Elizabeth Shaw

Recommendations on screening for cervical cancer

cervical cancer were diagnosed in Canada, with about 350 deaths. The number of cases of diagnosed cervical cancer in creases among women aged 25 years and older, peaking during the fifth decade of life (Figure 1). The incidence of and mortality due to cervical cancer in Canada have decreased substantially in the past 50 years, and long-term survival rates after treatment are high. Lifetime incidence was 1.5% in 1972, and is now 0.7%; risk of death from cervical cancer is now 0.2%. Most advanced cervical cancer (and associated mortality) occurs among women who have never undergone screening or who have had a long interval between Papanicolaou (Pap) tests. Screening for cervival cancer using the Pap test detects precursor lesions, thereby allowing earlier and potentially less invasive treatment than is re quired for disease that causes symptoms. The benefits of such screening on the incidence of invasive disease and death due to cervical cancer have been consistently shown in cohort and case–control studies. It is likely that much of the change seen in the incidence of cervical cancer in Canada is due to screening, but early and frequent (often annual) cervical screening is unnecessary: other countries have achieved similar outcomes with less frequent testing and starting screening at older ages. The similar levels of success with different approaches highlights uncertainties regarding the best ages at which to start and stop screening, screening intervals and screening methods. Furthermore, the benefits of screening must be balanced against its potential harms, such as additional follow-up tests for abnormal results and unnecessary treatment (e.g., owing to false -positives and overdiagnosis). The likelihood of abnormal Pap test results is highest for young women, and decreases with increasing age. Because the prevalence of highgrade abnormalities declines steadily with age, al though the incidence of cancer is higher, the proportion of abnormal results that represent serious abnormalities is greater among older women. Women whose initial Pap test result is abnormal may be asked to undergo a repeat test or have a colposcopy. The colposcopist may then biopsy the cervix. If the biopsy shows cervical intra epithelial neoplasia, the colposcopist may then treat the cervix by excising the transformation zone using various methods. These procedures cause short-term pain, bleeding and discharge, and may cause early loss of future pregnancies or premature labour. It is likely that many of these procedures can be considered overtreatment, because fewer than one-third of even high-grade abnormalities progress to cancer. This guideline provides updated recommendations for screening for cervical cancer in Canada based on new information about the epidemiology and diagnosis of cervical cancer and a new systematic search of the literature. This guideline updates the recommendations of the Canadian Task Force on Preventive Health Care that were last revised in 1994. Recommendations are presented for the use of Pap tests for women with no symptoms of cervical cancer who are or who have been sexually active, regardless of sexual orientation. Separate recommendations are provided for screening in women in the following age categories: younger than 20 years, 20–24 years, 25–29 years, 30– 69 years and 70 years or older. Re com mend ations Recommendations on screening for cervical cancer

Recommendations on screening for depression in adults

See related commentary by Bland and Streiner on page [753][1] and at [www.cmaj.ca/lookup/doi/10.1503/cmaj.130634][2] Depression is a mood disorder that affects the way a person feels, thinks or behaves, which may impair social or occupational functioning.[1][3] The onset of depression can be

The Effect of a Peer Counseling Program on Breastfeeding Initiation and Longevity in a Low-income Rural Population

Breastfeeding rates among low-income women in the east-south-central United States are among the lowest in the country. This study examined the effect of a peer counseling program on breastfeeding initiation and duration in a low-income rural population in West Tennessee. A postpartum survey and chart review were conducted with WIC clients at nine health departments. Response rate was 99% (291/293). Breastfeeding initiation and duration at 6 weeks were increased in the peer counselor group (n= 156) compared with women in the no-peer counselor group (n= 135) (53% vs. 33%,p<0.001, and 26% vs. 13%,p=0.006, respectively). Multivariate analysis revealed that women in the peer counselor group were significantly more likely to initiate breastfeeding (OR=2.43, 95% CI=1.23-4.67) and to be breastfeeding at 6 weeks (OR=2.78, 95% CI=2.08-9.5 1), than those in the no-peer counselor group.

