From Journal of the American Board of Family Medicine
John D. Keen, MD, MBA
posted: 01/02/2011; J Am Board Fam Med. 2010;23(6):775-782. © 2010 American Board of Family Medicine
Abstract
The US Preventive Services Task Force has emphasized individualized decision-making regarding participation in screening mammography for women ages 40 to 49.
Positive public opinion regarding screening mammography is understandable given that screening advocates have heavily promoted the slogan "early detection saves lives" while ignoring screening harms.
The goal of mammography screening advocates is to increase screening participation or uptake. The purpose of this paper is to promote physician and patient insight by presenting the age-related benefit and harms of screening.
At age 50, routine screening saves approximately 1 woman per 1000 over 10 years.
The life-saving proportion of screen-detected cancers is 5%, which means mammograms must detect 21 cancers to save one life. Almost half of screen-detected cancers represent pseudo-disease and would never become symptomatic yet alone lethal during a woman's lifetime.
Consequently, 40- and 50-year-old women are 10 times more likely to experience overdiagnosis and overtreatment than to have their lives saved. Analysis of events and outcomes per single screening round for women ages 40 to 49 show that approximately 9600 screening mammograms, 960 diagnostic exams, and 90 to 140 biopsies are required to save one life. Given the substantial harms of screening, advocates should refocus their priority from promoting uptake to promoting insight.
Introduction
Judging by recent media coverage, many of the 2.5 million breast cancer survivors in the United States, including 610,000 women with ductal carcinoma in situ (DCIS),[1] were outraged at the US Preventive Services Task Force for not continuing to advise routine screening mammography for women ages 40 to 49.
Based on an update of the evidence regarding the benefits and harms of screening, which was published in November 2009, the Task Force is re-emphasizing individualized decision making for these women.
The belief that earlier detection of breast cancer almost always is beneficial explains part of the negative public reaction to this recommendation.Assuming the truth of this premise, a woman with a screen-detected cancer has a valid and sound argument that "mammography saved my life."
Consequently, every breast cancer survivor and her friends and family have a reason to become screening mammography advocates. For instance, the founder of the Susan G. Komen Foundation claims that she is "one woman whose life was saved by early detection."
Public opinion regarding screening mammography is understandable given that the concept "earlier detection saves lives" has been heavily promoted but not clearly explained by mammography supporters including physician organizations, the American Cancer Society, and advocacy groups.
However, the premise of a near universal life-saving benefit from finding presymptomatic breast cancer through mammography is false.
The following is a quick analysis of the "life-saving proportion" of screen-detected cancer.
Women often die of breast cancer after screening; mammography achieves approximately a 1 in 5 life-saving benefit (the relative mortality risk reduction) in the subgroup of women who have lethal breast cancers. If all screen-detected breast cancers were rapidly lethal, the highest life-saving proportion would be 20%. In the United States, the diagnostic risk for breast cancer (screen-detected or not) is approximately 6 to 7 times the death risk over 15 years. Risk means an outcome for 1000 people at risk for an event over a period of time. Therefore, the lowest life-saving proportion would be 3% (1/5 × 1/7) in the larger subgroup of women who have been diagnosed with cancer.
The "pink ribbon" marketing of breast cancer awareness supports advocacy groups and aims to increase the uptake of (participation in) mammography. Ostensibly for the sake of public health, the advertising campaign has some negative consequences.
One side effect is distorted physician and public insight about the age-related benefit and the substantial harms of screening. For instance, in one survey more than half of US women thought that mammography helps to prevent or reduce the risk of contracting breast cancer. Gigerenzer et al reported that less than 2% of European women have insight into the absolute benefit of routine screening mammography, and most women overestimate the benefit by orders of magnitude. The absolute benefit derived from an overview of Swedish randomized screening trials is one breast cancer death averted (or one life saved) in the invited group versus the control group per 1000 women after 10 years.
The US Preventive Services Task Force deserves praise for promoting insight among younger women by stressing the well-known downstream screening harms that can result from false-positive mammograms.
These radiologist interpretations produce anxiety beyond the initial screen and require additional evaluations including diagnostic mammograms, ultrasounds, and biopsies that do not find a cancer. Any breast radiologist who has contact with patients sees this anxiety every day while performing diagnostic evaluations. However, the US Preventive Services Task Force has downplayed the major harm of screening.
