Eileen E. Reynolds

Screening mammography in women 40 to 49 years of age: a systematic review for the American College of Physicians.

Key Summary Points Meta-analyses of randomized, controlled trials demonstrate a 7% to 23% reduction in breast cancer mortality rates from screening mammography in women 40 to 49 years of age. Screening mammography is associated with an increased risk for mastectomy but a decreased risk for adjuvant chemotherapy and hormone therapy. The risk for radiation is small (30 to 200 breast cancer deaths occurred in an annual screening of 100000 women 40 to 49 years of age). Rates of false-positive mammograms are high (20% to 56% after 10 mammograms), but false-positive results have little effect on psychological health or subsequent mammography adherence. Although many women report pain at the time of mammography, few see pain as a deterrent to future screening. Breast cancer risk varies among women in their 40s and affects the absolute reduction in rates of breast cancer mortality and the absolute risk for false-positive results on screening mammography. Several decades after the first guidelines for breast cancer screening were published, the routine use of mammography among asymptomatic women remains a topic of considerable debate (1, 2). This debate surfaces occasionally on screening women 50 years of age or older but persists regularly for screening women in their 40s (3, 4). The persistence of this controversy suggests a level of unease with our current understanding of the benefits and risks of mammography and with how this understanding has been translated into screening recommendations. Understanding the risks and benefits of screening mammography among women in their 40s is important because of the critical position that breast cancer holds in that age group. In the United States, breast cancer is one of the most common causes of death for women in their 40s. In 2002, almost 5000 women between 40 and 49 years of age died of breast cancer, compared with the 6800 women who died of heart disease or 1500 women who died of HIV (5). However, despite the relative importance of breast cancer in this age group, the burden of breast cancer among women in their 40s is low for a population-based screening program. More than 98% of women will not develop breast cancer between 40 and 50 years of age, but they will be subject to the risks of population-based screening. Of the 44000 women who die of breast cancer each year, fewer than one fifth received their diagnoses between the ages of 40 and 49 years (6, 7). We describe the results of a systematic review of the benefits and risks for screening mammography among women 40 to 49 years of age. Currently, 8 published meta-analyses discuss the effect of mammography screening in women 40 to 49 years of age on breast cancer mortality rates (816). All but 1 demonstrate a reduction in mortality rates from screening mammography. Thus, we did not perform another meta-analysis of the effect of screening mammography on breast cancer mortality rates, but we reviewed briefly the benefits of mammography screening derived from published screening trials and meta-analyses. In addition, we focused on 2 areas that are less well-studied but may affect recommendations about screening mammography among women in this age group: 1) risks of mammography screening and 2) variation in the risks and benefits of mammography according to an individual womans characteristics. Methods Data Sources We created a framework of the potential risks and benefits of screening mammography to guide the literature search (Figure). On the basis of the framework, we searched MEDLINE, Pre-MEDLINE, and the Cochrane Central Register of Controlled Trials for English-language publications. We conducted the initial searches in spring 2004 and updated them in May 2005. General search strategies included Medical Subject Headings (MeSH) terms mammography or breast neoplasms and mass screening, as well as the keywords mammography, screening, and breast cancer. We conducted additional searches for each individual risk or benefit by using appropriate keywords and MeSH terms. We reviewed the references of all selected articles to identify additional relevant articles. Figure. Risks and benefits of screening mammography. Numbers correspond to the risks and benefits outlined in the Table. Study Selection Although previous systematic reviews have largely focused on randomized, controlled trials of mammography screening to quantify the benefit of screening on breast cancer mortality rates, most evidence about risks and other benefits of mammography is derived from observational studies, primarily prospective cohort studies (Table). Thus, we included a wide range of study designs in our review, with the included studies depending on the question and the available evidence. We used meta-analyses to assess the effect of mammography screening on breast cancer mortality rates and the risk for a false-positive mammogram at a single screening; randomized, controlled trials and prospective cohort studies to assess the effect of mammography on breast cancer treatment and the cumulative risk for a false-positive mammogram; and both prospective and cross-sectional observational studies to assess the other risks of mammography. We excluded case series and ecological designs for all risks except for ductal carcinoma in situ (DCIS), because most published data on DCIS outcomes are derived from these study designs. In addition, we reviewed the available publications from the 8 original mammography trials and the published simulation models of the effect of radiation from mammography screening. When possible, we focused on evidence from studies of screening mammography in women in their 40s or analyses of this age group within larger cohorts. When this was not possible, we used studies of screening mammography in older women. In the case of multiple publications from the same study, we included only the most recent publication in our analysis. Table. Risks and Benefits of Screening Mammography For study selection, a study investigator reviewed abstracts of all primary research articles to determine whether the full-text article should be retrieved. We retrieved 873 full-text articles, and 2 investigators reviewed them. In addition to the publications from the original trials, 117 of these articles met inclusion criteria. Data Extraction and Quality Assessment Two investigators abstracted information about the study design, setting, study sample, measures, analysis, and results. When needed, we contacted authors to clarify questions about study design or results. We evaluated study quality by using the approach proposed by the Centre for Evidence-Based Medicine (www.cebm.net/levels_of_evidence.asp) (Appendix Table 1). The lead investigator adjudicated any disagreements between the reviewers about article content and quality. Appendix Table 1. Evidence-Based Medicine Review Score: Criteria Used to Assess Study Quality* Role of the Funding Source The review was conducted under contract with the American College of Physicians. The funding source had no role in the collection, analysis, or interpretation of the data or in the decision to submit the article for publication. Results Benefits Breast Cancer Mortality Many meta-analyses have combined the results of major mammography screening trials to assess the effect of screening on breast cancer mortality rates. The latest meta-analysis demonstrated that screening mammography every 1 to 2 years in women 40 to 49 years of age results in a 15% decrease in breast cancer mortality after 14 years of follow-up (relative risk, 0.85 [95% CI, 0.73 to 0.99]) (12). This effect size is very similar to that reported by most previous meta-analyses of women 40 to 49 years of age (8, 10, 13, 14, 16). It is smaller than the 22% reduction seen among women 50 years of age or older (relative risk, 0.78 [CI, 0.70 to 0.87]) (12). The meta-analysis did not include the recently published results of the United Kingdom trial of annual mammography screening in 160921 women in their 40s (relative risk, 0.83 [CI, 0.66 to 1.04]) (17). However, this estimate is so similar to the results of the meta-analyses that the findings are unlikely to substantively change. Nevertheless, the effect of mammography screening on breast cancer mortality rates for women in their 40s remains controversial for several reasons. These reasons include concern about the quality of the trials that found mammography to have the largest benefit, the interval until the mortality rate reduction began, and the validity of death due to breast cancer as the primary end point (2). We review each issue in the following sections. Study quality is important because high-quality studies are more likely to provide accurate estimates of the effect size. However, judging study quality is difficult because of imperfect reporting and lack of consensus on criteria for evaluating studies. Furthermore, high-quality studies are relatively uncommon. In the setting of screening mammography for women 40 to 49 years of age, previous meta-analyses differ in their assessment of study quality and study inclusion. The Cochrane meta-analysis (2) excluded all but 2 of the 8 trials that provided information about this age group (the Canadian trial and the Malm trial). The most recent meta-analysis, which was from the U.S. Preventive Services Task Force (12), included all trials but the Edinburgh trial. Other meta-analyses have included all 8 trials (10, 11, 13, 14, 16). To a great extent, these differences arise from different levels of concern about inadequate or inconsistent information in study publications, including variation in the numbers of participants in sequential reports; differences in baseline characteristics among groups; and lack of information about randomization procedures, date of trial entry, and other study characteristics. Although many of these concerns cannot be fully resolved, recent analyses and critical reviews support the argument that none of the trials is suf

