News Release 

ACP issues new guidance statement for colorectal cancer screening

Embargoed news from Annals of Internal Medicine

American College of Physicians

Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information.

1. ACP issues new guidance statement for colorectal cancer screening

Abstract: http://annals.org/aim/article/doi/10.7326/M19-0642

Editorial: http://annals.org/aim/article/doi/10.7326/M19-2892

URLs go live when the embargo lifts

Physicians should screen for colorectal cancer in average-risk adults who do not have symptoms between the ages of 50 and 75, according to the American College of Physicians (ACP). Screening frequency depends upon the screening approach selected. The evidence-based guidance statement is published in Annals of Internal Medicine.

According to ACP President, Robert M. McLean, MD, MACP, not enough people in the United States get screened for colorectal cancer. He says that doctors and patients should select the screening test based on a discussion of the benefits, harms, costs, availability, frequency, and patient preferences. ACP suggests any one of the following screening strategies:

  • Fecal immunochemical test (FIT) or high sensitivity guaiac-based fecal occult blood test (gFOBT) every 2 years
  • Colonoscopy every 10 years
  • Flexible sigmoidoscopy every 10 years plus FIT every 2 years

ACP's guidance statement is for adults at average risk for colorectal cancer who do not have symptoms. It does not apply to adults with a family history of colorectal cancer, a long-standing history of inflammatory bowel disease, genetic syndromes such as familial cancerous polyps, a personal history of previous colorectal cancer or benign polyps, or other risk factors.

The author of an accompanying editorial from the University of Texas suggests that the methods used to develop ACP's guidance statement help to make sense of disparate screening advice from various organizations.

Notes and media contacts: For an embargoed PDF or to speak with someone from ACP, please contact Steve Majewski at SMajewski@acponline.org.

2. Treating recurrent C diff with fecal transplant increased survival, cut hospital stays, and reduced the risk of sepsis compared to treatment with antibiotics

Abstract: http://annals.org/aim/article/doi/10.7326/M18-3635

URLs go live when the embargo lifts

Treating recurrent Clostridioides difficile (CDI) with fecal microbiota transplantation (FMT) increased survival by nearly 30 percent, cut length of hospital stay in half, and reduced the risk of sepsis by nearly four times compared to treating with antibiotics. Findings from a prospective cohort study are published in Annals of Internal Medicine.

Recurrent CDI is often antibiotic-resistant and is associated with life-threatening complications, including bloodstream infections. A substantial proportion of patients with CDI are likely to develop bloodstream infections, most of which are caused by intestinal microbes and lead to death in more than 50 percent of patients. Fecal microbiota transplantation (FMT) is more effective than antibiotics in treating recurrent CDI, but its efficacy in preventing CDI-related BSI is uncertain.

Researchers from the Fondazione Policlinico Gemelli IRCCS, an academic tertiary centre in Rome, Italy, compared outcomes for 290 patients hospitalized with recurrent CDI who were treated with either FMT (n=109) or antibiotics (n=181). Five patients in the FMT group and 22 in the antibiotic group developed a bloodstream infection. Because of differences in the patients treated with FMT versus antibiotics in many baseline characteristics, including number of recurrences and CDI severity, comparative analyses were limited to a matched cohort. Risk for bloodstream infection was 23 percentage points lower in the FMT group and the FMT group also had 14 fewer days of hospitalization and a 32-percentage point increase in overall survival at 90 days compared with the antibiotic group. According to the researchers, these findings suggest that FMT may be an option not only for curing recurrent CDI but also for preventing its complications.

Notes and media contacts: For embargoed PDFs please contact Lauren Evans at Laevans@acponline.org. To speak with the lead author, Gianluca Ianiro, MD, please contact Paola Mariano at mariano.paola@gmail.com or himself at gianluca.ianiro@hotmail.it.