Overdiagnosis of breast cancer is the preclinical detection of either stable disease, such as forms of DCIS, or indolent or slow-growing tumors in older women. This pseudo-disease would never become symptomatic (and diagnosed) let alone metastatic (and lethal) during a woman's lifetime without screening. Because physicians must treat all true-positive or histologically confirmed mammograms as potentially lethal cancer, women with pseudo-disease can only be harmed by screening mammography.
In theory, earlier detection of localized cancer through screening mammography should result in a compensatory drop in future advanced cancer and cancer deaths, yet this has not occurred. Nevertheless, prominent breast radiologists continue to deny a significant problem with overdiagnosis, and the 2010 American Cancer Society guidelines do not mention overdiagnosis as a limitation of mammography. The problem of overdiagnosis is not publicized during screening invitations and most women are not aware of nonprogressive cancer.
The 2009 analysis of the screening trials by the Cochrane Database of Systemic Reviews calculated a 30% overdiagnosis rate (excess cancers and surgeries compared with control), or 0.3 ÷ 1.3 = 23% of all cancers in screened groups. Recent articles by Jorgensen and Gotzsche[27] and Jorgensen et al[28] include an overdiagnosis estimate for invasive cancer of 35% (52% including DCIS) in countries that have organized screening programs (34% of all cancers in screened populations, screen-detected or not), and 33% in a country that has organized screening and a control group. Morrell et al[29] estimated overdiagnosis in an organized program of between 30% and 42% for invasive cancer only. The US Preventive Services Task Force's estimate is between 1% and 10%.
Sackett[30] warned that history shows preventive medicine "experts" can be assertive, presumptuous, and overbearing. In today's mammography debate, some screening advocates claim to support individual decision making yet tell women what to do, confident that screening benefits outweigh the harms, while attacking those who question their promotion of screening.
Physicians who support insight should be indifferent to uptake. Given the reaction of specialists who have professional and financial interests in screening, primary care physicians will have to implement the US Preventive Services Task Force's recommendations.
In support of this goal, Table 1 summarizes the epidemiology of breast cancer. For perspective on the opportunity cost of the resources devoted to screening mammography, columns A and B show the 10-year, all-cause death risks for smoking and nonsmoking US women at ages 40, 50, and 60. In comparison, columns C and D show the diagnosis risk for breast cancer and DCIS, whereas column E shows the absolute death risk without screening mammography. Barratt et al[38] show similar estimates for Australia. Without screening, over a decade a 50-year-old woman has a 5 times greater risk of receiving a diagnosis of breast cancer than of dying from it. She also has a 10 times greater risk of dying from something besides breast cancer.
Table 2 derives estimates for the life-saving proportion of screen-detected cancers, the reciprocal or number needed to detect to save one life, and the extent of overdiagnosis for US women.[39–41] Column F shows lives saved, or the absolute risk reduction from an invitation to routine screening. The absolute risk reduction is simply the relative risk reduction multiplied by the absolute death risk (column E). The reciprocal, or number needed to invite for repeated screening over a decade, are 2500, 1300, and 400. Ignoring volunteer bias and adjusting for compliance,[38] at age 50 routine screening saves approximately one woman per 1000 over 10 years. The participation rate for US women and the uptake in the most recent screening mammography trial are 70%.[3,42] Column G, or screen-detected cancer among all diagnosed cancer (column C in Table 1) depends on the sensitivity of mammography and screening participation. Mathis et al found that 57% of breast cancer was screen-detected. Likewise, column H, or pseudo-disease estimates, depend on an overdiagnosis rate applied to all diagnosed cancer, screen-detected or not.
At age 50 almost half (42%; range, 9% to 62%) of all screen-detected cancers represent overdiagnosis of pseudo-disease. The only available estimate from the screening trials is 24%.
Estimated breast cancer events per 1000 US women over 10 years at different starting ages, assuming 68% participation in screening mammography. *Data sources are listed in Tables 1 and 2. †At age 50, routine screening saves 1 in 1000 women over 10 years.
For women at age 50, the benefit "1/1000 over 10" reframed means that through routine screening a woman can increase her breast cancer survival from 99.5% to 99.6%, and her overall survival as a nonsmoker from 96.3% to 96.4% over a decade.
