Annals of Internal Medicine tip sheet for April 16, 2013, issue

High-risk women may derive the most benefit, least harms from preventive drug therapy

Women at high risk for breast cancer may benefit most from preventive drug therapy. In 2002, the United States Preventive Services Task Force (USPSTF) recommended against routine use of tamoxifen and raloxifene for prevention of primary breast cancer for women at average risk. The Task Force recommended that clinicians discuss the potential benefits and harms of those drugs for women at high risk before prescribing them. To update its previous recommendations, the Task Force reviewed evidence published through December 2012. In placebo-controlled trials, both tamoxifen and raloxifene reduced the incidence of invasive breast cancer over the five-year treatment period, and both medications reduced fractures. In head-to-head trials, tamoxifen had greater effect at reducing invasive breast cancer than raloxifene, but also was associated with more thromboembolic events, endometrial cancer, and related gynecologic outcomes and cataracts compared with placebo and raloxifene. The evidence showed that women at highest risk for breast cancer derived the most benefit from drug treatment. Women who received tamoxifen, raloxifene, or exemestane had a 10-year breast cancer risk of 7.5 percent compared with a 21.3 percent risk for women on no treatment. The evidence will inform an upcoming recommendation statement from the USPSTF. A link to this article will go live at 5:00 p.m. on April 15 http://www.annals.org/article.aspx?doi=10.7326/0003-4819-158-8-201304160-00005.

Note: For an embargoed PDF, please contact Angela Collom. To speak with the author please contact Elisa Williams at willieli@ohsu.edu or 503-494-4530.

Abdominal computed tomography (CT) scans obtained for other clinical indications can be used to screen patients for osteoporosis. Osteoporosis is a common disease of the bones that increases risk for fracture, especially among older women. Central dual-energy x-ray absorptiometry (DXA) of the hips and lumbar spine is widely recognized as the reference standard for diagnosing osteoporosis, yet the procedure is underutilized. Nearly half of all female Medicare beneficiaries have never had a bone mineral density (BMD) test. Recognizing a need for safe and cost-effective alternatives to DXA screening, researchers sought to determine if CT scans performed for other clinical indications could be used to assess BMD. Researchers compared CT scans to DXA scans performed within 6 months of the CT for 1,867 patients over a 10-year period. They found that nearly half of patients with an osteoporotic vertebral compression fracture identified by the CT scan had been classified as having normal bone density by the DXA scan. The researchers conclude that CT scans can be used opportunistically to screen for osteoporosis without additional radiation exposure or cost. The authors of an accompanying editorial caution against adding more information to CT reports already replete with incidental findings, as only about half of incidental findings are ever acted on or confirmed. The authors suggest that CT reports linked to evidence summaries and actionable reminders that could be transmitted to primary care physicians may be a more effective way to increase the likelihood of follow up and treatment. A link to this article will go live at 5:00 p.m. on April 15 http://www.annals.org/article.aspx?doi=10.7326/0003-4819-158-8-201304160-00003.

Note: For an embargoed PDF, please contact Angela Collom. To speak with the lead author please contact Toni Morrissey at tmorrissey@uwhealth.org or 608-263-3223.

Using computer-aided detection (CAD) to assess mammograms increases diagnosis of early stage cancers, but also increases diagnostic testing for women without breast cancer. Researchers suggest these findings are likely fuel breast cancer screening debates. With CAD, radiologists use computer algorithms to mark and reassess potentially suspicious lesions that may have been missed on initial mammogram review. Despite limited evidence of its clinical effectiveness, the use of CAD in screening mammography has been broadly adopted. Researchers reviewed health records for 163,099 women aged 67 to 89 years receiving 409,459 mammograms to determine the associations between CAD use during screening mammography and the incidence of ductal carcinoma in situ (DCIS) and invasive breast cancer, invasive cancer stage, and diagnostic testing. The researchers found that use of CAD was associated with greater DCIS incidence, but found no difference in invasive breast cancer incidence. Among women with invasive cancer, use of CAD was associated with greater likelihood of detecting it in earlier stages (stages I and II vs II and IV). Use of CAD also increased diagnostic mammography, breast ultrasonography, and breast biopsy in women without cancer. A link to this article will go live at 5:00 p.m. on April 15 http://www.annals.org/article.aspx?doi=10.7326/0003-4819-158-8-201304160-00002.

Note: For an embargoed PDF, please contact Angela Collom. To speak with the lead author please contact Karen Finney at karen.finney@ucdmc.ucdavis.edu or 916-734-9064.

Patient-centered decision making (PCDM) leads to better health outcomes. PCDM occurs when the physician considers individual patient needs and circumstances when prescribing a care plan. For example, if a patient is unable to adhere to a thrice-daily medication regimen because of work responsibilities, modification of the plan to accommodate these circumstances would be considered PCDM. Researchers sought to determine if PCDM would affect health care outcomes compared with inattention to patient context. Researchers had 774 patients covertly audio-record encounters with their physicians. Those recordings were screened for "contextual red flags" that could affect health outcomes (e.g. missed appointments or lack of control over manageable chronic conditions).The researchers analyzed the tapes to see if the red flag surfaced during the visit and if the care plan was "contextualized" to accommodate the patient's needs. The recordings were analyzed against medical records to determine the relationship between PCDM and patient outcomes. The researchers found that health outcomes improved in 71 percent of patients whose physicians paid attention to their individual needs and circumstances compared to improvements in just 46 percent of patients whose physicians did not contextualize care plans. The author of an accompanying editorial writes that interventions to increase physician attention to patient context should focus on helping physicians link to needed services and support systems that can help them solve their patients' problems. A link to this article will go live at 5:00 p.m. on April 15 http://www.annals.org/article.aspx?doi=10.7326/0003-4819-158-8-201304160-00001.

Note: For an embargoed PDF, please contact Angela Collom. To speak with the lead author please contact Jeanne Galatzer-Levy at jgala@uic.edu or 312-996-1583.