Mark S. Johnson

Lung Cancer Screening with Sputum Cytologic Examination, Chest Radiography, and Computed Tomography: An Update for the U.S. Preventive Services Task Force

No major medical professional organization currently recommends screening for lung cancer. The U.S. Preventive Services Task Force (USPSTF) gave lung cancer screening a grade D recommendation in both 1985 and 1996, meaning that there were fair-quality data to recommend against screening for lung cancer (1) based largely on 3 negative trials conducted in the United States in the 1970s. Since the last Task Force review, several new studies of lung cancer screening have been reported, and greater attention has been directed toward the limitations of existing literature. This review was conducted to aid the current USPSTF in updating its lung cancer screening recommendation. Lung cancer is the leading cause of cancer-related death among men and women in the United States; in 2003, approximately 171 900 new cases and 157 200 lung cancerassociated deaths were predicted (2). Worldwide, lung cancer and lung cancerrelated deaths have been increasing in epidemic proportions (3, 4), with an estimated 1 million deaths in the year 2000 (5). Although there are other important risk factors for lung cancer (3, 6-10), cigarette smoking is the major risk factor. Approximately 87% of all lung, bronchial, and tracheal cancer is attributed to smoking (3). Consequently, the most important public health intervention that could reduce lung cancer incidence and deaths is changing smoking habits. Unfortunately, although overall prevalence rates of smoking in the United States have decreased over the past 2 decades, the prevalence of current adult smokers remains high at 24% (10, 11). In the clinical setting, smoking cessation programs, even in conjunction with drug therapy, have long-term smoking cessation rates of only 20% to 35% at 1 year among motivated volunteers in good-quality studies (12-14). In addition, in 1999, approximately 45.7 million adults (23.1%) were former smokers. Currently a high percentage of lung cancer cases occur in former smokers, since the risk for lung cancer does not decrease for many years after smoking cessation (15-17). Household exposure to secondhand smoke is substantial and is also associated with lung cancer (18). These smoking exposure rates, combined with large numbers of individuals with past or passive exposure to smoking, indicate that lung cancer will continue to be a major public health problem in the United States and worldwide. Lung cancer is fatal in more than 90% of affected persons (19). Survival is directly related to the stage of lung cancer at the time of diagnosis, ranging from 70% for stage I disease to less than 5% for stage IV disease (20, 21). Seventy-five percent of patients with lung cancer present with symptoms related to incurable advanced local or metastatic disease (19). Since lung cancer mortality is closely associated with disease stage at the time of diagnosis, it is believed (primarily on the basis of indirect evidence) (22-28) that early surgical resection is associated with better outcomes. Therefore, the current standard of practice is to resect most nonsmall-cell lung cancer without evidence of metastatic spread. For many of these reasons, screening for and treating early lung cancer is intuitively appealing. Methods This review discusses studies of chest radiography, sputum cytologic examination, and low-dose computed tomography (CT) for lung cancer screening and focuses on the outcomes of screening in populations. We reviewed the MEDLINE and Cochrane databases from their inception through January 2003 using the search terms lung neoplasms, lung cancer, and any screening. The search strategy is detailed in Appendix Table 1. To ensure complete ascertainment, we reviewed the bibliographies of reviews, editorials, book chapters, and letters discussing lung cancer screening, as well as a recent Cochrane review and analysis (29). We sought studies evaluating screening in the general population, as well as in high-risk populations, and included observational studies and clinical trials. Observational studies with control groups and controlled trials evaluating disease-specific mortality were evaluated for quality according to criteria created by the USPSTF (30) (Appendix). For the purposes of this review, high-risk persons are those who currently smoke or have ever smoked and low-risk persons are those who have never smoked. To rate each of the studies, we reviewed all original articles discussing the studys methods or findings. We also used studies of the various screening methods to estimate the screening test characteristics of chest radiography and low-dose CT. Finally, we used data from screening studies (when available), as well as clinical series, to evaluate the harms associated with screening and treatment. For completeness, all studies are described in the tables; however, only studies rated as fair or better quality are described in the text. Methodologic issues relevant to