The Future of General Internal Medicine: Report and Recommendations from the Society of General Internal Medicine (SGIM) Task Force on the Domain of General Internal Medicine

The Society of General Internal Medicine asked a task force to redefine the domain of general internal medicine. The task force believes that the chaos and dysfunction that characterize today’s medical care, and the challenges facing general internal medicine, should spur innovation. These are our recommendations: while remaining true to its core values and competencies, general internal medicine should stay both broad and deep—ranging from uncomplicated primary care to continuous care of patients with multiple, complex, chronic diseases. Postgraduate and continuing education should develop mastery. Wherever they practice, general internists should be able to lead teams and be responsible for the care their teams give, embrace changes in information systems, and aim to provide most of the care their patients require. Current financing of physician services, especially fee-for-service, must be changed to recognize the value of services performed outside the traditional face-to-face visit and give practitioners incentives to improve quality and efficiency, and provide comprehensive, ongoing care. General internal medicine residency training should be reformed to provide both broad and deep medical knowledge, as well as mastery of informatics, management, and team leadership. General internal medicine residents should have options to tailor their final 1 to 2 years to fit their practice goals, often earning a certificate of added qualification (CAQ) in special generalist fields. Research will expand to include practice and operations management, developing more effective shared decision making and transparent medical records, and promoting the close personal connection that both doctors and patients want. We believe these changes constitute a paradigm shift that can benefit patients and the public and reenergize general internal medicine.

