American Cancer Society guidelines for the early detection of cancer, 2003

Benefit and projected cost-effectiveness of anastrozole versus tamoxifen as initial adjuvant therapy for patients with early-stage estrogen receptor-positive breast cancer

BACKGROUND

Women who have estrogen receptor (ER)-positive disease with postmenopausal onset and who receive tamoxifen as standard adjuvant treatment constitute the largest subgroup of patients with breast cancer. Recent data from the ATAC ('Arimidex, Tamoxifen Alone or in Combination') randomized trial indicate that anastrozole significantly reduces breast cancer recurrence rates but does not provide any advantage in terms of survival at 4 years posttreatment. Furthermore, anastrozole and tamoxifen were found to have different toxicity profiles. The goals of the current study were to estimate the disease-free survival (DFS) rates and potential survival benefits associated with anastrozole use and to determine whether the incremental cost-effectiveness (ICE) was low enough to warrant an immediate switch to the use of this agent, as the long-term conclusions of the ATAC trial will not be available for several years.

METHODS

A computer simulation model assessed the outcomes of 64-year-old women with ER-positive breast cancer who subsequently received either anastrozole or tamoxifen for 5 years. Daily recurrence risks, as well as the relative risks associated with various treatment-related events, were calculated using data from the ATAC trial. Study endpoints included breast cancer recurrence-free survival, anticipated survival resulting from an anastrozole-induced decrease in systemic disease recurrence rates, and survival adjusted for quality of life and for hip fracture risk over periods of 4, 12, and 20 years.

RESULTS

After 4 years, the projected DFS benefit associated with anastrozole was 14 days, with an ICE of $167,500 per year. Projected 12 and 20 years into the future, DFS benefits increased to 2.9 months and 5.3 months, respectively. The corresponding benefits in terms of overall survival were 0.9 months and 2.0 months, respectively, with the ICE becoming < $100,000 per life year once the projection horizon exceeded 12 years. The inclusion of quality-of-life weightings for nonfatal outcomes modestly favored anastrozole in the short term; however, if anastrozole use is associated with an increased risk of hip fracture, then the long-term benefit associated with this agent is reduced by approximately 25%.

CONCLUSIONS

Adjuvant anastrozole is projected to result in a substantial improvement in DFS for patients with breast cancer. If this DFS benefit were to ultimately lead to a survival benefit, then the ICE of anastrozole use would be acceptable for patients expected to live longer than 12 years. Decision models are useful for generating realistic projections for stakeholders who are considering competing options that impact survival and quality of life and have associated societal costs.

Family physicians' knowledge of risk factors for cervical cancer

BACKGROUND

A woman's risk for cervical cancer has been used by physicians to guide the initiation and frequency of a Pap smear. The aim of this study was to determine family physicians' knowledge of risk factors for cervical cancer and perceived importance of risk in screening women.

METHODS

The self-administered questionnaire was mailed to 5000 randomly selected active members of the American Academy of Family Physicians (AAFP).

RESULTS

Data from 2748 usable questionnaires indicated the mean number of risks considered for cervical cancer was 4.5. Physician's age and the number of reported risks were inversely correlated (p = 0.0001). Female physicians reported significantly more risk factors than male physicians (p = 0.05). The number of Pap smears performed per month was positively correlated with the number of risk factors reported (p = 0.001). Only 10% of the physicians indicated that they perform a Pap smear at the same interval regardless of the risk of the woman.

CONCLUSIONS

This sample of family physicians has a limited understanding of the risk factors for cervical cancer. This was true regardless of the age, gender, training, race, geographic location, or practice setting of the responding physician. Yet the usual practice of screening for cervical cancer reported by these physicians would suggest that knowledge and use of risk factors would be a critical aspect of screening for cervical cancer.

