Irena Stijacic-Cenzer

Time lag to benefit after screening for breast and colorectal cancer: meta-analysis of survival data from the United States, Sweden, United Kingdom, and Denmark

Objectives To determine a pooled, quantitative estimate of the length of time needed after breast or colorectal cancer screening before a survival benefit is observed. Design Meta-analysis of survival data from population based, randomized controlled trials comparing populations screened and not screened for breast or colorectal cancer. Trials were identified as high quality by reviews from the Cochrane Collaboration and United States Preventive Services Task Force. Setting Trials undertaken in the United States, Denmark, United Kingdom, and Sweden. Population Screened patients older than 40 years. Primary outcome measures Time to death from breast or colorectal cancer in screened and control populations. Interventions Fecal occult blood testing for colorectal cancer screening, mammography for breast cancer screening. Results Our study included five and four eligible trials of breast and colorectal cancer screening, respectively. For breast cancer screening, 3.0 years (95% confidence interval 1.1 to 6.3) passed before one death from breast cancer was prevented for every 5000 women screened. On average across included studies, it took 10.7 years (4.4 to 21.6) before one death from breast cancer was prevented for 1000 women screened. For colorectal cancer screening, 4.8 years (2.0 to 9.7) passed before one death from colorectal cancer was prevented for 5000 patients screened. On average across included studies, it took 10.3 years (6.0 to 16.4) before one death from colorectal cancer was prevented for 1000 patients screened. Conclusions Our results suggest that screening for breast and colorectal cancer is most appropriate for patients with a life expectancy greater than 10 years. Incorporating time lag estimates into screening guidelines would encourage a more explicit consideration of the risks and benefits of screening for breast and colorectal cancer.

Predicting 10-Year Mortality for Older Adults

TO THE EDITOR: Preventive interventions such as cancer screening exposes patients to immediate risks with delayed benefits, suggesting that risks outweigh the benefits in patients with limited life expectancy. Guidelines now recommend considering the likelihood of long-term survival when evaluating whether preventive interventions with long lagtimes-to-benefit (such as CRC screening and intensive glycemic control) are more likely to help or harm an individual patient.1, 2 However, most mortality indices have focused on short-term mortality risk (≤5 years).3, 4 To help clinicians identify patients who are at low risk for 10-year mortality and thus most likely to benefit from these preventive interventions, we examined whether our previously developed 4-year mortality index5 accurately predicted 10-year mortality.

Time to benefit for colorectal cancer screening: survival meta-analysis of flexible sigmoidoscopy trials.

Objective To determine the time to benefit of using flexible sigmoidoscopy for colorectal cancer screening. Design Survival meta-analysis. Data sources A Cochrane Collaboration systematic review published in 2013, Medline, and Cochrane Library databases. Eligibility criteria Randomized controlled trials comparing screening flexible sigmoidoscopy with no screening. Trials with fewer than 100 flexible sigmoidoscopy screenings were excluded. Results Four studies were eligible (total n=459 814). They were similar for patients’ age (50-74 years), length of follow-up (11.2-11.9 years), and relative risk for colorectal cancer related mortality (0.69-0.78 with flexible sigmoidoscopy screening). For every 1000 people screened at five and 10 years, 0.3 and 1.2 colorectal cancer related deaths, respectively, were prevented. It took 4.3 years (95% confidence interval 2.8 to 5.8) to observe an absolute risk reduction of 0.0002 (one colorectal cancer related death prevented for every 5000 flexible sigmoidoscopy screenings). It took 9.4 years (7.6 to 11.3) to observe an absolute risk reduction of 0.001 (one colorectal cancer related death prevented for every 1000 flexible sigmoidoscopy screenings). Conclusion Our findings suggest that screening flexible sigmoidoscopy is most appropriate for older adults with a life expectancy greater than approximately 10 years.

Detained and Distressed: Persistent Distressing Symptoms in a Population of Older Jail Inmates.