Table 2 from the US Preventive Services Task Force update[3] provides downstream average outcomes for a single screening round for different age groups. By applying the number needed to detect to save one life, the flowchart in Figure 2 shows estimated events and outcomes per screening round, including false-negative and false-positive mammograms and biopsies needed to save one life. The overdiagnosis ratio at the bottom means that, for women aged 40 to 59, approximately 10 women receive unnecessary mastectomies or lumpectomies and possibly chemotherapy and radiation treatment for every life saved.[26]
Conclusion
The limited age-related benefit from screening mammography means that, for younger breast cancer survivors, mammography most likely (>95%) did not save their lives. Forty- and 50-year-old women thinking about participating in screening are 10 times more likely to experience overdiagnosis and overtreatment than to have their lives saved by mammography.
Given this reality, screening advocates should refocus their priority from promoting uptake to promoting insight.
Primary care physicians have an obligation to understand the harms and benefits of screening to help empower their patients to make individual decisions.
If younger women decline screening participation because of increased understanding about benefits and harms, all physicians should appreciate this decision as a reasonable choice.
http://www.medscape.com/viewarticle/733710_2
Wednesday, January 12, 2011
Monday, January 10, 2011
Power Posing: Fake It Until You Make It
Published: September 20, 2010
Author: Julia Hanna
Executive Summary:
Nervous about an upcoming presentation or job interview? Holding one's body in "high-power" poses for short time periods can summon an extra surge of power and sense of well-being when it's needed, according to Harvard Business School professor Amy J.C. Cuddy.
Key concepts include:
* Holding one's body in expansive, "high-power" poses for as little as two minutes stimulates higher levels of testosterone and lower levels of cortisol.
* In addition to causing hormonal shifts, power poses lead to increased feelings of power and a greater tolerance for risk.
* People often are more influenced by how they feel about you than by what you're saying.
* The research has broad implications for people who suffer from feelings of powerlessness and low self-esteem due to their hierarchical rank or lack of resources.
Amy J. C. Cuddy is an assistant professor in the Negotiation, Organizations and Markets unit at Harvard Business School.
We can't be the alpha dog all of the time. Whatever our personality, most of us experience varying degrees of feeling in charge. Some situations take us down a notch while others build us up.
New research shows that it's possible to control those feelings a bit more, to be able to summon an extra surge of power and sense of well-being when it's needed: for example, during a job interview or for a key presentation to a group of skeptical customers.
"Our research has broad implications for people who suffer from feelings of powerlessness and low self-esteem due to their hierarchical rank or lack of resources," says HBS assistant professor Amy J.C. Cuddy, one of the researchers on the study.
"It's not about the content of the message, but how you're communicating it."
In "Power Posing: Brief Nonverbal Displays Affect Neuroendocrine Levels and Risk Tolerance", Cuddy shows that simply holding one's body in expansive, "high-power" poses for as little as two minutes stimulates higher levels of testosterone (the hormone linked to power and dominance in the animal and human worlds) and lower levels of cortisol (the "stress" hormone that can, over time, cause impaired immune functioning, hypertension, and memory loss).
The result? In addition to causing the desired hormonal shift, the power poses led to increased feelings of power and a greater tolerance for risk.
"We used to think that emotion ended on the face," Cuddy says. "Now there is established research showing that while it's true that facial expressions reflect how you feel, you can also 'fake it until you make it.
' In other words, you can smile long enough that it makes you feel happy. This work extends that finding on facial feedback, which is decades old, by focusing on postures and measuring neuroendocrine levels."
The experiment
In their article, to be published in a forthcoming Psychological Science, Cuddy and coauthors Dana R. Carney and Andy J. Yap of Columbia University detail the results of an experiment in which forty-two male and female participants were randomly assigned to a high- or low-power pose group.
No one was told what the study was about; instead, each participant believed it was related to the placement of ECG electrodes above and below his or her heart.
Subjects in the high-power group were manipulated into two expansive poses for one minute each: first, the classic feet on desk, hands behind head; then, standing and leaning on one's hands over a desk.
Those in the low-power group were posed for the time period in two restrictive poses: sitting in a chair with arms held close and hands folded, and standing with arms and legs crossed tightly.
Saliva samples taken before and after the posing measured testosterone and cortisol levels. To evaluate risk tolerance, participants were given $2 and told they could roll a die for even odds of winning $4. Finally, participants were asked to indicate how "powerful" and "in charge" they felt on a scale from one to four.