Disparities in health and health care - Moving from describing the problem to a call for action

During the past two decades the overall health of the nation has improved. However, the dramatic disparities in the morbidity and mortality experienced by African Americans, Latinos, Native Americans, Asians, and Pacific Islanders provide compelling evidence that many Americans have not experienced this health dividend.1 Disparities in health and in access to health care have been documented repeatedly across a broad range of medical conditions and for a wide variety of traditionally disadvantaged groups such as those in racial or ethnic minorities, women, and older persons. These differences have been noted in health outcomes such as quality of life2,3 and mortality,4–10 processes of care such as utilization of cardiac procedures after myocardial infarction6,7,11–15 or access to primary prevention,16,17 quality and appropriateness of care,18–24 and the prevalence of common chronic medical conditions.25

Adoption of a wiki within a large internal medicine residency program: a 3-year experience.

OBJECTIVE To describe the creation and evaluate the use of a wiki by medical residents, and to determine if a wiki would be a useful tool for improving the experience, efficiency, and education of housestaff. MATERIALS AND METHODS In 2008, a team of medical residents built a wiki containing institutional knowledge and reference information using Microsoft SharePoint. We tracked visit data for 3 years, and performed an audit of page views and updates in the second year. We evaluated the attitudes of medical residents toward the wiki using a survey. RESULTS Users accessed the wiki 23,218, 35,094, and 40,545 times in each of three successive academic years from 2008 to 2011. In the year two audit, 85 users made a total of 1082 updates to 176 pages and of these, 91 were new page creations by 17 users. Forty-eight percent of residents edited a page. All housestaff felt the wiki improved their ability to complete tasks, and 90%, 89%, and 57% reported that the wiki improved their experience, efficiency, and education, respectively, when surveyed in academic year 2009-2010. DISCUSSION A wiki is a useful and popular tool for organizing administrative and educational content for residents. Housestaff felt strongly that the wiki improved their workflow, but a smaller educational impact was observed. Nearly half of the housestaff edited the wiki, suggesting broad buy-in among the residents. CONCLUSION A wiki is a feasible and useful tool for improving information retrieval for house officers.

Polycystic ovary syndrome: a review for primary providers.

PCOS is a metabolic syndrome that exists throughout the world with much clinical heterogeneity. PCOS is now appreciated as encompassing two interrelated metabolic phenomena--insulin resistance and hyperandrogenism. Patients present with oligo-amenorrhea and clinical hyperandrogenism, and the diagnosis is based on clinical grounds with few laboratory tests necessary. Because patients are at higher than normal risk for diabetes, glucose intolerance, and hyperlipidemia, and perhaps at higher risk for coronary heart disease, newly diagnosed patients with PCOS should be evaluated for glucose intolerance and hyperlipidemia. The cornerstone of therapy today includes weight management, and further therapeutic intervention is focused on reproductive and cardiovascular health and treatment of insulin resistance. Clinical case continued The 17-year-old mentioned in the beginning of this article probably does have PCOS. She fits the clinical criteria: oligo-ovulation and hyper-androgenism (the acne and hirsutism). In addition, she is obese, which is also associated with PCOS. Her TSH and prolactin were normal, and as her presentation was not suggestive of an adrenal tumor or congenital adrenal hyperplasia (she had mild hirsutism, and those diagnoses are associated with more severe hyperandrogenism), no further laboratory evaluation was deemed necessary. Once the diagnosis was made, she was screened for lipid abnormalities and for glucose intolerance. Her LDL was 150, HDL 35; oral glucose tolerance test (OGTT) was normal. A pregnancy test was negative, and she was started on OCPs. Devoting herself to exercise and dietary change, she lost 10 pounds in her first 3 months after diagnosis. Her hirsutism and acne have improved with the OCPs and weight loss, and her menses are regular. She has elected to defer oral insulin sensitizers until her weight loss has stabilized. Findings PCOS is common in reproductive-aged women. Diagnosis is clinical and is supported by lab findings; there is significant clinical heterogeneity. Insulin resistance is likely central to the pathophysiology along with androgen excess. Health implications include infertility, diabetes, endometrial cancer, hyperlipidemia, and possibly coronary heart disease. Treatment is evolving and includes weight loss, OCPs, and insulin sensitizers.