Hypercoagulable state testing and malignancy screening following venous thromboembolic events

Mounting interest in hypercoagulability, increased availability of hypercoagulable state test 'panels' and enhanced ability to identify abnormalities in tested patients have prompted widespread testing. Testing for acquired and inherited hypercoagulable states uncovers an abnormality in over 50% of patients presenting with an initial venous thromboembolic event (VTE) but may have minimal actual impact on management in most of these patients. Such laboratory screening should be reserved for patients in whom the results of individual tests will significantly impact the choice of anticoagulant agent, intensity of anticoagulant therapy, therapeutic monitoring, family screening, family planning, prognosis determination, and most of all duration of therapy. Testing 'just to know' is neither cost-effective nor clinically appropriate. The most important testing in patients following acute VTE may be age- and gender-specific cancer screening. Cancer screening following VTE seems most prudent in older individuals and in those with idiopathic VTE and no laboratory evidence for an inherited hypercoagulable state. Cancer screening should focus on identification of treatable cancers and those where diagnosis in an early stage favorably impacts patient survival. Extensive searches for occult malignancy employing whole-body computed tomography and serum tumor markers may identify more cancers but without affecting patient outcome. We advocate that physicians should focus their attention more on VTE prophylaxis and proper treatment and less on costly and, at times, invasive testing of questionable value.

Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults

BACKGROUND

We evaluated the performance characteristics of computed tomographic (CT) virtual colonoscopy for the detection of colorectal neoplasia in an average-risk screening population.

METHODS

A total of 1233 asymptomatic adults (mean age, 57.8 years) underwent same-day virtual and optical colonoscopy. Radiologists used the three-dimensional endoluminal display for the initial detection of polyps on CT virtual colonoscopy. For the initial examination of each colonic segment, the colonoscopists were unaware of the findings on virtual colonoscopy, which were revealed to them before any subsequent reexamination. The sensitivity and specificity of virtual colonoscopy and the sensitivity of optical colonoscopy were calculated with the use of the findings of the final, unblinded optical colonoscopy as the reference standard.

RESULTS

The sensitivity of virtual colonoscopy for adenomatous polyps was 93.8 percent for polyps at least 10 mm in diameter, 93.9 percent for polyps at least 8 mm in diameter, and 88.7 percent for polyps at least 6 mm in diameter. The sensitivity of optical colonoscopy for adenomatous polyps was 87.5 percent, 91.5 percent, and 92.3 percent for the three sizes of polyps, respectively. The specificity of virtual colonoscopy for adenomatous polyps was 96.0 percent for polyps at least 10 mm in diameter, 92.2 percent for polyps at least 8 mm in diameter, and 79.6 percent for polyps at least 6 mm in diameter. Two polyps were malignant; both were detected on virtual colonoscopy, and one of them was missed on optical colonoscopy before the results on virtual colonoscopy were revealed.

CONCLUSIONS

CT virtual colonoscopy with the use of a three-dimensional approach is an accurate screening method for the detection of colorectal neoplasia in asymptomatic average-risk adults and compares favorably with optical colonoscopy in terms of the detection of clinically relevant lesions.

Colorectal cancer screening at a Veterans Affairs hospital

BACKGROUND

Because of limited resources and common barriers to widespread screening, the Surgery Service of the Indianapolis Veterans Affairs Medical Center has focused its colorectal screening program on patients undergoing hernia repair. Our objective was to examine the success, safety, pathology results, and educational benefit of this nontraditional screening program.

METHODS

The study was a retrospective analysis of a prospectively collected database (1991 to 2002). Initial screening colonoscopy was performed on 263 average-risk Veterans Affairs patients, 217 (83%) in conjunction with hernia repair. Visualized polyps were removed or biopsied during colonoscopy and pathology reports for all specimens were examined. Results were compared with published screening studies.

RESULTS

Complete colonoscopy, defined as cecal intubation, was performed in 93% of initial screening colonoscopies. There were no major complications, including perforation, excessive bleeding, or death, from colonoscopy. Initial colonoscopy showed adenomas in 67 patients (25%), hyperplastic polyps in 34 (13%), and invasive cancer in 4 (1.5%). Follow-up endoscopies revealed cancer in 2 additional patients, 3 and 5 years after initial screening.

CONCLUSIONS

This program is an important training resource for surgical residents. Screening colonoscopy performed in conjunction with hernia repair has produced results consistent with more conventional methods. The Surgery Service at the Indianapolis Veterans Affairs Medical Center is providing colorectal cancer screening with a high degree of safety and success in the face of limited resources and common barriers to implementation of widespread screening.

