Andrew M.D. Wolf

American Cancer Society Guideline for the Early Detection of Prostate Cancer: Update 2010

In 2009, the American Cancer Society (ACS) Prostate Cancer Advisory Committee began the process of a complete update of recommendations for early prostate cancer detection. A series of systematic evidence reviews was conducted focusing on evidence related to the early detection of prostate cancer, test performance, harms of therapy for localized prostate cancer, and shared and informed decision making in prostate cancer screening. The results of the systematic reviews were evaluated by the ACS Prostate Cancer Advisory Committee, and deliberations about the evidence occurred at committee meetings and during conference calls. On the basis of the evidence and a consensus process, the Prostate Cancer Advisory Committee developed the guideline, and a writing committee drafted a guideline document that was circulated to the entire committee for review and revision. The document was then circulated to peer reviewers for feedback, and finally to the ACS Mission Outcomes Committee and the ACS Board of Directors for approval. The ACS recommends that asymptomatic men who have at least a 10‐year life expectancy have an opportunity to make an informed decision with their health care provider about screening for prostate cancer after they receive information about the uncertainties, risks, and potential benefits associated with prostate cancer screening. Prostate cancer screening should not occur without an informed decision‐making process. Men at average risk should receive this information beginning at age 50 years. Men in higher risk groups should receive this information before age 50 years. Men should either receive this information directly from their health care providers or be referred to reliable and culturally appropriate sources. Patient decision aids are helpful in preparing men to make a decision whether to be tested. CA Cancer J Clin 2010;60:70–98.

American Cancer Society lung cancer screening guidelines

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American Cancer Society prostate cancer survivorship care guidelines.

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Does Informed Consent Alter Elderly Patients' Preferences for Colorectal Cancer Screening?: Results of a Randomized Trial

OBJECTIVE: To assess the impact of informed consent on elderly patients’ colorectal cancer (CRC) screening preferences.DESIGN: Randomized, controlled trial.SETTING: Four general internal medicine practices.PATIENTS: We studied 399 elderly patients visiting their primary care provider for routine office visits.INTERVENTIONS: Patients were randomized to receive either a scripted control message briefly describing CRC screening methods or one of two informational interventions simulating an informed consent presentation about CRC screening. One intervention described CRC mortality risk reduction in relative terms; the other, in absolute terms.MEASUREMENTS AND MAIN RESULTS: The main outcome measure was intent to begin or continue fecal occult blood testing (FOBT), flexible sigmoidoscopy, or both. There was no difference in screening interest between the control group and the two information groups (p=.8). The majority (63%) of patients intended to begin or continue CRC screening. Informed patients were able to gauge more accurately the positive predictive value of screening (p=.0009). Control patients rated the efficacy of screening higher than did patients receiving relative risk reduction information, who rated it higher than did patients receiving absolute risk reduction information (p=.0002).CONCLUSIONS: Elderly patients appeared to understand CRC screening information and use it to gauge the efficacy of screening, but provision of information had no impact on their preferences for screening. In view of the large proportion who preferred not to be screened, we conclude that elderly patients should be involved in the screening decision. However, factors other than provision of information must determine their CRC screening preferences.

Attitudes of elderly subjects toward "truth telling" for the diagnosis of Alzheimer's disease.

This study expands on previous research regarding attitudes of older adults toward disclosure of the diagnosis of Alzheimers disease (AD). Two hundred patients 65 years or older completed a questionnaire assessing opinions about being told the diagnosis of AD versus cancer. Most responded they wanted to be told if they had AD or terminal cancer (92% for AD, 86.5% for cancer, P = .06). Those with personal experience with AD were significantly less likely to want to know themselves if they had AD than were those without personal experience (P <.0001). A variety of reasons were given for wanting to be told the diagnosis of AD, including a small minority (1.7%) who would consider suicide. Although these results appear to support recent American Medical Association guidelines favoring disclosure of a dementia diagnosis, complex issues remain. Further research is needed to develop guidelines for physicians in disclosing dementia diagnoses that includes outcome studies of disclosure to patients. (J Geriatr Psychiatry Neurol 2003; 16:90-93)

Predictors of Interest in Prostate-Specific Antigen Screening and the Impact of Informed Consent: What Should We Tell Our Patients?

