1. ACP says Federal Government Needs to Improve Health Support for Indigenous Communities
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Indigenous populations continue to suffer significant barriers and disparities in health care, due in part to the federal government failing to provide adequate health support and services for these communities, says the American College of Physicians (ACP) in a new position paper. ACP says that policymakers have an obligation to fulfill the federal trust responsibility to provide equitable health care and other services to Indigenous populations in the U.S., including sufficient financial resources to support their care. The full position paper is published in Annals of Internal Medicine.
In recent years, Indigenous populations have experienced high rates of chronic diseases, death due to unintentional and intentional injuries, and infant mortality. These disparities have arisen in-part from the historical trauma associated with decades of racism, discrimination, and violence; subsequent poor social drivers of health; the degradation of Indigenous traditions, culture, and society; and inadequate access to and chronic insufficient funding of health care services for Indigenous populations.
ACP offers several recommendations for public policymakers at the federal level to strengthen the health and well-being of Indigenous populations in a manner that reflects the need for self-determination and collaboration while ensuring federal obligations are met. Specifically, ACP believes:
Increased funding is needed for health services for Indigenous people, particularly given the identified disparities and inequities in federal funding.
Community-driven public policy, developed under the leadership of Indigenous leaders is necessary to remedy the injustices, disparities, and inequities experienced by Indigenous individuals and communities.
Improved support is needed to prioritize health and wellness promotion, chronic disease prevention, and other public health interventions addressing morbidities with high incidence in Indigenous communities; and that policy makers must team with Indigenous leaders to address the full range of underlying social drivers of health associated with disproportionately high rates of poverty experienced by Indigenous communities.
A multidisciplinary approach, developed by Indigenous populations in collaboration with other experts in the field, is necessary to implement culturally appropriate interventions to address the underlying drivers that exacerbate physical, mental, and behavioral health issues and contribute to catastrophic rates of suicide in Indigenous communities.
Community-driven collaboration is needed among relevant governments, agencies, and Indigenous leaders to develop plans to mitigate the high rates of violence experienced in Indigenous populations. ACP also supports actions to increase Indigenous representation in medical school student bodies and the medical workforce.
2. One sigmoidoscopy significantly reduces long-term CRC incidence in both men and women
CRC mortality reduced by 20 percent over a 15-year follow-up period
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A pooled analysis evaluating the 15-year effect of sigmoidoscopies has found that receiving one sigmoidoscopy significantly reduces long-term incidence of colorectal cancer (CRC) in both men and women. The analysis is published in Annals of Internal Medicine.
Colorectal cancer is the third most common cancer worldwide, with more than 1.9 million new cases and more than 930,000 deaths each year. Sigmoidoscopy and colonoscopy screening provide an opportunity for CRC reduction by detecting early cancer and removing premalignant polyps. However, there has been uncertainty as to how long the benefits of sigmoidoscopy screening lasts, and whether the benefits differ by sex.
Researchers from Norway, the United States, Italy and the United Kingdom conducted an analysis of four randomized trials comprising more than 274,000 participants over a follow-up period of minimum 15 years comparing sigmoidoscopy screening to usual care. The data showed that persons screened at least once experienced a 21% reduction in CRC incidence compared to usual care. The data also showed that receiving at least one screening reduced CRC-related mortality by 20% and all-cause mortality by 2%. The CRC incidence varied by gender, with men experiencing a 25% incidence reduction and women experiencing a 16% incidence reduction. According to the authors, possible explanations for the CRC incidence difference between men and women include differences in the quality of bowel preparation, more technically challenging procedures in women, and a higher incidence and larger proportion of proximal colon cancer in women.
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3. Most persons screened for lung cancer meet USPSTF criteria, but adherence to follow-up screening low
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A cohort study of more than one million people has found that most persons screened for lung cancer meet U.S. Preventative Services Task Force (USPSTF) criteria, but men, persons who formerly smoked, and younger eligible patients are less likely to be screened. Adherence to follow-up screening was also poor. The findings are published in Annals of Internal Medicine.