understanding screening studies include lead-time bias (when the time of diagnosis is advanced by screening but the time of death is unchanged), length bias (bias toward detecting less aggressive tumors in a periodically screened sample) (31), and volunteer bias (a type of selection bias in which volunteers are compared with nonvolunteers) (32). Overdiagnosis occurs when cancer that would never have been important during an individuals lifetime is diagnosed and treated. These biases can be eliminated only in randomized, controlled trials that include death as an outcome. Therefore, public health guidelines and this review place the most emphasis on information from randomized, controlled trials. This research was funded by the Agency for Healthcare Research and Quality. Agency staff and USPSTF members reviewed interim analyses and the final report. Before preparation of this manuscript, the full report was reviewed by 17 content experts in lung cancer screening and was revised accordingly. Data Synthesis In our searches, we identified 809 citations and abstracts; 149 full-text papers were reviewed. Of these, 1 randomized trial of chest radiography in conjunction with a multiphasic screening program (33, 34) and 5 randomized, controlled trials of chest radiography, sputum cytologic examination, or both as screening for lung cancer (35-40) were reviewed. In addition, 6 casecontrol studies (41-46), 1 nonrandomized, controlled trial (47), and 4 older cohort studies (48-52) were reviewed (Appendix Table 2). We also reviewed 6 recent cohort studies of lung cancer screening with CT (53-62). Lung Cancer Screening with Chest Radiography with or without Sputum Cytologic Examination Controlled Trials The methods and quality of the 6 randomized, controlled trials and the single nonrandomized, controlled trial of lung cancer screening (33-40, 47, 63-85) are shown in Tables 1 and 2. The Figure shows the relative risks and 95% CIs of these randomized trials. In the 1960s, the Northwest London Mass Radiography Service conducted a cluster randomized trial of chest radiography screening in approximately 55 000 men older than 40 years of age (35, 36). In this trial, 29 723 male factory workers from 75 randomly identified firms were offered chest radiography every 6 months and were compared with 25 300 controls from other factories who were offered screening at baseline and at 3 years. After 3 years, the annual mortality rate from lung cancer was 0.7 per 1000 person-years in the intervention group and 0.8 per 1000 person-years in the control group, not a statistically significant difference. Table 1. Controlled Trials of Lung Cancer Screening with Chest Radiography with or without Sputum Cytologic Examination Table 2. Methods and Quality of Controlled Trials of Lung Cancer Screening Figure. Mortality in randomized, controlled trials of lung cancer screening with chest radiography with or without sputum cytologic examination. The National Cancer Institute sponsored 3 randomized, controlled trials of lung cancer screening in male smokers in the United States in the 1970s (37-39, 63, 64, 68, 73-75, 80). The Memorial Sloan-Kettering Study (37, 63-67) and the Johns Hopkins Study (38, 68-72) were identical in design and were conducted to evaluate the incremental benefit of adding sputum cytologic examination to annual chest radiography. Of the 20 427 male smokers ( 20 pack-years of smoking) age 45 years or older who volunteered for these 2 studies, 10 234 were randomly assigned to a dual-screening group that was offered screening with chest radiography annually and sputum cytologic examination every 4 months for 5 years; 10 233 were assigned to a chest radiography group that was offered annual screening for 5 years. Each group was followed for 5 to 8 years. In the Memorial Sloan-Kettering Study, baseline screening identified 30 (6.0 per 1000) malignant tumors in the dual-screening group and 23 (4.6 per 1000) in the chest radiography group (63). After prevalence screening, 114 subsequent (incident) cases of lung cancer were identified in the dual-screening group and 121 were identified in the annual radiography group during the screening period. Thirty-three and 32 cases, respectively, were diagnosed in the 2 years following screening. When the incidence and prevalence tumors are combined, 144 cases of lung cancer were detected in each group during the study (37, 64, 67); 40% of all lung cancer detected was stage I. The mortality rate was 2.7 per 1000 person-years in both the chest radiography and dual-screening groups. In the Johns Hopkins Study, prevalence screening identified 39 malignant tumors in the dual-screening group and 40 in the chest radiography group (38, 71). After 8 years of follow-up, 194 incident cases of cancer were identified in the dual-screening group and 202 were identified in the chest radiography group. The mortality rates were 3.4 per 1000 person-years in the dual-screening group and 3.8 per 1000 person-years in the control group (not statistically significant differences) and were similar t