Survival and prognosis of women with invasive cervical cancer according to age

OBJECTIVES

We assessed survival and compared clinical and pathological prognostic factors of women with invasive cervical cancer according to the age in order to define a cutoff point where screening should become useless.

METHODS

The survival of 308 women with invasive cervical cancer treated at Bordeaux University Hospital between 1976 and 1996 was evaluated on December 31, 2000. Kaplan-Meier survival curves calculated with regard to age were compared by the log-rank test. Prognostic factors were assessed according to age (cutoff 65 years) and included in a Cox model. Survival of women in our population within a particular age group was compared to survival of women of the same age range, using indirect standardization.

RESULTS

The 5-year survival rate of women under 65 (n = 221), between 65 and 74 (n = 56), and over 75 (n = 31) was 75%, 69%, 42%, respectively (P < 0.001). Compared to women under 65, women over 65 had a significantly lower Karnofsky performance status and a significantly more advanced clinical stage cancer involving vaginal bleeding. Age, gross cervical appearance, clinical vaginal involvement, histologic grade, and microscopic cervical and parametrial involvements were independent prognostic factors. Compared to women under 65, the risk of mortality was 1.3, 95% CI = 0.8-2.7, P = 0.189, for women aged 65-74, and 2.3, 95% CI = 1.1-3.9, P = 0.022, for women over 75. Mortality of women with invasive cervical cancer was significantly higher than that of women in the general population in the indirect standardization model (SMR = 1.9, 95% CI = 1.5-2.2), except beyond age 75.

CONCLUSIONS

Age was a significant prognostic factor in our study and advanced stages were significantly increased after 65. However, survival after 75 was not different from that of the population. These considerations address the question of the maintenance of screening between 65 and 75.

Problems in screening colorectal cancer in the elderly

AIM: To explore the problems in the screening of colorectal carcinoma in the elderly.

METHODS: Three models of colorectal cancer prevention were examined: standard screening, active check-up of suspected cases and summons to have endoscopic check-up for previously diagnosed colorectal polyps. The study was performed among three groups of elderly individuals: Group 1 (167 cases), hospitalized asymptomatic individuals without symptoms in large intestines. Group 2 (612 cases): old individuals at home for the aged, out of which 32 showed symptoms of colon disorders; Group 3 (44 cases): elderly people with diagnosed polyps. As a result of 1788 rectosigmoidoscopies, we identified 61 individuals with polyps, out of which 44 patients were over 65 years old. However, only 9 of these 44 individuals agreed to have the endoscopy performed again.

RESULTS: One cancer and 13 polyps were detected in Group 1, and two polyps in Group 2. However, it should be noted that only eleven individuals from Group 2 agreed to have the endoscopy. In Group 3, there were no relapses of the polyps among the nine individuals who came back for the endoscopy.

CONCLUSION: Poor understanding of the screening procedures is one of the greatest problems in early detection of the cancer in the aged. Paradoxically, the cooperation is better with hospitalized patients, than with “successfully old” persons.

Management options for symptomatic hemorrhoids

Hemorrhoids remain one of the most common colorectal complaints. They are defined as a pathologic engorgement of the submucosal vascular plexus. Although they are often asymptomatic, hemorrhoids may cause bleeding, prolapse and, less commonly, pain. This review gives an update on various treatment options for symptomatic hemorrhoids, which include conservative treatments, office interventions, and surgical procedures, depending on the individual constellation of symptoms. Objective findings and expectations are also addressed. Recent advances (eg, stapled hemorrhoidectomy and use of alternate energy sources) are emphasized, and treatment under special circumstances (HIV, pregnancy, inflammatory bowel disease, and liver disease) is outlined.

