsies, all women undergoing regular screening mammography are at risk for the diagnosis and treatment of noninvasive and invasive breast cancer that would otherwise not have become a threat to their health, or even apparent, during their lifetime (known as overdiagnosis). Beginning mammography screening at a younger age and screening more frequently may increase the risk for overdiagnosis and subsequent overtreatment. Women with a parent, sibling, or child with breast cancer are at higher risk for breast cancer and thus may benefit more than average-risk women from beginning screening in their 40s. Go to the Clinical Considerations section for information on implementation of the C recommendation. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women aged 75 years or older. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the benefits and harms of digital breast tomosynthesis (DBT) as a primary screening method for breast cancer. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging (MRI), DBT, or other methods in women identified to have dense breasts on an otherwise negative screening mammogram. (I statement) These recommendations apply to asymptomatic women aged 40 years or older who do not have preexisting breast cancer or a previously diagnosed high-risk breast lesion and who are not at high risk for breast cancer because of a known underlying genetic mutation (such as a BRCA1 or BRCA2 gene mutation or other familial breast cancer syndrome) or a history of chest radiation at a young age. See Figure 1 for a summary of the recommendation and suggestions for clinical practice. Figure 1. Screening for breast cancer: clinical summary. Appendix Table 1 describes the USPSTF grades, and Appendix Table 2 describes the USPSTF classification of levels of certainty about net benefit. Appendix Table 1. What the USPSTF Grades Mean and Suggestions for Practice Appendix Table 2. USPSTF Levels of Certainty Regarding Net Benefit Supplement. Consumer Fact Sheet Rationale Importance Breast cancer is the second-leading cause of cancer death among women in the United States. In 2015, an estimated 232000 women were diagnosed with the disease and 40000 women died of it. It is most frequently diagnosed among women aged 55 to 64 years, and the median age of death from breast cancer is 68 years (1). Benefit and Harms of Screening and Early Treatment The USPSTF found adequate evidence that mammography screening reduces breast cancer mortality in women aged 40 to 74 years. The number of breast cancer deaths averted increases with age; women aged 40 to 49 years benefit the least and women aged 60 to 69 years benefit the most. Age is the most important risk factor for breast cancer, and the increased benefit observed with age is at least partly due to the increase in risk. Women aged 40 to 49 years who have a first-degree relative with breast cancer have a risk for breast cancer similar to that of women aged 50 to 59 years without a family history. Direct evidence about the benefits of screening mammography in women aged 75 years or older is lacking. The USPSTF found adequate evidence that screening for breast cancer with mammography results in harms for women aged 40 to 74 years. The most important harm is the diagnosis and treatment of noninvasive and invasive breast cancer that would otherwise not have become a threat to a womans health, or even apparent, during her lifetime (that is, overdiagnosis and overtreatment). False-positive results are common and lead to unnecessary and sometimes invasive follow-up testing, with the potential for psychological harms (such as anxiety). False-negative results (that is, missed cancer) also occur and may provide false reassurance. Radiation-induced breast cancer and resulting death can also occur, although the number of both of these events is predicted to be low. The USPSTF found inadequate evidence on the benefits and harms of DBT as a primary screening method for breast cancer. Similarly, the USPSTF found inadequate evidence on the benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, MRI, DBT, or other methods in women identified to have dense breasts on an otherwise negative screening mammogram. In both cases, while there is some information about the accuracy of these methods, there is no information on the effects of their use on health outcomes, such as breast cancer incidence, mortality, or overdiagnosis rates. USPSTF Assessment The USPSTF concludes with moderate certainty that the net benefit of screening mammography in women aged 50 to 74 years is moderate. The USPSTF concludes with moderate certainty that the net benefit of screening mammography in the general population of women aged 40 to 49 years, while positive, is small. The USPSTF concludes that the evidence on mammography screening in women age 75 years and older is insufficient, and the balance of benefits and harms cannot be determined. The USPSTF concludes that the evidence on DBT as a primary screening method for breast cancer is insufficient, and the balance of benefits and harms cannot be determined. The USPSTF concludes that the evidence on adjunctive screening for breast cancer using breast ultrasound, MRI, DBT, or other methods in women identified to have dense breasts on an otherwise negative screening mammogram is insufficient, and the balance of benefits and harms cannot be determined. Clinical Considerations Benefit of Screening The results of the meta-analysis of clinical trials from the systematic evidence review commissioned by the USPSTF are summarized in Table 1. Over a 10-year period, screening 10000 women aged 60 to 69 years will result in 21 (95% CI, 11 to 32) fewer breast cancer deaths. The benefit is smaller in younger women: Screening 10000 women aged 50 to 59 years will result in 8 (CI, 2 to 17) fewer breast cancer deaths, and screening 10000 women aged 40 to 49 years will result in 3 (CI, 0 to 9) fewer breast cancer deaths (2, 3). Most of these trials began enrollment more than 30 years ago, and these estimates may not reflect the current likelihood of avoiding a breast cancer death with contemporary screening mammography technology. Mammography imaging has since improved, which may result in more tumors being detected at a curable stage today than at the time of these trials. However, breast cancer treatments have also improved, and as treatment improves, the advantage of earlier detection decreases, so that some of the women who died of breast cancer in the nonscreened groups in these trials would survive today. Table 1. Breast Cancer Deaths Avoided (95% CI) per 10 000 Women Screened by Repeat Screening Mammography Over 10 Years: Data From Randomized, Controlled Trials* Harms of Screening The most important harm of screening is the detection and treatment of invasive and noninvasive cancer that would never have been detected, or threaten health, in the absence of screening (overdiagnosis and overtreatment). Existing science does not allow for the ability to determine precisely what proportion of cancer diagnosed by mammography today reflects overdiagnosis, and estimates vary widely depending on the data source and method of calculation used (2, 4). In the United States, the rate of diagnosis of invasive plus noninvasive breast cancer increased by 50% during the era of mammography screening (Figure 2) (5). It is not possible to know with certainty what proportion of that increase is due to overdiagnosis and what proportion reflects other reasons for a rising incidence. If overdiagnosis is the only explanation for the increase, 1 in 3 women diagnosed with breast cancer today is being treated for cancer that would never have been discovered or caused her health problems in the absence of screening. The best estimates from randomized, controlled trials (RCTs) evaluating the