A prospective investigation of physical health outcomes in abused and neglected children: new findings from a 30-year follow-up.

OBJECTIVES We investigated whether abused and neglected children are at risk for negative physical health outcomes in adulthood. METHODS Using a prospective cohort design, we matched children (aged 0-11 years) with documented cases of physical and sexual abuse and neglect from a US Midwestern county during 1967 through 1971 with nonmaltreated children. Both groups completed a medical status examination (measured health outcomes and blood tests) and interview during 2003 through 2005 (mean age=41.2 years). RESULTS After adjusting for age, gender, and race, child maltreatment predicted above normal hemoglobin, lower albumin levels, poor peak airflow, and vision problems in adulthood. Physical abuse predicted malnutrition, albumin, blood urea nitrogen, and hemoglobin A1C. Neglect predicted hemoglobin A1C, albumin, poor peak airflow, and oral health and vision problems, Sexual abuse predicted hepatitis C and oral health problems. Additional controls for childhood socioeconomic status, adult socioeconomic status, unhealthy behaviors, smoking, and mental health problems play varying roles in attenuating or intensifying these relationships. CONCLUSIONS Child abuse and neglect affect long-term health status-increasing risk for diabetes, lung disease, malnutrition, and vision problems-and support the need for early health care prevention.

Adoption of body mass index guidelines for screening and counseling in pediatric practice.

OBJECTIVE: The purpose of this study was to examine pediatrician implementation of BMI and provider interventions for childhood overweight prevention and treatment. METHODS: Data were obtained from the American Academy of Pediatrics (AAP) Periodic Survey of Fellows No. 65, a nationally representative survey of AAP members. Surveys that addressed the provision of screening and management of childhood overweight and obesity in primary care settings were mailed to 1622 nonretired US AAP members in 2006. RESULTS: One thousand five (62%) surveys were returned; 677 primary care clinicians in active practice were eligible for the survey. Nearly all respondents (99%) reported measuring height and weight at well visits, and 97% visually assess children for overweight at most or every well-child visit. Half of the respondents (52%) assess BMI percentile for children older than 2 years. Most pediatricians reported that they do not have time to counsel on overweight and obesity, that counseling has poor results, and that having simple diet and exercise recommendations would be helpful in their practice. Pediatricians in large practices and those who had attended continuing medical education on obesity were more familiar with national expert guidelines, were more likely to use BMI percentile, and had higher self-efficacy in practices related to childhood and adolescent overweight and obesity. Multivariate analysis revealed that pediatricians with better access to community and adjunct resources were more likely to use BMI percentile. CONCLUSIONS: BMI-percentile screening in primary pediatric practice is underused. Most pediatricians believe that they can and should try to prevent overweight and obesity, yet few believe there are good treatments once a child is obese. Training, time, and resource limitations affect BMI-percentile use. Awareness of national guidelines may improve rates of BMI-percentile use and recognition of opportunities to prevent childhood and adolescent obesity.

Customer satisfaction, perceived risk and affective commitment: an investigation of directions of influence

– This paper aims to examine competing models of the directionality of influences between customer satisfaction, affective commitment, and the customers perceptions of risk associated with a service organization. It also aims to include the effects of a customers prior experience with the organization and experience with other organizations in the service category in the models., – Structural equation models of data from a survey to customers of a performing arts organization (sample size=401) are used to test the hypotheses., – The study suggests that commitment has a positive influence on customer satisfaction and diminishes risk perceptions. There is less support for a model in which satisfaction increases commitment and reduces perceived risk., – There has been recent controversy as to whether customer satisfaction leads to customer loyalty. This study provides a different perspective by suggesting that customers with high commitment to an organization use satisfaction surveys to express their loyalty.

The Economic Burden of Hospitalizations Associated With Child Abuse and Neglect

OBJECTIVES This study assessed the economic burden of child abuse-related hospitalizations. METHODS We compared inpatient stays coded with a diagnosis of child abuse or neglect with stays of other hospitalized children using the 1999 National Inpatient Sample of the Healthcare Costs and Utilization Project. RESULTS Children whose hospital stays were coded with a diagnosis of abuse or neglect were significantly more likely to have died during hospitalization (4.0% vs 0.5%), have longer stays (8.2 vs 4.0 days), twice the number of diagnoses (6.3 vs 2.8), and double the total charges (19,266 vs 9513 US dollars) than were other hospitalized children. Furthermore, the primary payer was typically Medicaid (66.5% vs 37.0%). CONCLUSION Earlier identification of children at risk for child abuse and neglect might reduce the individual, medical, and societal costs.

Screening and Counseling for Childhood Obesity: Results from a National Survey

Purpose: To examine family physicians’ beliefs and practices about using body mass index (BMI) percentiles to screen for childhood overweight and obesity. Methods: Surveys about management of childhood overweight were mailed to 1800 American Academy of Family Physician members in 2006. Results: 729 surveys were returned; 445 were eligible. Most (71%) members were familiar with BMI guidelines; 41% were familiar with American Academy of Family Physician recommendations about overweight. Most (78%) had tools available to calculate BMI; fewer have enough time for overweight screening (55%), and only 45% reported computing BMI percentile at most or every well visit for children older than 2. Having an electronic health record increased BMI screening rates. Family physicians felt prepared to discuss weight, but only 43% believed their counseling was effective and many (55%) lack community or referral services. Most (72%) wanted simple diet and exercise recommendations for patients. Reimbursement for weight-related services is insufficient: 86% say that patients cannot pay for services not covered by insurance. Factor analysis identified clinician self-efficacy, resources, and reimbursement as factors related to calculating BMI percentiles. Conclusions: BMI is underutilized by family physicians. Most believe they should try to prevent overweight and have tools to use BMI, but clinicians have few resources available for treatment, have low self-efficacy, and report inadequate reimbursement.

