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Should women have an annual pelvic exam? Depends on who you ask

American College of Physicians

1. Should women have an annual pelvic exam? Depends on who you ask.

Annals of Internal Medicine and Beth Israel Deaconess Medical Center go "Beyond the Guidelines" to discuss differing opinions on screening pelvic examinations in adult women
Free content: http://www.annals.org/article.aspx?doi=10.7326/M15-1220
URL goes live when the embargo lifts

An internist and a gynecologist discuss opposing views on routine pelvic exam in a multicomponent educational article being published in Annals of Internal Medicine.

For decades, pelvic exams have been a regular part of a woman's annual doctor visit. In 2014, new evidence-based guidelines from the American College of Physicians (ACP) recommended against routine pelvic exam for asymptomatic adult women at average risk. The evidence showed that the diagnostic accuracy of the screening pelvic examination for detecting ovarian cancer or bacterial vaginosis is low; the test rarely detects noncervical cancer or other treatable conditions; and was not associated with improved health outcomes. ACP found no evidence on the diagnostic accuracy of the test for other conditions such as asymptomatic pelvic inflammatory disease, benign conditions, or gynecologic cancers other than cervical or ovarian. In contrast, the American College of Obstetrics and Gynecology (ACOG) maintains its position that annual pelvic exams are necessary to recognize issues such as incontinence and sexual dysfunction. They say the test also offers an invaluable opportunity for physicians to discuss important sexual health issues with their patients.

In a new 'Beyond the Guidelines' article, an internist and a gynecologist discuss these differing approaches to care for a real patient. Each clinician discusses how he or she would balance benefits, harms, and patient preferences with regard to pelvic exam. All 'Beyond the Guidelines' papers are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center in Boston and include print, video, and educational components. A list of topics is available at http://www.annals.org/grandrounds.

Note: The URLs, including video link, will be live when the embargo lifts. For an embargoed PDF, please contact Cara Graeff. To interview the lead author, please contact Lizzie Williamson at erwillia@bidmc.harvard.edu or 617-632-8217.


2. Cancer prevention efforts needed as patients live longer with HIV

Abstract: http://www.annals.org/article.aspx?doi=10.7326/M14-2768
URL goes live when the embargo lifts

According to an article published in Annals of Internal Medicine, the effectiveness of antiretrorivral therapy has enabled persons with HIV to live long enough to develop cancer, especially Kaposi sarcoma, non-Hodgkin lymphoma, and lung cancer. Targeted cancer screening and prevention efforts may be needed for this population.

Cancer has become increasingly common in patients with HIV. Researchers sought to determine if this increase is due to persons living longer or to a true increase in the incidence of cancer. They compared time trends in cumulative cancer incidence by age 75 in 86,620 persons with HIV and 196,987 persons without HIV. HIV patients had an approximately one in 25 lifetime risk for developing Kaposi sarcoma, non-Hodgkin lymphoma, or lung cancer. They also had an increasing cumulative incidence over time for anal, colorectal, and liver cancer. The increased risk for all cancers could be attributed to a steeply declining mortality rate.

Researchers suggest that persons with HIV may benefit from increased cancer screening and prevention efforts. They suggest that persons with HIV continue with antiretroviral therapy and quit smoking. More research is needed to determine the benefits and harms of routine lung cancer screening with low-dose computed tomography for patients with HIV.

Note: For an embargoed PDF, please contact Angela Collom. To speak with the lead author, Dr. Michael Silverberg, please contact Ann Wallace at Ann.M.Wallace@kp.org or 510-891-3563.


3. Guidelines International Network publishes principles for disclosing and managing conflicts of interest

Abstract: http://www.annals.org/article.aspx?doi=10.7326/M14-1885
URL goes live when the embargo lifts

Based on expressions of need from its members, the Board of Trustees of the Guidelines International Network (G-I-N) has developed principles for disclosing and managing conflicts of interest (COIs) for researchers involved in the development of guidelines. These principles are published in Annals of Internal Medicine.

COIs create a risk for bias in decisions or recommendations and systematic approaches to the disclosure of interests and COI management are necessary to minimize this risk. Established in 2002, the G-I-N is a network of guideline developers, comprising 100 organizations and 127 persons from 48 countries. The G-I-N has published guideline development standards that emphasize the importance of disclosing and managing COIs, but these standards do not elaborate on specific COI management.

Twelve guideline developers from most regions of the world with backgrounds in evidence-based medicine and guideline development used a consensus-based process to develop the G-I-N principles for managing COIs. The panel consulted published research and existing policies and guideline manuals to inform the development of 9 principles for disclosing interests and managing COIs. While it is often impossible to avoid all COIs when developing specific guidelines or when working in certain settings, the principles are designed to create a system of checks and balances that make COIs fully transparent. A complete summary of the principles is available at http://www.annals.org/article.aspx?doi=10.7326/M14-1885.

Note: For an embargoed PDF, please contact Angela Collom. To speak Dr. Amir Qaseem from the G-I-N Board of Trustees, please contact Steve Majewski at smajewski@acponline.org or 215-351-2514.

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