Controlling for subjects' baseline levels of both hormones, Cuddy and her coauthors found that high-power poses decreased cortisol by about 25 percent and increased testosterone by about 19 percent for both men and women.
In contrast, low-power poses increased cortisol about 17 percent and decreased testosterone about 10 percent.
Not surprisingly, high-power posers of both sexes also reported greater feelings of being powerful and in charge. In addition, those in the high-power group were more likely to take the risk of gambling their $2; 86 percent rolled the die in the high-power group as opposed to 60 percent of the low-power posers.
Previous research established that situational role changes can cause shifts in hormone levels. In primate groups, for example, after an alpha male dies the testosterone levels of the animal replacing him go up. The hormonal shifts measured in this experiment show that such changes can be influenced independent of role, situation, or any consciously focused thoughts about power. The physical poses are enough.
And that, she suggests, has broad implications for people who suffer from feelings of powerlessness and low self-esteem due to their hierarchical rank or lack of resources.
Why we judge
Cuddy's overall research agenda focuses on stereotyping and questions around how we form judgments of others' warmth and competence.
Just Because I'm Nice, Don't Assume I'm Dumb reveals how and why we come to snap judgments about coworkers (and how to fight that natural instinct). The article was cited as a "Breakthrough Business Idea" for 2009 by Harvard Business Review.
"The power poses paper came about in part because my coauthor Dana and I had noticed that women in our classes seemed to be participating less," says Cuddy, who teaches the MBA elective Power and Influence.
"Some of the women exhibited body language associated with low power, so we wondered if that was in turn affecting how they feel," she adds, citing the "fake it till you make it" research that shows smiling can affect feelings and hormone levels.
"It's about understanding what moves people."
"The poses that we used in the experiment are strongly associated across the animal kingdom with high and low dominance for very straightforward evolutionary reasons. Either you want to be big because you're in charge, or you want to close in and hide your vital organs because you're not in charge.
"It does appear that even this minimal manipulation can change people's physiology and psychology and, we hope, lead to very different, meaningful outcomes, whether it's how they perform in a job interview or how they participate in class."
Cuddy acknowledges that there are moderating factors in how easily some groups can use traditional power poses. It would run counter to social norms, for example, if a woman wearing a skirt sat with her feet up on her desk while talking to a colleague.
"I'm not saying it's fair, but there is a different range for women versus men," says Cuddy, who also teaches several HBS Executive Education programs.
Female managers seem to have an intuition about the need to communicate confidence by striking expansive poses through other means. They might use a whiteboard as a prop that they can reach out and rest a hand on—allowing them to take up more space.
"There are implications across cultures as well," she adds. Cuddy believes American poses are bigger and more flamboyant than what would be acceptable in Korea or Japan, for example, and expects to focus on this question in future research.
Warmth versus competence
It ultimately boils down to how we connect to one another. In general, she says, people form impressions of others through a matrix of how much we trust and like them and how much we think they're competent and respect them.
For the most part people underestimate the powerful connection of warmth and overestimate the importance of competence.
"We are influenced, and influence others, through very unconscious and implicit processes," she says. "People tend to spend too much energy focusing on the words they're saying—perfectly crafting the content of the message—when in many cases that matters much less than how it's being communicated. People often are more influenced by how they feel about you than by what you're saying. It's not about the content of the message, but how you're communicating it.
"Many students believe that if they have a great idea, they should be able to magnetize their audience toward them because their audience will recognize the 'greatness' of that idea—that they'll get on board because the idea is so good," she continues.
"I try to show students that it doesn't work that way—you have to go meet people where they are and then all move together.
You have to connect with them before you can lead them."
If understanding how you are influenced and can influence others feels a bit too Machiavellian, Cuddy helps bring it down a notch.
"It's not about politics," she says. "It's about understanding what moves people."
About the author
Julia Hanna is associate editor of the HBS Alumni Bulletin.
Author: Julia Hanna
Executive Summary:
Nervous about an upcoming presentation or job interview? Holding one's body in "high-power" poses for short time periods can summon an extra surge of power and sense of well-being when it's needed, according to Harvard Business School professor Amy J.C. Cuddy.
Key concepts include:
* Holding one's body in expansive, "high-power" poses for as little as two minutes stimulates higher levels of testosterone and lower levels of cortisol.
* In addition to causing hormonal shifts, power poses lead to increased feelings of power and a greater tolerance for risk.
* People often are more influenced by how they feel about you than by what you're saying.