Using nontraditional risk factors in coronary heart disease risk assessment: U.S. Preventive Services Task Force recommendation statement.

DESCRIPTION New recommendation from the U.S. Preventive Services Task Force (USPSTF) on the use of nontraditional, or novel, risk factors in assessing the coronary heart disease (CHD) risk of asymptomatic persons. METHODS Systematic reviews were conducted of literature since 1996 on 9 proposed nontraditional markers of CHD risk: high-sensitivity C-reactive protein, ankle-brachial index, leukocyte count, fasting blood glucose, periodontal disease, carotid intima-media thickness, coronary artery calcification score on electron-beam computed tomography, homocysteine, and lipoprotein(a). The reviews followed a hierarchical approach aimed at determining which factors could practically and definitively reassign persons assessed as intermediate-risk according to their Framingham score to either a high-risk or low-risk strata, and thereby improve outcomes by means of aggressive risk-factor modification in those newly assigned to the high-risk stratum. RECOMMENDATION The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of using the nontraditional risk factors studied to screen asymptomatic men and women with no history of CHD to prevent CHD events. (I statement).

Screening for Dementia and Investigating Its Causes

OBJECTIVE To examine, from the perspective of primary care physicians, the value of mental status findings and ancillary tests in diagnosing dementia or its causes. DATA SOURCES Studies identified using MEDLINE and bibliographies of pertinent articles. STUDY SELECTION Selection based on availability of information on specific findings or tests, the criterion standard used to confirm diagnoses, the disease spectrum, and the richness of the reported data. DATA EXTRACTION Data collected on sensitivity and specificity. In many cases, the originally reported data are re-analyzed to illustrate the usefulness of alternative cut-off values or to answer specific clinical questions. Likelihood ratios estimated to summarize test results. DATA SYNTHESIS Probability of dementia is greatly reduced (likelihood ratio, 0.06 to 0.2) when either normal serial 7s, 7-digit span, 3-item recall, or clock drawing test results are obtained; abnormal results only moderately increase the odds of disease. Low (less than or equal to 20), intermediate (21 to 25), or high (greater than or equal to 26) scores on the Mini-Mental State Examination (MMSE) increase (likelihood ratio greater than or equal to 8.2), have little effect (likelihood ratio, 1.3 to 2.4), or decrease (likelihood ratio, 0.06 to 0.1) the odds of disease. The usefulness of tests to investigate the cause of dementia varies depending on the pretest probability of the specific condition. CONCLUSIONS Several useful methods exist to screen for cognitive impairment, and clinicians need to be familiar with the strengths and limitations of their preferred screening methods. In investigating the cause of dementia, routinely obtaining a VDRL test, cerebral imaging studies, serum cobalamin level, or folate level is unwarranted.

Recent trends in chronic disease, impairment and disability among older adults in the United States

BackgroundTo examine concurrent prevalence trends of chronic disease, impairment and disability among older adults.MethodsWe analyzed the 1998, 2004 and 2008 waves of the Health and Retirement Study, a nationally representative survey of older adults in the United States, and included 31,568 community dwelling adults aged 65 and over. Measurements include: prevalence of chronic diseases including hypertension, heart disease, stroke, diabetes, cancer, chronic lung disease and arthritis; prevalence of impairments, including impairments of cognition, vision, hearing, mobility, and urinary incontinence; prevalence of disability, including activities of daily living (ADLs) and instrumental activities of daily living (IADLs).ResultsThe proportion of older adults reporting no chronic disease decreased from 13.1% (95% Confidence Interval [CI], 12.4%-13.8%) in 1998 to 7.8% (95% CI, 7.2%-8.4%) in 2008, whereas the proportion reporting 1 or more chronic diseases increased from 86.9% (95% CI, 86.2%-89.6%) in 1998 to 92.2% (95% CI, 91.6%-92.8%) in 2008. In addition, the proportion reporting 4 or more diseases increased from 11.7% (95% CI, 11.0%-12.4%) in 1998 to 17.4% (95% CI, 16.6%-18.2%) in 2008. The proportion of older adults reporting no impairments was 47.3% (95% CI, 46.3%-48.4%) in 1998 and 44.4% (95% CI, 43.3%-45.5%) in 2008, whereas the proportion of respondents reporting 3 or more was 7.2% (95% CI, 6.7%-7.7%) in 1998 and 7.3% (95% CI, 6.8%-7.9%) in 2008. The proportion of older adults reporting any ADL or IADL disability was 26.3% (95% CI, 25.4%-27.2%) in 1998 and 25.4% (95% CI, 24.5%-26.3%) in 2008.ConclusionsMultiple chronic disease is increasingly prevalent among older U.S. adults, whereas the prevalence of impairment and disability, while substantial, remain stable.