Breast cancer overdiagnosis common among older women

Annals of Internal Medicine Tip Sheet    

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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. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.     

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1. Breast cancer overdiagnosis common among older women

Abstract: https://www.acpjournals.org/doi/10.7326/M23-0133

Editorial: https://www.acpjournals.org/doi/10.7326/M23-1895

URL goes live when the embargo lifts 

A study of more than 50,000 women found that continued breast cancer screening after age 70 was associated with a greater incidence of cancer that likely would not have caused symptoms in the patient’s lifetime. These findings suggest that overdiagnosis may be common among older women who are diagnosed with breast cancer after screening. The study is published in Annals of Internal Medicine.

Clinical guidelines advising screening in older women vary because the balance of benefits and harms of screening in this population is unclear. Some previous research has indicated that the mortality benefit of screening may be limited to women under the age of 75. Possible harms of screening in older women include frequent false positives that require invasive testing and procedures, and overdiagnosis itself is now considered an important additional harm from screening. Overdiagnosis may be defined as detecting a cancer, often through screening, that would not have caused symptoms in a person’s lifetime.

Researchers from the Yale School of Medicine conducted a retrospective cohort study of 54,635 women aged 70 years and older who had been recently screened for breast cancer. The authors found that the risk of overdiagnosis increased significantly with age. They report that among women aged 70 to 74, up to an estimated 31 percent of breast cancer found among screened women was overdiagnosed. In women aged 74 to 84 years, up to 47 percent of breast cancer found among screened women was overdiagnosed. They also found that the risk of overdiagnosis was highest in women aged 85 years and older, who experienced up to a 54 percent rate of overdiagnosis. The authors note that they did not see statistically significant reductions in breast cancer-specific death associated with screening. These findings suggest that overdiagnosis should be explicitly considered when making screening decisions, along with considering possible benefits of screening.

An accompanying editorial by authors from Johns Hopkins University highlights the frequency of overdiagnosis from cancer screening and the harms of overdiagnosis. The authors add that additional overdiagnosis harms include the risk of complications from overtreatment, unnecessary anxiety, financial hardship, and unnecessary consumption of limited resources. The argue that the answer to the problem of overdiagnosis is further study of genomics and improved understandings of the biopsy and pathologic appearance of cancer.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author Ilana B. Richman, MD, MHS, please contact Michael Masciadrelli at michael.masciadrelli@yale.edu.

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2. Health care workers face increased risk for fatal drug overdoses

Abstract: https://www.acpjournals.org/doi/10.7326/M23-0902  

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A study of health care workers (HCWs) found that registered nurses, social or behavioral health workers, and health care support workers were at increased risk for drug overdose death, suggesting the need to identify and intervene on those at high risk. The findings are published in Annals of Internal Medicine.

The increasing number of drug overdose deaths in the United States, mostly involving opioids, has prompted efforts to identify high-risk populations and offer preventive interventions. Drug overdose risk among certain occupational groups is unknown. HCWs regularly prescribe or administer medicines, experience job stress, and engage in physically strenuous tasks that could put them at risk for musculoskeletal injury that could result in opioid dependency.

Researchers from Columbia University analyzed a prospective cohort of 176,000 HCWs aged 26 years and older between 2008 and 2019. The authors evaluated 6 HCW groups: physicians; registered nurses; other diagnosing and treating health care workers; health technicians; health care support workers; and social or behavioral health workers. The authors found that 0.07 percent of their study sample died of a drug overdose during the follow-up period. They found that compared with employed adults who were not HCWs, the adjusted hazards of drug overdose deaths were significantly increased for social or behavioral health workers, registered nurses, and health care support workers. According to the authors, the high risks for drug overdose among health care workers underscore the need for new initiatives to reduce health care worker stress, prevent burnout, identify at-risk workers, and, when necessary, accelerate their access to confidential substance use evaluation and treatment.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author Mark Olfson, MD, MPH, please contact Stephanie Berger at sb2247@cumc.columbia.edu.