Overview of breast health care guidelines for countries with limited resources

Among women around the globe, breast cancer is both the most common cancer and the leading cause of cancer-related death. Women in economically disadvantaged countries have a lower incidence of breast cancer, but poorer survival rates for the disease relative to women in affluent countries. Evidence suggests that breast cancer mortality can be reduced if resources are applied to the problem in a systematic way. The purpose of the Global Summit Consensus Conference was to begin a process to develop guidelines for improving breast health care in countries with limited resources-those with either low- or medium-level resources based on World Health Organization (WHO) criteria. Breast cancer experts and patient advocates representing 17 countries and 9 world regions participated in the conference. They reviewed the existing breast health guidelines, which generally assume unlimited resources. Individual panels then discussed and debated how limited resources can best be applied to improve three areas of breast health care--early detection, diagnosis, and treatment--and how to integrate these areas in building a breast health care program. The panelists unanimously agreed on the guiding principle that all women have the right to access to health care. They also agreed that collecting data on breast cancer is imperative for deciding how best to apply resources and for measuring progress. The panelists acknowledged the considerable challenges in implementing breast health care programs when resources are limited, as well as the need to build a program that is specific to each country's unique situation. The panelists noted that the development of centralized, specialized cancer centers may be a cost-effective way to deliver breast cancer care to some women when it is not possible to deliver such care to women nationwide. In countries with limited resources, at least half of the women have advanced or metastatic breast cancer at the time of diagnosis. Because advanced breast cancer has the poorest survival rate and is the most resource intensive to treat, measures to reduce the stage at diagnosis are likely to have the greatest overall benefit in terms of both survival and costs. Women should have access to diagnosis and treatment if efforts are undertaken to improve early detection of breast cancer. The panels' findings outline specific steps for prioritizing the use of limited resources to decrease the impact of breast cancer around the globe.

Early detection of breast cancer in countries with limited resources

Breast cancer is commonly diagnosed at late stages in countries with limited resources. Efforts aimed at early detection can reduce the stage at diagnosis, potentially improving the odds of survival and cure, and enabling simpler and more cost-effective treatment. Early detection of breast cancer entails both early diagnosis in symptomatic women and screening in asymptomatic women. Key prerequisites for early detection are ensuring that women are supported in seeking care and that they have access to appropriate, affordable diagnostic tests and treatment. We therefore propose the following sequential action plan: 1) promote the empowerment of women to obtain health care, 2) develop infrastructure for the diagnosis and treatment of breast cancer, 3) begin early detection efforts through breast cancer education and awareness, and 4) when resources permit, expand early detection efforts to include mammographic screening. Public education and awareness can promote earlier diagnosis, and these goals can be achieved in simple and cost-effective ways, such as dissemination of messages through mass media. All women have the right to education about breast cancer, but it must be culturally appropriate and targeted and tailored to the specific population. When resources become available for screening, they should be invested in screening mammography, as it is the only modality that has thus far been shown to reduce breast cancer mortality. Clinical breast examination (CBE) and breast self-examination (BSE) are important components of routine breast care in countries with access to mammography and are important for general breast health education in all countries. However, the evidence does not support the use of CBE and BSE as lifesaving screening methods at this time, recognizing that data from countries with very limited resource are lacking. When widespread screening is not possible, screening can begin in an institution, city, or region, or by targeting screening to women at highest risk. A pilot program can be an ideal way to define the best approach to screening. To succeed, early detection efforts must include the health care providers with whom women have contact; these providers may be physicians, nurses, midwives, traditional healers, or others. There are tremendous differences among and within countries, and a program to promote early detection must be tailored to each country's unique situation.

Challenges to cancer control by screening

Population-based screening seems to be a common-sense strategy for controlling cancer, but recent reports have raised controversy concerning the benefits of common screening procedures. Intense efforts to develop and evaluate novel screening technologies are underway; however, effective use of any screening method must take into account any underlying biological considerations. What are these biological issues, and what challenges do clinicians face in screening for common cancers?

A qualitative study of communication skills for male cancer screening discussions

BACKGROUND

Cancer screening guidelines acknowledge the need for physician-patient discussions on appropriate tests. This study examined expert clinician communication practices associated with prostate and colorectal cancer screening and testicular cancer early detection for male patients.

METHODS

Recorded observation and qualitative analysis of transcripts from 38 standardized patient interactions.

RESULTS

Most effective communication practices were elicited from the data and incorporated into a model for male cancer screening discussions.

CONCLUSIONS

Qualitative analysis of expert clinician interactions can identify best communication practices leading to the development of a communication model used in medical student teaching.