Irene S. Tekawa

A Comparison of Fecal Occult-Blood Tests for Colorectal-Cancer Screening

BACKGROUND Hemoccult II, a widely used guaiac test for fecal occult blood, has a low sensitivity for detecting colorectal neoplasms in asymptomatic patients at average risk. In such patients, the performance characteristics of screening tests developed to improve on Hemoccult II are not known. METHODS A set of three fecal occult-blood tests--Hemoccult II; Hemoccult II Sensa, a more sensitive guaiac test; and HemeSelect, an immunochemical test for human hemoglobin--was mailed to all patients 50 years of age or older who were scheduled for personal health appraisals at the Kaiser Permanente Medical Center in Oakland, California. The performance of each test and of a combination test (HemeSelect to confirm positive Hemoccult II Sensa results) was evaluated by identifying screened patients who had colorectal neoplasma (carcinoma or a polyp > or = 1 cm in diameter) in the two years after screening. RESULTS Of the 10,702 eligible patients, 8104 (75.7 percent) had at least one interpretable sample and were screened on the basis of at least one test; 96 percent of these patients had complete two-year follow-up. The sensitivity of the tests for detecting carcinoma was lowest with Hemoccult II (37.1 percent; 95 percent confidence interval, 19.7 to 54.6 percent), intermediate with the combination test (65.6 percent; 95 percent confidence interval, 47.6 to 83.6 percent) and with HemeSelect (68.8 percent; 95 percent confidence interval, 51.1 to 86.4 percent), and highest with Hemoccult II Sensa (79.4 percent; 95 percent confidence interval, 64.3 to 94.5 percent). The specificity for detecting carcinoma was 86.7 percent with Hemoccult II Sensa, 94.4 percent with HemeSelect, 97.3 percent with the combination test, and 97.7 percent with Hemoccult II. HemeSelect and the combination test detected more colorectal carcinomas and polyps than Hemoccult II, with only slight increases in the number of colonoscopies needed. CONCLUSIONS HemeSelect and a combination test in which HemeSelect is used to confirm positive Hemoccult II Sensa results improve on Hemoccult II in screening patients for colorectal carcinoma.

Effect of cigar smoking on the risk of cardiovascular disease, chronic obstructive pulmonary disease, and cancer in men.

BACKGROUND The sale of cigars in the United States has been increasing for the past six years. Cigar smoking is a known risk factor for certain cancers and for chronic obstructive pulmonary disease (COPD). However, unlike the relation between cigarette smoking and cardiovascular disease, the association between cigar smoking and cardiovascular disease has not been clearly established. METHODS We performed a cohort study among 17,774 men 30 to 85 years of age at base line (from 1964 through 1973) who were enrolled in the Kaiser Permanente health plan and who reported that they had never smoked cigarettes and did not currently smoke a pipe. Those who smoked cigars (1546 men) and those who did not (16,228) were followed from 1971 through the end of 1995 for a first hospitalization for or death from a major cardiovascular disease or COPD, and through the end of 1996 for a diagnosis of cancer. RESULTS In multivariate analysis, cigar smokers, as compared with nonsmokers, were at higher risk for coronary heart disease (relative risk, 1.27; 95 percent confidence interval, 1.12 to 1.45), COPD (relative risk, 1.45; 95 percent confidence interval, 1.10 to 1.91), and cancers of the upper aerodigestive tract (relative risk, 2.02; 95 percent confidence interval, 1.01 to 4.06) and lung (relative risk, 2.14; 95 percent confidence interval, 1.12 to 4.11), with evidence of dose-response effects. There appeared to be a synergistic relation between cigar smoking and alcohol consumption with respect to the risk of oropharyngeal cancers and cancers of the upper aerodigestive tract. CONCLUSIONS Independently of other risk factors, regular cigar smoking can increase the risk of coronary heart disease, COPD, and cancers of the upper aerodigestive tract and lung.

HOME BLOOD PRESSURE MONITORING : EFFECT ON USE OF MEDICAL SERVICES AND MEDICAL CARE COSTS

The objective of this study was to determine whether a hypertension management program in which patients monitor their own blood pressure (BF) at home can reduce costs without compromising BP control. The prospective, randomized, controlled 1-year clinical trial was conducted at four medical centers of the Kaiser Permanente Medical Care Program in the San Francisco Bay Area. Of 467 patients with uncomplicated hypertension who were referred by their physicians, 37 declined to participate in the study; 215 were randomly assigned to a Usual Care (UC) group and 215 to a Home BP group. Twenty-five UC patients and 15 Home BP patients did not return for year-end BP measurements. Patients in the UC group were referred back to their physicians. Patients in the Home BP group were trained to measure their own BP and return the readings by mail. Patients were given a standard procedure to follow in case of unusually high or low BP readings at home. The number and type of outpatient medical services used were obtained from patient medical records for the study year and the prior year. Costs of care for hypertension were calculated by assigning relative value units to each outpatient service. Trained technicians measured each patients BP at entry into the study and 1 year later. Home BP patients made 1.2 fewer hypertension-related office visits than UC patients during the study year (95% confidence interval (CI): 0.8,1.7). Mean adjusted cost for physician visits, telephone calls, and laboratory tests associated with hypertension care was