PURPOSE Screening for prostate cancer with the prostate-specific antigen (PSA) remains highly controversial. We sought to discern which patient factors predict interest in the PSA and how informed consent impacts these predictors. PATIENTS AND METHODS In a randomized trial that found that informed consent decreases patient interest in PSA screening, potential predictors of interest were analyzed separately in the uninformed (n = 102) and informed (n = 103) cohorts to examine the effects of the informational intervention. RESULTS Univariate predictors of PSA screening interest (P < 0.05) among uninformed patients included perceived efficacy of screening, perceived seriousness of an abnormal PSA, and willingness to accept treatment risks. Among patients who had been informed about PSA screening, univariate predictors included family history of prostate cancer, perceived susceptibility to prostate cancer, age (inverse association), and perceived efficacy, although informed patients rated PSA efficacy significantly lower than uninformed patients (P < 0.001). In multivariate logistic regression modeling for the uninformed cohort, perceived screening efficacy (P < 0.001), perceived seriousness (P < 0.05), and willingness to accept treatment risks (P < 0.05) together were significant predictors of PSA screening interest. Among informed patients, perceived efficacy (P < 0.001), perceived susceptibility (P = 0.01), and younger age (P = 0.01) together predicted interest in screening. CONCLUSIONS In contrast to uninformed patients, patients given information about PSA screening and prostate cancer are more likely to be interested in screening if they have a family history of prostate cancer, are younger, or otherwise consider themselves susceptible to developing prostate cancer. Uninformed patients are more likely to base their screening interest on the perceived seriousness of prostate cancer and on their willingness to accept treatment risks.

Prostate cancer screening 2010: updated recommendations from the American Cancer Society.

In 2009, the American Cancer Society (ACS) initiated a series of systematic evidence reviews to update recommendations for early prostate cancer detection. The evidence reviews focused on studies of screening, the performance of screening tests, harms associated with testing and therapy for localized prostate cancer, and shared and informed decision making in prostate cancer screening. Based on this evidence, the ACS recommends that asymptomatic men who have at least a 10-year life expectancy have an opportunity to make an informed decision with their health care provider about screening for prostate cancer after receiving information about the uncertainties, risks, and potential benefits associated with prostate cancer screening. Prostate cancer screening should not occur without an informed decision-making process. Men at average risk should receive this information beginning at age 50. Men in higher-risk groups should receive this information before age 50. Men should either receive this information directly from their health care providers or be referred to reliable and culturally appropriate sources. Patient decision aids are helpful in preparing men to make a decision whether to be tested, and the use of such aids is encouraged.

Grading the New US Preventive Services Task Force Prostate Cancer Screening Recommendation