Resident and faculty adherence to common guidelines.

Medical educators increasingly need to demonstrate that curricular innovations lead not only to changes in clinical competence but also to changes in patients’ outcomes and quality of care. During the past decade chart audits, or ‘‘report cards,’’ in areas of preventive health or disease management have been used to measure quality of care at the levels of the practicing physician, physician group, and health plan. Critique of the medical record also has been used to evaluate physicians-in-training. Report cards have been used to examine the effectiveness of a residency curriculum and to provide residents with ongoing feedback about their record keeping on outpatients and preventive care practices. Studies have demonstrated that residents improve their performances when they are given feedback with report cards. However, it is still uncertain whether such improvement is secondary to the feedback or a so-called ‘‘maturation effect’’—that performance improves as residents progress through residency training. It also is unknown whether residents’ performances on chart audits differ from that of faculty. Moreover, report cards of residents have not been thoroughly studied as a possible method of formal performance assessment. Our goals were (1) to describe and compare the performances of internal medicine interns, senior residents, and faculty members on a number of measures of quality of care in prevention and disease management; (2) to explore how the residents’ performance on a global chart audit compared with more standard performance assessments; (3) to assess the variability in and reproducibility of various prevention and disease-management scores; and (4) to examine performances for interns and residents related to physician gender, outpatient practice model, and primary care versus categorical training.

Educational Innovations Project—Program Participation and Education Publications

AAIM is the largest academically focused specialty organization representing departments of internal medicine at medical schools and teaching hospitals in the United States and Canada. As a consortium of five organizations, AAIM represents department chairs and chiefs; clerkship, residency, and fellowship program directors; division chiefs; and academic and business administrators as well as other faculty and staff in departments of internal medicine and their divisions.

Residency Training — A Decade of Duty-Hours Regulations

Panelists discuss the effects of the controversial ACGME regulations regarding duty hours and supervision.

Chest Pain Suggestive of a Life-Threatening Condition: A Department of Medicine Morbidity and Mortality Conference

Received September 11, 2015; revised October 5, 2015; accepted October 6, 2015. From Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (CTP, MCG); Division of Oncology Beth Israel Deaconess Medical Center, Harvard Medical School, Boston,MA (KL); Department ofMedicine, Beth Israel Deaconess Medica Center, Harvard Medical School, Boston, MA (EER); Psychiatric Consultation Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA (TAS); Liver Transplant Center, Beth Israel DeaconessMedical Center, HarvardMedical School, Boston, MA (EBT). Send correspondence and reprint requests to Elliot B. Tapper, M.D., Liver Center, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston MA 02115; e-mail: etapper@bidmc.harvard.edu & 2016TheAcademy of PsychosomaticMedicine. Published by Elsevier Inc. All rights reserved. Introduction

Update: A 39-Year-Old Man With a Skin Infection

Update: A 39-Year-Old Man With a Skin Infection IN A CLINICAL CROSSROADS ARTICLE PUBLISHED IN JANUARY 2008, Robert C. Moellering, MD, discussed Mr M, a 39year-old man with episodes of skin infections on his thigh and his left index finger. In the article, Dr Moellering discussed the nature of Mr M’s index finger infection, the options for treatment, and the likelihood of recurrence. Mr M had no history of trauma or exposure to a pathogen, had fairly severe pain,wasafebrile, andhadsignificant lymphangitic streaking. Based on these symptoms, Dr Moellering identified a streptococcusoracommunity-associatedmethicillin-resistantStaphylococcusaureus(CA-MRSA)strainas likelyculpritsandrecommendedtreatingwithantibioticstocoverbothSaureusandStreptococcuspyogenes.Hesuggestedthat followingMrM’sdrainage and intravenous antibiotics, he be discharged taking oral antimicrobial therapy to complete the course. Because Mr M had onlyhad1serious infection,DrMoelleringwasnotconcerned thatMrMhadanunderlying immunodeficiencyand, thus,did notrecommendworkup;DrMoelleringalsodidnotrecommend any ongoing prevention or prophylaxis to prevent future infectionsbecauseofthelackofevidencethatsuchtreatmentwould be efficacious.