ACP issues guidance statement for breast cancer screening

1. ACP issues guidance statement for breast cancer screening of average-risk women with no symptoms
Great majority of average-risk women with no symptoms will benefit from mammography every other year beginning at age 50
Notes: HD video soundbites of ACP's president discussing the guidance statement are available to download at URL to come.
Abstract: http://annals.org/aim/article/doi/10.7326/M18-2147
Editorial: http://annals.org/aim/article/doi/10.7326/M19-0726
URLs go live when the embargo lifts

In a new evidence-based guidance statement published in Annals of Internal Medicine, the American College of Physicians (ACP) says that average-risk women between the ages of 50 and 74 should undergo breast cancer screening with mammography every other year. ACP's guidance statement does not apply to patients with prior abnormal screening results or to higher risk populations, such as women with a personal history of breast cancer or a genetic mutation known to increase risk.

In average-risk women between the ages of aged 40 and 49 years, physicians should discuss whether to screen for breast cancer with mammography before age 50. Discussion should include the potential benefits and harms and a woman's preferences. The potential harms outweigh the benefits in most women aged 40 to 49 years.

Evidence shows that annual mammography results in more harm than mammography every other year, and little difference exists in breast cancer mortality for screening every year versus screening every other year but will substantially reduce screening harms. Compared to women screened every other year, more women screened annually receive a recommendation for a biopsy after a false-positive result biennially (7.0 percent vs. 4.8 percent).

Harms of breast cancer screening include overdiagnosis, overtreatment, false positive results (from a test showing an abnormality even though the woman does not have breast cancer), radiation exposure and radiation associated breast cancers and breast cancer deaths, as well as worry and distress from tests and procedures including breast biopsies. About 20 percent of women diagnosed with breast cancer over a 10-year period will be overdiagnosed and likely overtreated. Overdiagnosis means a woman is diagnosed with a breast cancer that would not have made her sick or led to her death if not diagnosed or treated (overtreatment). Therefore, finding this cancer is not of clinical benefit to the woman.

In an accompanying editorial, Joann G. Elmore, MD, MPH, and Christoph I. Lee, MD, MS, write: "The results of [ACP's] assessment are 4 guidance statements that provide clarity and simplicity amidst the chaos of diverging guidelines. These ACP guidance statements represent convergence across differing recommendations while highlighting important points for physicians to consider in shared decision-making conversations with their patients about routine breast cancer screening."

Media contact: For an embargoed PDF or to talk to an ACP spokesperson, please contact Steve Majewski at SMajewski@acponline.org or 215-351-2514.

2. Nutrients from food, not supplements, linked to lower risks of death, cancer
Excess calcium intake from supplement use linked to increased risk of death from cancer
Abstract: http://annals.org/aim/article/doi/10.7326/M18-2478
URLs go live when the embargo lifts

Adequate intake of certain nutrients was associated with a reduction in all-cause mortality, but only when those nutrients were derived from food, not from supplements. Excess calcium intake from supplement use was found to be linked to an increased risk of cancer death when supplement doses exceeded 1,000 mg/day. Findings from an observational study are published in Annals of Internal Medicine.

More than half of U.S. adults report using dietary supplements in the previous 30 days, despite controversy surrounding their benefits and risks. Researchers from Friedman School of Nutrition Science and Policy at Tufts University used a nationally representative sample comprised of data on more than 27,000 U.S. adults ages 20 and older to evaluate the association between dietary supplement use and death from all causes, cardiovascular disease (CVD), and cancer. Participants were asked during an in-house interview whether they had used any dietary supplements in the previous 30 days. Those who reported supplement use were asked the product name, frequency, and duration for each nutrient. Nutrient intake from foods was assessed using 24-hour diet recalls conducted by trained interviewers.

