Clarence Lam

Screening for prostate cancer: a review of the evidence for the U.S. Preventive Services Task Force.

BACKGROUND Screening can detect prostate cancer at earlier, asymptomatic stages, when treatments might be more effective. PURPOSE To update the 2002 and 2008 U.S. Preventive Services Task Force evidence reviews on screening and treatments for prostate cancer. DATA SOURCES MEDLINE (2002 to July 2011) and the Cochrane Library Database (through second quarter of 2011). STUDY SELECTION Randomized trials of prostate-specific antigen-based screening, randomized trials and cohort studies of prostatectomy or radiation therapy versus watchful waiting, and large observational studies of perioperative harms. DATA EXTRACTION Investigators abstracted and checked study details and quality using predefined criteria. DATA SYNTHESIS Of 5 screening trials, the 2 largest and highest-quality studies reported conflicting results. One found that screening was associated with reduced prostate cancer-specific mortality compared with no screening in a subgroup of men aged 55 to 69 years after 9 years (relative risk, 0.80 [95% CI, 0.65 to 0.98]; absolute risk reduction, 0.07 percentage point). The other found no statistically significant effect after 10 years (relative risk, 1.1 [CI, 0.80 to 1.5]). After 3 or 4 screening rounds, 12% to 13% of screened men had false-positive results. Serious infections or urine retention occurred after 0.5% to 1.0% of prostate biopsies. There were 3 randomized trials and 23 cohort studies of treatments. One good-quality trial found that prostatectomy for localized prostate cancer decreased risk for prostate cancer-specific mortality compared with watchful waiting through 13 years of follow-up (relative risk, 0.62 [CI, 0.44 to 0.87]; absolute risk reduction, 6.1%). Benefits seemed to be limited to men younger than 65 years. Treating approximately 3 men with prostatectomy or 7 men with radiation therapy instead of watchful waiting would each result in 1 additional case of erectile dysfunction. Treating approximately 5 men with prostatectomy would result in 1 additional case of urinary incontinence. Prostatectomy was associated with perioperative death (about 0.5%) and cardiovascular events (0.6% to 3%), and radiation therapy was associated with bowel dysfunction. LIMITATIONS Only English-language articles were included. Few studies evaluated newer therapies. CONCLUSION Prostate-specific antigen-based screening results in small or no reduction in prostate cancer-specific mortality and is associated with harms related to subsequent evaluation and treatments, some of which may be unnecessary. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.

Clinical Preventive Medicine: Causing More Identity Crisis for Preventive Medicine or Helping to Manage the Crisis

In their article entitled “Preventive Medicine’s Identity Crisis” Jung and Lushniak eloquently addressed a longlasting discussion on the identity of the specialty of preventive medicine (PM). In 2011, the identity crisis in the PM field became more acute for PM residency training programs when the Accreditation Council for Graduate Medical Education required all PM residents to have a minimum of 2 months direct patient care experience during each year of the program. Defining direct patient care in the context of PM residency training and developing a well-rounded clinical experience is a challenging task. Residents enter the program with different levels of clinical experience, some have completed a full residency (or a clinical fellowship) before joining PM residency training, and others choose the PM field because of their interest in public health rather than clinical medicine. In addition, defining direct patient care in a specialty that struggles to identify itself as a distinct medical specialty is complicated; at the same time, PM addresses well-established concepts, such as public health, and those evolving ones, such as population health and lifestyle medicine. On the other hand, the Accreditation Council for Graduate Medical Education requirement provided a timely opportunity for residency programs to test different clinical settings varying from primary care and urgent care clinics to public health clinics, such as tuberculosis, smoking cessation, and sexually transmitted disease clinics, to fulfill the requirements. Some programs used this opportunity to strengthen their connections with lifestyle medicine and adopted it as the definition of clinical PM. In our view, this new challenge has provided the PM field with a platform to address its identity crisis and to redefine its connections to the fields of public health, population health, and lifestyle medicine. We agree with the definition that Jung and Lushniak provided for the PM specialty, identifying PM specialists as public health physicians, population health as a concept or a goal, and public health as a function or activity. Along the same