Distressing symptoms are associated with poor function, acute care use, and mortality in older adults. The number of older jail inmates is increasing rapidly, prompting calls to develop systems of care to meet their healthcare needs, yet little is known about multidimensional symptom burden in this population. This cross‐sectional study describes the prevalence and factors associated with distressing symptoms and the overlap between different forms of symptom distress in 125 older jail inmates in an urban county jail. Physical distress was assessed using the Memorial Symptom Assessment Scale. Several other forms of symptom distress were also examined, including psychological (Generalized Anxiety Disorder Scale, Patient Health Questionnaire), existential (Patient Dignity Inventory), and social (Three Item Loneliness Scale). Information was collected on participant sociodemographic characteristics, multimorbidity, serious mental illness (SMI), functional impairment, and behavioral health risk factors through self‐report and chart review. Chi‐square tests were used to identify factors associated with physical distress. Overlap between forms of distress was evaluated using set theory analysis. Overall, many participants (74%) reported distressing symptoms, including having one or more physical (44%), psychological (37%), existential (54%), or social (45%) symptoms. Physical distress was associated with poor health (multimorbidity, functional impairment, SMI) and low income. Of the 93 participants with any symptom, 49% reported three or more forms of distress. These findings suggest that an optimal model of care for this population would include a geriatrics–palliative care approach that integrates the management of all forms of symptom distress into a comprehensive treatment paradigm stretching from jail to the community.

Changing Patterns of Glucose-Lowering Medication Use in VA Nursing Home Residents With Diabetes, 2005 to 2011.

OBJECTIVE Although nursing home (NH) residents make up a large and growing proportion of Americans with diabetes mellitus, little is known about how glucose-lowering medications are used in this population. We sought to examine glucose-lowering medication use in Veterans Affairs (VA) NH residents with diabetes between 2005 and 2011. RESEARCH DESIGN AND METHODS Retrospective cohort study, using linked laboratory, pharmacy, administrative, and NH Minimum Dataset (MDS) 2.0 databases in 123 VA NHs. A total of 9431 long-stay (>90 days) VA NH residents older than 65 followed for 52,313 person-quarters. We identified receipt of glucose-lowering medications, including insulin, metformin, sulfonylureas, thiazolidinediones, and others (alpha-glucosidase inhibitors, meglitinides, glucagonlike peptide-1 analogs, dipeptidyl peptidase-4 inhibitors and amylin analogs) per quarter. RESULTS The rates of sulfonylurea use in long-stay NH residents dropped dramatically from 24% in 2005 to 12% in 2011 (P < .001), driven in large part by the dramatic decrease in glyburide use (10% to 2%, P < .001). There was sharp drop in thiazolidinedione use in 2007 (4% to <1%, P < .001). Metformin use was stable, ranging between 7% and 9% (P = .24). Insulin use increased slightly from 30% to 32% (P < .001). Use of other classes of glucose-lowering medications was stable (P = .22) and low, remaining below 1.3%. CONCLUSIONS AND RELEVANCE Between 2005 and 2011, there were dramatic declines in use of sulfonylureas and thiazolidinediones in VA NH residents, suggesting that prescribing practices can be quickly changed in this setting.

Older adults in jail: high rates and early onset of geriatric conditions

BackgroundThe number of older adults in the criminal justice system is rapidly increasing. While this population is thought to experience an early onset of aging-related health conditions (“accelerated aging”), studies have not directly compared rates of geriatric conditions in this population to those found in the general population. The aims of this study were to compare the burden of geriatric conditions among older adults in jail to rates found in an age-matched nationally representative sample of community dwelling older adults.MethodsThis cross sectional study compared 238 older jail inmates age 55 or older to 6871 older adults in the national Health and Retirement Study (HRS). We used an age-adjusted analysis, accounting for the difference in age distributions between the two groups, to compare sociodemographics, chronic conditions, and geriatric conditions (functional, sensory, and mobility impairment). A second age-adjusted analysis compared those in jail to HRS participants in the lowest quintile of wealth.ResultsAll geriatric conditions were significantly more common in jail-based participants than in HRS participants overall and HRS participants in the lowest quintile of net worth. Jail-based participants (average age of 59) experienced four out of six geriatric conditions at rates similar to those found in HRS participants age 75 or older.ConclusionsGeriatric conditions are prevalent in older adults in jail at significantly younger ages than non-incarcerated older adults suggesting that geriatric assessment and geriatric-focused care are needed for older adults cycling through jail in their 50s and that correctional clinicians require knowledge about geriatric assessment and care.

Cognition and Incarceration: Cognitive Impairment and Its Associated Outcomes in Older Adults in Jail: Cognitive Impairment in Jail

To determine prevalence of, and outcomes associated with, a positive screen for cognitive impairment in older adults in jail.