Based on participants' responses, the researchers concluded that adequate intakes of vitamin K and magnesium were associated with a lower risk of death, but only when derived from food. Adequate intakes of vitamin A, vitamin K, and zinc were associated with a lower risk of death from CVD, but again, only when derived from food, not from supplements. They also found that excess intake of calcium from supplement use was associated with higher risk of death from cancer.

According to the researchers, dietary supplements still had no effect on the risk of death when used by people with low nutrient intake from food. The data indicated that use of vitamin D supplements by individuals with no sign of vitamin D deficiency was associated with an increased risk of death from all causes including cancer. Further research on this potential connection is needed.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the senior clinical author, Fang Fang Zhang, MD, PhD, please contact Lisa LaPoint at lisa.lapoint@tufts.edu or 617-636-3707.

3. Medical Graphic narratives may improve patient comprehension and relieve anxiety before coronary angiography
Abstract: http://annals.org/aim/article/doi/10.7326/M18-2976
URLs go live when the embargo lifts

Medical graphic novels used as a supplement to patient information and consent materials may help to improve patient comprehension and relieve anxiety before coronary angiography. A brief research report is published in Annals of Internal Medicine.

A large proportion of patients having coronary interventions do not seem to understand the rationale for treatment and have erroneous perceptions regarding expected benefits. Researchers from the Charité - Universitätsmedizin Berlin, Germany, sought to determine whether supplementing standard informed consent materials with a comic would improve patient comprehension, anxiety, and satisfaction. They randomly assigned 121 consecutive hospitalized patients who were having coronary angiography at the Berlin-based university hospital Charité to receive information about their procedure from a standard informed consent form either with or without a comic containing graphic illustrations explaining key concepts. They found that patients in the comic group had significantly better comprehension as assessed by questionnaire. The patients also expressed less anxiety and greater satisfaction with regard to their experience. According to the researchers, these findings suggest that complementary graphic illustrations may substantially improve the practice of patient informed consent.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview authors Anna Brand or Verena Stangl, please contact the authors at anna.brand@charite.de or verena.stangl@charite.de, or Corporate Spokesperson Manuela Zingl at presse@charite.de.

4. Intensive treatment models for HCV shown to be effective for injection drug users
Directly observed therapy was associated with greater adherence than self-administered treatment
Abstract: http://annals.org/aim/article/doi/10.7326/M18-1715
URLs go live when the embargo lifts

Intensive treatment models were shown to be effective for treating hepatitis C virus (HCV) in people who inject drugs. All models tested resulted in sustained virologic response, but directly observed therapy (DOT) was associated with greater adherence than self-administered individual treatment (SIT). Findings from a randomized controlled trial are published in Annals of Internal Medicine.

Many people who inject drugs are denied treatment for HCV infection, even if they are receiving opioid agonist therapy. Research suggests that HCV in people who inject drugs may be treated effectively, but optimal models of care have not been evaluated in randomized controlled trials.

Researchers from Prisma Health, Clemson University, and University of South Carolina School of Medicine-Greenville in South Carolina and Albert Einstein College of Medicine in New York randomly assigned 150 adult injection drug users in an opioid-agonist therapy program to undergo HCV treatment with a direct-acting antiviral in one of three interventions: DOT; group treatment (GT); or SIT to determine which approach was most effective for promoting adherence and achieving sustained virologic response. Using electronic blister packs to monitor medication adherence, the researchers found that adherence was greater in the DOT than the SIT group and that increased adherence was associated with increased likelihood of sustained virologic response. Drinking alcohol to intoxication and psychiatric illness were associated with poor adherence, which suggests that additional adherence support may be warranted for people who inject drugs and use alcohol or have a psychiatric disorder and are receiving HCV treatment.

According to the researchers, the PREVAIL (Prevent Resistance Eliminate Virus and Improve Life) study was the first randomized trial to test intensive models for providing HCV care with direct-acting antivirals in people who inject drugs receiving opioid-antagonist therapy.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the senior author, Alain H. Litwin, MD, MS, MPH, please contact Frances Kathleen Parrish at fparris@clemson.edu.

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