Benjamin Stripe

The Diagnostic Yield of Cardiac Catheterization in Low-Risk Troponinemia

Invited Commentary Informed Choice in Cancer Screening A couple of years ago one of my undergraduate students was interested in how men felt about overdiagnosis in prostate cancer screening. He surveyed 30 men who worked for Dartmouth College Facilities or the local police and fire departments. Their mean age was 50 years; half had been screened with prostate-specific antigen. Ten percent would not agree to screening if it resulted in more than 1 overtreated person per 1 cancer death adverted, and 63% would not agree to screening if it resulted in 25 or more overtreated persons per 1 death adverted. He never submitted his work for publication. (I never submitted anything for publication as an undergraduate. Did you?) Luckily, he is not the only one interested in the topic. Wegwarth and Gigerenzer1 begin to provide a broader view of how Americans feel about screening when given the context of overdiagnosis. They performed an online survey of 317 men and women aged 50 to 69 years, most of whom had undergone screening. They found that 51% would not agree to screening if it resulted in more than 1 overtreated person per 1 cancer death adverted and 87% would not agree if more than 20 received overtreatment per 1 death adverted. Wow. That implies that millions of Americans might not choose to be screened if they knew the whole story; however, most do not. Many of our patients understand that treatments have benefits and harms. They understand there are reasons not to take medication (because it can produce adverse effects) and reasons not to undergo surgery (because it can lead to complications). In addition, they get the idea that the benefits outweigh the harms when given severe symptoms and effective treatment, but may not given when mild symptoms or minimally effective treatment. Our patients have been taught to think differently about screening. There are no harms. It’s always good to know. It is just about gathering information. Of course you want it. It is a brain-dead decision. In reality, the truth is more nuanced. There are benefit and harms to consider in screening—just as there are in treatment. There’s no longer any argument about this. Even the American Cancer Society signs on to the idea of overdiagnosis— using the word in its materials on breast, lung, and prostate cancer screening.2-4 The arguments are, instead, about the magnitude of the benefits and harms. Wegwarth and Gigerenzer finesse this problem by asserting the relative magnitude of benefit and harm (eg, 1 cancer death averted vs 10 overdiagnosed) and then ask patients what they would choose. They found that 69% of the sample would not choose screening given the foregoing trade-off. Is that really accurate? There are many issues to consider. Is this sample really representative of Americans in this age range or is it skewed by being an online survey? Is there some framing effect in play? How well did the respondents understand the numbers? Did the survey introduction overweight the harms of overdiagnosis and overtreatment, while underweighting the benefit of avoiding a cancer death? To all of the above, the short answer is: I do not know. But I do know this: it should be studied further. The potential implications for screening practice are huge. Other researchers should get involved and investigate how our patients can best understand the trade-offs and how we can learn what they want. That is challenging enough, but there is more to do. We need to come to some consensus about what the benefit and harm numbers are. They will be different for different screening tests, and different for patients of various ages. Nor can we pretend to know a single right number. Whether it is prostatespecific antigen, mammography, or colorectal cancer screening, there is plenty of uncertainty about the magnitude of both the benefits and the harms. So, we will need to think in terms of giving patients plausible ranges—not single numbers—to express the benefits and harms of cancer screening. Doing so will open another question for research: What level of precision is needed for various outcomes to allow most people to make a decision? There is plenty of work to do.

Delayed Left Main Narrowing From the Native Left Aortic Valve Leaflet After Transcatheter Aortic Valve Replacement With the Lotus Valve: A Successful Intervention for a Novel Complication

An 89-year-old woman with severe symptomatic aortic valve stenosis and poor surgical candidacy underwent transcatheter aortic valve replacement (TAVR) with a 23-mm Lotus valve (Boston Scientific, Marlborough, Massachusetts). Preoperative computed tomography demonstrated aortic sinuses and coronary

Initial clinical experience with the FlexPoint Steerable Transseptal Needle in left-sided structural heart procedures

The purpose of this study is to describe the initial clinical experience with a steerable transseptal needle (STSN) for left‐sided structural heart procedures.