Randomized Comparison of 3 Methods to Screen for Domestic Violence in Family Practice

PURPOSE We undertook a study to compare 3 ways of administering brief domestic violence screening questionnaires: self-administered questionnaire, medical staff interview, and physician interview. METHODS We conducted a randomized trial of 3 screening protocols for domestic violence in 4 urban family medicine practices with mostly minority patients. We randomly assigned 523 female patients, aged 18 years or older and currently involved with a partner, to 1 of 3 screening protocols. Each included 2 brief screening tools: HITS and WAST-Short. Outcome measures were domestic violence disclosure, patient and clinician comfort with the screening, and time spent screening. RESULTS Overall prevalence of domestic violence was 14%. Most patients (93.4%) and clinicians (84.5%) were comfortable with the screening questions and method of administering them. Average time spent screening was 4.4 minutes. Disclosure rates, patient and clinician comfort with screening, and time spent screening were similar among the 3 protocols. In addition, WAST-Short was validated in this sample of minority women by comparison with HITS and with the 8-item WAST. CONCLUSIONS Domestic violence is common, and we found that most patients and clinicians are comfortable with domestic violence screening in urban family medicine settings. Patient self-administered domestic violence screening is as effective as clinician interview in terms of disclosure, comfort, and time spent screening.

Screening for overweight in children and adolescents: where is the evidence? a commentary by the childhood obesity working group of the US Preventive Services Task Force

The prevalence of childhood and adolescent overweight has tripled over the past 2 decades, and associations have been identified between dietary patterns, physical activity, sedentary behaviors, and overweight. Some believe that pediatricians can easily recognize an overweight or obese child or adolescent and that there are sufficient therapeutic options to offer these patients and their families. However, primary care clinicians face obese and overweight children, adolescents, and parents every day, and most clinicians rarely document overweight.

Intimate Partner Violence and Cancer Screening among Urban Minority Women

Purpose: To evaluate the association of intimate partner violence (IPV) with breast and cervical cancer screening rates. Methods: We conducted retrospective chart audits of 382 adult women at 4 urban family medicine practices. Inclusion criteria were not being pregnant, no cancer history, and having a partner. Victims were defined as those who screened positive on at least one of 2 brief IPV screening tools: the HITS (Hurt, Insult, Threat, Scream) tool or Women Abuse Screening Tool (short). Logistic regression models were used to examine whether nonvictims, victims of emotional abuse, and victims of physical and/or sexual abuse were up to date for mammograms and Papanicolaou smears. Results: Prevalence of IPV was 16.5%. Compared with victims of emotional abuse only, victims of physical and/or sexual abuse aged 40 to 74 were associated with 87% decreased odds of being up to date on Papanicolaou smears (odds ratio, 0.13; 95% CI, 0.02–0.86) and 84% decreased odds of being up to date in mammography (odds ratio, 0.16; 95% CI, 0.03–0.99). There was no difference in Papanicolaou smear rates among female victims and nonvictims younger than 40. Conclusions: Because of the high prevalence of IPV, screening is essential among all women. Clinicians should ensure that victims of physical and/or sexual abuse are screened for cervical cancer and breast cancer, particularly women aged 40 or older. Cancer screening promotion programs are needed for victims of abuse.

Knowledge flows in marketing: An analysis of journal article references and citations

Recent articles in Marketing Theory have criticized the cumulativeness and the diffusion of knowledge emanating from academic journals in marketing. The normative and the social exchange theories of citation propose that intellectual influence and knowledge transfer may be traced by examining relationships between references and citations of journal articles. Analysis of a sample of articles drawn from eight marketing journals suggests that marketing knowledge exhibits both cumulativeness and knowledge diffusion. For example, analysis of the sample of articles indicates that there is significant reciprocating influence between references and citations within a journal, across marketing journals, and across disciplinary boundaries. The influences of article references on citations are analyzed relative to the effect of the journal of publication on citations. Results indicate that the perceived quality of the journal rather than the accessibility of the journal is also influential on citations of articles.