Cohort study of thyroid cancer in a San Francisco Bay area population

88.76 per patient per year in the Home BP group, 29% less than in the UC group (95% CI:

Hemoccult Screening in Detecting Colorectal Neoplasm: Sensitivity, Specificity, and Predictive Value: Long-Term Follow-up in a Large Group Practice Setting

16.11,

Marijuana use and mortality.

54.74). The annualized cost of implementing the home BP system was approximately

Marijuana use and cancer incidence (California, United States)

28 per patient during the study year and would currently be approximately

Colonoscopic Screening of Persons With Suspected Risk Factors far Colon, Cancer: II. Past History of Colorectal Neoplasms

15. After 1 year, BP control in men in the Home BP group was better than in men in the UC group; BP control was equally good in women in both groups. Management of uncomplicated hypertension based on periodic home BP reports can achieve BP control with fewer physician visits, resulting in substantial cost savings.

Marijuana use and injury events resulting in hospitalization

Using data from a large health plan, we performed a cohort study of thyroid cancer among 204,964 persons (aged 10–89 at baseline in 1964–1973, 54% female) followed for a median of 20 years. There were 196 incident thyroid cancers (73 in men, 123 in women). Risk was independently and positively related to female gender [relative risk (RR) = 1.56, 95% confidence interval (CI) = 1.12–2.19], Asian race (RR = 2.86, 95% CI = 1.76–4.65), completed college or post‐graduate education (RR = 1.76, 95% CI = 1.20–2.59), history of goiter (RR = 3.36, 95% CI = 1.82–6.20), radiation of the neck region (RR = 2.33, 95% CI = 1.28–4.23) and family history of thyroid disease (RR = 2.18, 95% CI = 1.17–4.05). An inverse association was found for black race (RR = 0.55, 95% CI = 0.33–0.91). Cigarette smoking, alcohol consumption, personal history of hyperthyroidism, hypothyroidism, overweight or obesity, weight gain since age 20, height, occupational exposures, reproductive factors, oral contraceptives and hormone use did not show statistically significant relations to thyroid cancer. These results provide further evidence for a role of female gender, radiation, goiter, Asian race, high educational attainment and family history of thyroid disease in the etiology of thyroid cancer.

Alcohol drinking and cigarette smoking: an exploration of the association in middle-aged men and women

STUDY OBJECTIVE To determine the sensitivity, specificity, and predictive value of Hemoccult II tests for detecting colorectal neoplasm (colorectal carcinoma or polyp or both). STUDY DESIGN Prospective analyses of asymptomatic patients (greater than or equal to 45 years) followed for 4 years after screening with Hemoccult II testing and retrospective analyses of patients, with known colorectal carcinoma or polyps or both who had Hemoccult II testing within 2 years of diagnosis. SETTING A large, health maintenance organization practice. MEASUREMENTS AND MAIN RESULTS In the prospective analysis, the sensitivity of Hemoccult II was 50% for colorectal carcinoma diagnosed within 1 year of testing, 43% within 2 years, and 25% within 4 years. For polyps, sensitivity was 36% at 1 year, 28% at 2 years, and 17% at 4 years. Specificity was 99%. The predictive value of a positive test for colorectal carcinoma was 8% at 1 year, 10% at 2 years, and 11% at 4 years. On the basis of the retrospective analyses, the sensitivity of Hemoccult II for colorectal carcinoma diagnosed within 1 year of testing was 66% and was 61% within 2 years. Many of these patients had symptoms when tested. CONCLUSIONS An asymptomatic patient age 45 or older with a positive Hemoccult II test has about a chance of 1 in 10 for having colorectal carcinoma and a 1-in-3 chance of having either a colorectal carcinoma or polyp: The same patient with a negative Hemoccult test has a 0.2% chance of having a colorectal carcinoma diagnosed within 2 years of testing and a 0.7% chance of having a polyp. Within 4 years of testing the chance increases to 0.5% for colorectal carcinoma and 1.5% for polyps. If Hemoccult II slides are the only screening method used for detecting asymptomatic colorectal neoplasms, 50% to 60% of lesions will remain undetected. Clinical interpretation of Hemoccult screening requires appreciation of its limits as well as its benefits.