ON OCTOBER 11, 2011, THE US PREVENTIVE SERvices Task Force (USPSTF) issued for public comment a draft recommendation statement regarding screening for prostate cancer. The public comment period is a new step taken by the USPSTF prior to finalizing its recommendation statements to help make its recommendations clearer and more useful to primary care providers. In taking this step, the task force signaled its intention to change its 2008 recommendation from a grade I statement (the current evidence is insufficient to assess the balance of the benefits and harms of the service) to a grade D recommendation—“The US Preventive Services Task Force . . . recommends against prostatespecific antigen (PSA)-based screening for prostate cancer.” Following an updated review of the evidence, the USPSTF concluded that there is moderate certainty that the harms of PSA-based screening for prostate cancer outweigh the benefits. The reaction from the media to the impending change has been swift, and organizations that support screening for prostate cancer in general have criticized the new recommendation. Is this reaction justified? In support of its D recommendation, the USPSTF highlighted 3 randomized screening trials (gauged to be of “fair” quality, the highest quality evidence they found). Yet, 2 of these 3 trials demonstrated a benefit to screening in terms of reducing prostate cancer-specific mortality. One trial, the European Randomized Study of Screening for Prostate Cancer, found that 1410 men must be screened an average of 1.7 times over 9 years to prevent 1 prostate cancer death, comparable with the benefit from screening mammography in 50to 59-year-old women (which has a B recommendation from the USPSTF). Although this study prespecified the 55to 69-year-old age group as the core group for analysis of PSA screening, the task force chose to include in its analysis results from several of the countries that enrolled men outside the core age range, negating the positive findings. The other positive study cited by the USPSTF, the Goteborg trial, found a much lower number needed to screen, ie, 293 men would need to undergo screening to save 1 life from prostate cancer. The task force noted that this trial constituted a subgroup of the European Randomized Study of Screening for Prostate Cancer and discounted the results because they were inconsistent with the main results. The third study, the prostate component of the US Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, was indeed negative but was limited by a high prescreening rate in both the screening and control groups of the study and by a similarly high contamination rate in the control group (ie, many men in the control group also underwent screening outside of the trial), mitigating against finding any true benefit to screening. Regardless of the controversy surrounding the question of benefit, there is unanimity in the estimation of harm. All agree that men face serious risks from diagnostic testing and treatment of screen-detected prostate cancers, ranging from sexual, urinary, and bowel injury to treatment-related death. Moreover, many men who are diagnosed with and treated for prostate cancer have cancers that were never destined to harm them, illustrating the thorny problems of overdiagnosis and overtreatment. The crux of the prostate controversy, however, is that many men place such a high value on averting death from cancer that they are willing to undergo risk and harm to achieve that goal. Many other men are not. How can clinicians reconcile this difference in the context of a guideline? It is by engaging men in informed decision making, and in this area, the task force recommendation is consistent with those of other organizations, such as the American Cancer Society. In wording almost identical to that of the American Cancer Society 2010 guideline, the task force recommends that men who are being considered for screening participate in an informed decision, preferably with their physician, that they not be tested without their consent and that communitybased screening without informed consent be discontin-

Faculty development for the 21st century: Lessons from the Society of General Internal Medicine-Hartford Collaborative Centers for the Care of Older Adults

In this review of a recent set of faculty development initiatives to promote geriatrics teaching by general internists, nontraditional strategies to promote sustained change were identified, included enrolling a limited number of “star” faculty, creating ongoing working relationships between faculty, and developing projects for clinical or education program improvement. External funding, although limited, garnered administration support and was associated with changes in individual career trajectories. Activities to enfranchise top leadership were felt essential to sustain change.

Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society

In the United States, colorectal cancer (CRC) is the fourth most common cancer diagnosed among adults and the second leading cause of death from cancer. For this guideline update, the American Cancer Society (ACS) used an existing systematic evidence review of the CRC screening literature and microsimulation modeling analyses, including a new evaluation of the age to begin screening by race and sex and additional modeling that incorporates changes in US CRC incidence. Screening with any one of multiple options is associated with a significant reduction in CRC incidence through the detection and removal of adenomatous polyps and other precancerous lesions and with a reduction in mortality through incidence reduction and early detection of CRC. Results from modeling analyses identified efficient and model‐recommendable strategies that started screening at age 45 years. The ACS Guideline Development Group applied the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria in developing and rating the recommendations. The ACS recommends that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high‐sensitivity stool‐based test or a structural (visual) examination, depending on patient preference and test availability. As a part of the screening process, all positive results on noncolonoscopy screening tests should be followed up with timely colonoscopy. The recommendation to begin screening at age 45 years is a qualified recommendation. The recommendation for regular screening in adults aged 50 years and older is a strong recommendation. The ACS recommends (qualified recommendations) that: 1) average‐risk adults in good health with a life expectancy of more than 10 years continue CRC screening through the age of 75 years; 2) clinicians individualize CRC screening decisions for individuals aged 76 through 85 years based on patient preferences, life expectancy, health status, and prior screening history; and 3) clinicians discourage individuals older than 85 years from continuing CRC screening. The options for CRC screening are: fecal immunochemical test annually; high‐sensitivity, guaiac‐based fecal occult blood test annually; multitarget stool DNA test every 3 years; colonoscopy every 10 years; computed tomography colonography every 5 years; and flexible sigmoidoscopy every 5 years. CA Cancer J Clin 2018;68:250–281.