Recommendations on screening for prostate cancer with the prostate-specific antigen test

See related commentary on page [1201][1] and at [www.cmaj.ca/lookup/doi/10.1503/cmaj.141252][2] Prostate cancer is the most commonly diagnosed non–skin cancer in men and the third leading cause of cancer-related death among men in Canada.[1][3] The current estimated lifetime risk of diagnosis is

Recommendations for prevention of weight gain and use of behavioural and pharmacologic interventions to manage overweight and obesity in adults in primary care

The prevalence of obesity in adults has increased worldwide and has almost doubled in Canada, from 14% in 1978/79[1][1] to 26% in 2009–2011,[2][2] with 2% of men and 5% of women having a body mass index (BMI) score greater than 40 (Appendix 1, available at [www.cmaj.ca/lookup/suppl/doi:10.1503/

Recommendations for growth monitoring, and prevention and management of overweight and obesity in children and youth in primary care

The prevalence of obesity in Canadian children has risen dramatically from the late 1970s, more than doubling among both boys and girls.1 Based on growth curves generated by the World Health Organization, the prevalence of overweight and obesity in Canadian children aged 2 to 17 years in 2004 was about 35%.1,2 More recent estimates from 2009 to 2011 based on measured weight and height for children aged 5 to 17 years suggest that 32% are overweight (20%) or obese (12%), with the prevalence of obesity almost twice as high in boys (15%) than in girls (8%)3 (Appendix 1, available at www.cmaj.ca/lookup/suppl /doi :10.1503/cmaj.141285/-/DC1). Studies suggest that excess weight in children often persists into adulthood.4–6 Childhood obesity is associated with an increased risk of cardiovascular disease and diabetes in adolescence7 and later in life.8,9 It is now recognized that obesity is a complex problem that will require action from multiple sectors and “systems thinking.”10 Within primary care, the chronic disease model has been proposed as a framework for managing obesity, supporting children and families to manage body weight over time.10 For childhood obesity, the complexity may include parents’ knowledge, parenting style and the family activity environment.11 Whereas options for management of childhood obesity include behavioural, pharmacologic and surgical approaches offered or referred by primary care,10 it is recognized that interventions must be familycentred and may involve services delivered by an interdisciplinary team.11 The 2006 Canadian Clinical Practice Guidelines on the Management and Prevention of Obesity in Adults and Children provided recommendations for the prevention and management of obesity in Canadians of all ages.12 The last task force guidance specifically on childhood obesity was in 1994; it focused on screening for and treatment of obesity in children, but did not address primary prevention.13 The current guideline provides recommendations for growth monitoring and prevention of overweight and obesity in healthy-weight children and adolescents aged 17 years and younger in primary care settings, and guidance for primary care practitioners on the effectiveness of overweight and obesity management in children and youth aged 2 to 17 years.

A Systematic Review of Postgraduate Palliative Care Curricula

BACKGROUND Palliative care is part of comprehensive family practice; however, many physicians do not feel confident in the biomedical and psychosocial realms. Although improving residency training to address this is necessary, there is little consensus on the best education methods. OBJECTIVE To conduct a systematic review of postgraduate curricula in palliative care to incorporate the most effective components into a family medicine education program. METHODS Studies of palliative care curricula conducted in postgraduate medical training programs that contained an evaluative component and published since 1980 were systematically examined by investigator pairs using standard selection criteria and data collection forms. Discrepancies were resolved by consensus. The outcomes examined were communication skills, knowledge, attitudes, and comfort/confidence level. RESULTS 28 studies were included after reviewing 174 abstracts. Most studies (n = 21) used survey pre-post design with no control group. Outcomes were grouped into communication skills, knowledge and attitudes and confidence. Workshops with simulated patients or role plays improved communication skills. Relatively brief strategies such as short workshops showed objective improvements in focused knowledge areas. Either clinical rotations or multi-faceted interventions were required to produce improvements more broadly in knowledge base. Only a few studies examined the sustainability of outcomes. CONCLUSIONS An effective palliative care curriculum will need to use a multifaceted approach, incorporating a variety of intentional strategies to address the multiple competencies required. There is a need for more rigorous curricular evaluation.

Prospective evaluation of colposcopic features in predicting cervical intraepithelial neoplasia: degree of acetowhite change most important.