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3. Generic fluticasone-salmeterol as effective as brand-name version

Abstract: https://www.acpjournals.org/doi/10.7326/M23-0615 

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A propensity score-matched cohort study of patients treated for chronic obstructive pulmonary disease (COPD) in routine practice found that the use of generic and brand-name fluticasone–salmeterol was associated with similar outcomes. The findings are published in Annals of Internal Medicine.

In 2019, the U.S. Food and Drug Administration (FDA) approved the first generic maintenance inhaler for

asthma and COPD. The inhaler, Wixela Inhub (fluticasone–salmeterol; Viatris), is a substitutable version of the dry powder inhaler Advair Diskus (fluticasone–salmeterol; GlaxoSmithKline). When approving complex generic products like inhalers, the FDA applies a special “weight-of-evidence” approach. In this case, manufacturers were required to perform a randomized controlled trial in patients with asthma but not COPD, although the product received approval for both indications.

Researchers from Brigham and Women's Hospital and Harvard Medical School conducted a propensity score–matched cohort study of 10,012 matched pairs using either generic or brand-name fluticasone–salmeterol for COPD. The authors found that compared with brand-name use, generic use was associated with a nearly identical incidence of first moderate or severe COPD exacerbation. They also report that use of generic fluticasone-salmeterol was associated with similar rates of first pneumonia hospitalization as the brand-name reference drug. According to the authors, their study adds important new data supporting the clinical equivalence of generic and brand-name fluticasone–salmeterol in a group of patients who were not included in clinical trials leading to generic version approval.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, William B. Feldman, MD, DPhil, MPH, please contact him at wbfeldman@bwh.harvard.edu.

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4. Physicians who care for patients of reproductive potential should initiate conversations about contraception

Contraception discussions become critical as pregnancy-associated mortality increases and abortion access decreases in the U.S.

Abstract: https://www.acpjournals.org/doi/10.7326/M23-1418

Editorial: https://www.acpjournals.org/doi/10.7326/M23-1717

URL goes live when the embargo lifts 

A new Annals ‘In the Clinic’ provides a detailed summary of contraceptive methods and presents evidence-based discussion points that physicians can use to initiate a dialogue with their patients of reproductive potential. The timing of this release is crucial as pregnancy-associated mortality is on the rise, abortion access is decreasing, and the mini pill has just been approved for over-the-counter use in the United States. The ‘In the Clinic’ feature is published in Annals of Internal Medicine.

The paper suggests shared decision making between physicians and patients. It includes reference to the PATH Questionnaire on Parenting and Pregnancy Attitudes and Timing, a brief Q&A tool that provides a framework for discussing reproductive desires. For patients who desire contraception, the paper outlines the benefits, harms, and efficacy of several available methods. A reference table provides an at-a-glance reference for busy clinicians and an information for patients page provides key takeaway messages. The paper includes a section on emergency contraception methods, including counseling on medical and surgical abortion.

According to an editorial from cardiologist Amy A. Sarma, MD from Massachusetts General Hospital, preconception and contraceptive counseling has never been more important. In fact, she emphatically states that "this is our lane" as physicians. She writes that all clinicians who care for patients of reproductive potential should become comfortable discussing pregnancy intent, preconception risk assessment, and contraceptive counseling. Such conversations should not be restricted to primary care, gynecology, or even Women’s Heart Health programs, as many people of reproductive potential never present to such settings. She says that all encounters with patients of reproductive potential present opportunities to help them realize their pregnancy goals and avoid unintended pregnancy.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. speak with the corresponding author Amy A. Sarma, MD, please contact asarma1@partners.org.

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5. Analysis suggests access to primary care could play an important role in reducing hospitalizations

Abstract: https://www.acpjournals.org/doi/10.7326/M23-0876  

URL goes live when the embargo lifts 

A secondary analysis of a randomized encouragement study found that Medicare patients who received social needs case management had a 3% increase in primary care visits and an 11% reduction in inpatient hospitalizations. These findings suggest that increased access to primary care could play an important role in reducing acute care use. A brief research report is published in Annals of Internal Medicine.