3. Recent changes in California vaccine exemption laws projected to have limited effect on increasing childhood vaccination rates

Highly-motivated parents may find ways around the laws to continue to avoid vaccination

Abstract: http://annals.org/aim/article/doi/10.7326/M19-1933

Editorial: http://annals.org/aim/article/doi/10.7326/M19-3111

URLs go live when the embargo lifts

A study found that laws developed in California to decrease the number of children who are exempt from receiving vaccines may have little effect. This is because parents motivated by a hesitancy to vaccinate continue to find alternate pathways around the laws. Findings from the brief research report are published in Annals of Internal Medicine.

In 2015, California passed Senate Bill 277 (SB277), which banned nonmedical exemptions from school-entry vaccine mandates. However, in the first 3 years after SB277 was passed, rates of both medical exemptions and students who were exempt from requirements and not up to date on vaccination increased. In response, California passed Senate Bill 276 (SB276) in 2019, adding additional scrutiny to medical exemptions.

Led by a researcher at the University of North Carolina at Chapel Hill, a group of scholars studied publicly available data on vaccination and school enrollment to estimate the percentage of California schoolchildren with an exemption from vaccination from 2015 to 2027 under three different scenarios: 1) current exemption use continues (no SB276); 2) the potential effect of SB276; or 3) a hypothetical scenario in which neither SB277 or SB276 was implemented (for comparison).

The researchers estimate that a large percentage of California schoolchildren will continue to be exempted from vaccination, even after the passage of the new laws. These findings demonstrate how the persistence of vaccine hesitancy and alternate pathways to avoid vaccination may mitigate the effects of efforts to increase vaccination coverage in schools.

Notes and media contacts: For embargoed PDFs please contact Lauren Evans at Laevans@acponline.org. To reach the lead author, Paul L. Delamater, PhD, please contact Melody Kramer at mjkramer@email.unc.edu.

4. Lung cancer screening is cost-effective but underutilized

Abstract: http://annals.org/aim/article/doi/10.7326/M19-0322

Editorial: http://annals.org/aim/article/doi/10.7326/M19-2797

URLs go live when the embargo lifts

Lung cancer screening with low-dose computed tomography is cost-effective, regardless of the age at which individuals stop being screened. Primary care physicians should encourage ever-smokers meeting the criteria for annual screening to undergo screening. Findings from a comparative modeling study are published in Annals of Internal Medicine.

Lung cancer is the leading cause of cancer death in the United States, yet only a small percent of eligible persons undergo annual screening. Current guidelines include different age cutoffs beyond which screening is not recommended: 80 years for the U.S. Preventive Services Task Force (USPSTF); 77 years for the Centers for Medicare and Medicaid Services (CMS); and 74 years for the National Lung Screening Trial (NLST). Screening in an older population would detect more lung cancer cases but is associated with a higher chance of overdiagnosis and unnecessary intervention, as older participants are more likely to die of causes other than lung cancer. An important policy question is whether lowering the age cutoff would improve the cost-effectiveness of lung cancer screening.

A study by the National Cancer Institute's (NCI) Cancer Intervention and Surveillance Modeling Network (CISNET) Lung Group, led by researchers at Harvard Medical School - Massachusetts General Hospital, used shared inputs for smoking behavior, costs, and quality of life to develop four microsimulation models evaluating the health and cost outcomes of annual lung cancer screening with low-dose computed tomography among current, former, and never-smokers from the 1960 U.S. birth cohort. The four models estimated that the CMS and NLST screening strategies have higher probabilities of being cost-effective than does the USPSTF strategy. Increasing the screening age cutoff resulted in greater mortality reduction but also higher costs and overdiagnosis rates, as was expected.

According to an accompanying editorial from Tufts Medical Center, these findings may help to inform health policy decisions regarding age cutoffs for lung cancer screening. The editorial suggests prioritizing policy efforts to improve screening rates.

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Notes and media contacts: For embargoed PDFs please contact Lauren Evans at LaEvans@acponline.org. To speak with the lead author, Chung Yin Kong, PhD, please contact Terri Janos TJANOS@PARTNERS.ORG and Michael Morrison MDMORRISON@PARTNERS.ORG.

Also new in this issue:

Type 2 Diabetes

Sandeep Vijan, MD

In the Clinic

Abstract: https://annals.org/aim/article/doi/10.7326/AITC201911050

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