Objective. To prospectively evaluate the contribution of three colposcopic features—degree of acetowhite change, blood vessel pattern, and lesion margin—to the diagnosis of cervical intraepithelial neoplasia. Materials and Methods. A total of 301 women, who participated in two randomized controlled trials and a cross-sectional study of human papillomavirus testing and who were referred to a regional colposcopy center, were studied. Women were examined by colposcopists, who prospectively scored all abnormal transformation zones using three features. The site with the highest score (the most abnormal site) was biopsied and histology reviewed by two pathologists. Results. In multivariate analysis, degree of acetowhite change was the only feature significantly associated with cervical intraepithelial neoplasia. Conclusions. Grading lesion severity using degree of acetowhite change alone gave comparable results to grading using the three combined features.

Postpartum care--what's new?

Purpose of review The postpartum period is a time of significant emotional, social, and physical change for most women. This review focuses on recent evidence supported by systematic reviews and randomized, controlled trials to guide the care of postpartum women who are otherwise healthy. Recent findings Mental health outcomes are improved with postpartum support in at-risk women. Postpartum depression can be treated either pharmacologically or with counseling; however, exercise and omega-3 fatty acids are emerging as potentially effective alternatives. Intrauterine devices are safe and effective methods of contraception in the postpartum period. There has yet to be an effective, postpartum, smoking-cessation program developed, although intensive motivational counseling shows some promising early results. Bladder dysfunction continues to be a significant problem for women even at 10 years postpartum. Pelvic floor muscle exercises can help prevent and treat incontinence at 12 months, but longer-term follow-up studies are needed. Prevalence studies suggest that bowel dysfunction is common in the postpartum period, but randomized, controlled trials are limited to treatment in women with third-degree perineal damage. Summary Although some recommendations can be made for evidence-based postpartum care, many important questions related to the postpartum period have not been examined by rigorous methodologies.

Prospective evaluation of colposcopic features in predicting cervical intraepithelial neoplasia: Degree of acetowhite change most important

The results of three coordinated studies using patients from community family practices and a university student health clinic in Ontario, Canada, between May 1995, and October 1998 were presented in this paper. Two randomized trials involved human papillomavirus (HPV) testing in women at least 17 years of age who were undergoing routine cytologic screening after an abnormal Pap smear. The third study was a cross-sectional trial of HPV testing in women 18 years of age and older with ASCUS (abnormal squamous cells of undetermined significance) who had been referred for colposcopic examination. The data presented are the results of colposcopic examination and directed biopsy in these patients. At colposcopy, 5% acetic acid was applied to the cervix, and the features of the abnormal transformation zone were evaluated. The colposcopist used a 3-point scale to rate the degree of acetowhite change, the size of the lesion margin, and the blood vessel pattern in the lesion (Table 1). The site with the greatest point total for all 3 features was biopsied. A total of 301 patients had data available for evaluation. The women were an average of 40 years of age, and most (80%) were high school graduates, Forty-nine percent were in a committed relationship, 45% were smokers, and 43% were taking oral contraceptives. They had an average of 4 lifetime sexual partners and an average age at first intercourse of 17.3 years. Cervical cytology diagnosed atypical cells of undetermined significance (ASCUS) or a low-grade intraepithelial lesion (LSIL) in 81% of patients. Nineteen percent had a high-grade intraepithelial lesion (HSIL). Histologic examination of the biopsy specimen showed cervical intraepithelial neoplasia (CIN) 1 in 43 patients (14%) and CIN 2 or 3 in 96 (32%). Biopsy results were normal for 43% percent of patients (n = 162). In univariate logistic regression analysis, there was a significant association with the presence of CIN of any type for each of the 3 cervical features evaluated. A score of 2 points on the 3-point scale had an odds ratio for association with any CIN of 2.7 for lesion margin size, 10.1 for acetowhite change, and 2.0 for blood vessel pattern. However, when unconditional and stepwise multivariate regression analyzes were performed, the results of each analysis showed that only the degree of acetowhite change retained a significant association with CIN 2 or 3. A score of 2 had an odds ratio for association with CIN 2 or 3 of 2.4 for lesion margin size and 2.11 for blood vessel pattern compared with 22.1 for acetowhite change.