Researchers from the University of California, Berkeley, School of Public Health conducted a secondary analysis of a study that assigned Medicaid beneficiaries with a high risk for acute care to use social needs case management or to be observed in the control group. The goal was to evaluate the impacts of social needs case management intervention on use of outpatient health care, behavioral health services, and jail intakes. The researchers found that the intervention group had significantly higher rates of primary care visits compared with the control group. No differences were found between the treatment groups for specialty care visits, behavioral health visits, psychiatric emergency visits, or jail intakes. The authors say that case management could increase primary care use by flexibly helping patients overcome social barriers to care. They cite the example of case managers helping patients find transportation, navigate the health care system, and facilitate insurance coverage.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author Mark D. Fleming, PhD, please contact Mark.fleming@berkeley.edu.

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6. Experts discuss benefits and risks of different guideline-approved treatment approaches for C. difficile infection

‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center

Abstract: https://www.acpjournals.org/doi/10.7326/M23-0754 

URL goes live when the embargo lifts

In a new Annals ‘Beyond the Guidelines’ feature, an infectious diseases specialist and a gastroenterologist discuss the benefits and risks of different treatment approaches for Clostridioides difficile infection (CDI). The experts consider clinical practice guidelines and provide rationale for how their recommendations may or may not fall within those guidelines. 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. A CME/MOC activity accompanies each article.

C. difficile is a bacterium that causes diarrhea and colitis and often occurs in patients who are taking or have taken antibiotics. Targeted antibiotic treatment is typically used for nonsevere and severe infection while fecal microbiota transplantation (FMT) or colectomy are sometimes used for more fulminant cases. Although not a treatment for CDI, bezlotoxumab, an intravenous monoclonal antibody against C. difficile toxin, is sometimes used to prevent disease recurrence.

The Infectious Diseases Society of America/Society for Healthcare Epidemiology of America (IDSA/SHEA) and the American College of Gastroenterology (ACG) each recently updated guidelines on the management of patients with CDI with a few subtle differences. For cases of nonsevere disease, the IDSA/SHEA conditionally recommends fidaxomicin over vancomycin. The ACG does not state a preference between these 2 antibiotics; rather, it provides equally strong recommendations for vancomycin and fidaxomicin, as well as a recommendation to consider oral metronidazole in low-risk patients. The IDSA/SHEA guidelines do not make any recommendation for or against FMT in fulminant disease but do highlight some of the potential risks. In a strong recommendation, the ACG suggests consideration of FMT for fulminant disease refractory to antibiotics, especially in patients who are poor surgical candidates, noting that “careful donor selection and screening can mitigate the risk of infection transmission.” The ACG’s guideline makes a conditional recommendation for bezlotoxumab in primary disease in those deemed at high risk for recurrence. In a conditional recommendation, IDSA/SHEA suggests this medication infusion for those with recurrent disease within the last 6 months, but separately also acknowledges the potential benefit for those with risk factors for recurrence “in settings where logistics is not an issue.”

The experts discuss their treatment recommendations based on a specific case of Ms. C, a 48-year-old woman with severe infection. A video testimonial from Ms. C accompanies the discussion. Carolyn D. Alonso, MD, the infectious diseases specialist, largely agrees with IDSA/SHEA guidelines in her treatment recommendations for the case presented, while Jessica R. Allegretti, MD, MPH, a gastroenterologist, recommends care more closely aligned with recommendations from the ACG. These discussions and the accompanying videos are particularly useful to practicing clinicians because not all patient cases are straightforward. ‘Beyond the Guidelines’ gives physicians tools to think critically when faced with challenging cases.

A complete list of ‘Beyond the Guidelines’ topics is available at www.annals.org/grandrounds.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. For an interview with the discussants, please contact Kendra McKinnon at Kmckinn1@bidmc.harvard.edu.