In 2013, the USPSTF recommended annual lung cancer screening (LCS) using low-dose computed tomography (LDCT) for the first time in adults aged 55 to 80 years who had a smoking history of at least 30 pack-years and currently smoked or quit within the past 15 years. The initial criteria for eligibility included approximately eight million Americans. In 2021, the Task Force expanded eligibility for screening, nearly doubling the size of the eligible population.
Researchers from the Hollings Cancer Center at the Medical University of South Carolina and members of the American Cancer Societies Roundtable on Lung Cancer studied the first million people to receive LCS and be entered into the Lung Cancer Screening Registry (LCSR). The authors analyzed LCS data collected between 2015 and 2019 from 3,625 facilities reporting to the LCSR. They found that 90.8% of persons screened met the 2013 USPSTF criteria. Compared with the eligible U.S. population, screened persons were older, more likely to be female, and more likely to currently smoke. The data also showed that adherence to annual follow-up screening is low, which may reduce cost-effectiveness and diminish mortality benefits. As such, providers should emphasize with patients that screening in those eligible should be performed yearly.
An accompanying editorial from the Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, New York highlights some of the sobering findings from the study and suggests ways for clinicians to improve national lung cancer screening rates and reduce deaths. The author recommends that physicians take complete smoking histories from patients, not refer patients to screenings when they are not likely to benefit, and work with their healthcare systems to ensure higher adherence to screening follow-ups. The author also touches on the importance of focusing screening messaging efforts on eligible patients from historically underserved populations.
4. Physicians debate CRC guidelines, available screening options for younger patients
‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center
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In a new Annals ‘Beyond the Guideline’s feature, a primary care physician and a gastroenterologist discuss the recommendation to begin colorectal cancer (CRC) screening at age 45, review options for CRC screening, and discuss how to choose among the available options. All ‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center (BIDMC) in Boston and include print, video, and educational components published in Annals of Internal Medicine.
CRC is the third leading cause of cancer death for men and women in the United States. It is diagnosed most frequently among persons aged 65 to 74 years. However, among persons younger than 50 years, incidence rates have been increasing since the mid-1990s. In 2021, partially because of the rising incidence, the United States Preventive Services Task Force (USPSTF) recommended CRC screening for adults aged 45 to 49 years. The USPSTF does not recommend a specific screening test, but both stool-based and direct visualization tests are available and cost-effective.
BIDMC Grand Rounds discussants, Carol M. Mangione, MD, MSPH, Chair of the U.S. Preventive Services Task Force, as well as Chief of the Division of General Internal Medicine & Health Services Research and a Professor of Medicine at David Geffen Medical School, and David S. Weinberg, MD, MSc, Chair of the Department of Medicine at Fox Chase Cancer Center and a Professor of Medicine at Temple University Medical School recently discussed the case of Ms. N., a 44 year-old woman deciding between CRC screening options after receiving a recommendation from her doctor.
In their assessments, Drs. Mangione and Weinberg agree that Ms. N. should pursue the screening test she is most likely to have performed. This consensus is in line with current USPSTF recommendations. Dr. Mangione agrees with teh USPSTF recommendation that Ms. N. should be screened at 45 rather than 50, because the Task Force determed that screening adults aged 45 to 49 provides moderate benefit for reducing the CRC mortality rate and increasing life-years gained. Dr. Weinberg, however, expressed concern that there is no direct evidence to support that persons 45 to 49 years of age will derive the same benefit from CRC screening. The discussangs also agreed that reaching the 80 percent screening rate goal for persons aged 50 to 74 years is critcally important, especially as clinicians start thinking about screening those 45 to 49 years of age we simultaneously need to identify and addrss barriers to screening the broader population.
A complete list of ‘Beyond the Guidelines’ topics is available at www.annals.org/grandrounds.
Also in this issue :
In the Clinic
Joseph H. Donroe, MD, MPH, MHS ; E. Jennifer Edelman, MD, MHS
Annals of Internal Medicine
Method of Research
Subject of Research
Supporting the Health and Well-Being of Indigenous Communities: A Position Paper From the American College of Physicians
Article Publication Date