* The research has broad implications for people who suffer from feelings of powerlessness and low self-esteem due to their hierarchical rank or lack of resources.
Amy J. C. Cuddy is an assistant professor in the Negotiation, Organizations and Markets unit at Harvard Business School.
We can't be the alpha dog all of the time. Whatever our personality, most of us experience varying degrees of feeling in charge. Some situations take us down a notch while others build us up.
New research shows that it's possible to control those feelings a bit more, to be able to summon an extra surge of power and sense of well-being when it's needed: for example, during a job interview or for a key presentation to a group of skeptical customers.
"Our research has broad implications for people who suffer from feelings of powerlessness and low self-esteem due to their hierarchical rank or lack of resources," says HBS assistant professor Amy J.C. Cuddy, one of the researchers on the study.
"It's not about the content of the message, but how you're communicating it."
In "Power Posing: Brief Nonverbal Displays Affect Neuroendocrine Levels and Risk Tolerance", Cuddy shows that simply holding one's body in expansive, "high-power" poses for as little as two minutes stimulates higher levels of testosterone (the hormone linked to power and dominance in the animal and human worlds) and lower levels of cortisol (the "stress" hormone that can, over time, cause impaired immune functioning, hypertension, and memory loss).
The result? In addition to causing the desired hormonal shift, the power poses led to increased feelings of power and a greater tolerance for risk.
"We used to think that emotion ended on the face," Cuddy says. "Now there is established research showing that while it's true that facial expressions reflect how you feel, you can also 'fake it until you make it.
' In other words, you can smile long enough that it makes you feel happy. This work extends that finding on facial feedback, which is decades old, by focusing on postures and measuring neuroendocrine levels."
The experiment
In their article, to be published in a forthcoming Psychological Science, Cuddy and coauthors Dana R. Carney and Andy J. Yap of Columbia University detail the results of an experiment in which forty-two male and female participants were randomly assigned to a high- or low-power pose group.
No one was told what the study was about; instead, each participant believed it was related to the placement of ECG electrodes above and below his or her heart.
Subjects in the high-power group were manipulated into two expansive poses for one minute each: first, the classic feet on desk, hands behind head; then, standing and leaning on one's hands over a desk.
Those in the low-power group were posed for the time period in two restrictive poses: sitting in a chair with arms held close and hands folded, and standing with arms and legs crossed tightly.
Saliva samples taken before and after the posing measured testosterone and cortisol levels. To evaluate risk tolerance, participants were given $2 and told they could roll a die for even odds of winning $4. Finally, participants were asked to indicate how "powerful" and "in charge" they felt on a scale from one to four.
Controlling for subjects' baseline levels of both hormones, Cuddy and her coauthors found that high-power poses decreased cortisol by about 25 percent and increased testosterone by about 19 percent for both men and women.
In contrast, low-power poses increased cortisol about 17 percent and decreased testosterone about 10 percent.
Not surprisingly, high-power posers of both sexes also reported greater feelings of being powerful and in charge. In addition, those in the high-power group were more likely to take the risk of gambling their $2; 86 percent rolled the die in the high-power group as opposed to 60 percent of the low-power posers.
Previous research established that situational role changes can cause shifts in hormone levels. In primate groups, for example, after an alpha male dies the testosterone levels of the animal replacing him go up. The hormonal shifts measured in this experiment show that such changes can be influenced independent of role, situation, or any consciously focused thoughts about power. The physical poses are enough.
And that, she suggests, has broad implications for people who suffer from feelings of powerlessness and low self-esteem due to their hierarchical rank or lack of resources.
Why we judge
Cuddy's overall research agenda focuses on stereotyping and questions around how we form judgments of others' warmth and competence.
Just Because I'm Nice, Don't Assume I'm Dumb reveals how and why we come to snap judgments about coworkers (and how to fight that natural instinct). The article was cited as a "Breakthrough Business Idea" for 2009 by Harvard Business Review.
"The power poses paper came about in part because my coauthor Dana and I had noticed that women in our classes seemed to be participating less," says Cuddy, who teaches the MBA elective Power and Influence.
"Some of the women exhibited body language associated with low power, so we wondered if that was in turn affecting how they feel," she adds, citing the "fake it till you make it" research that shows smiling can affect feelings and hormone levels.
"It's about understanding what moves people."
"The poses that we used in the experiment are strongly associated across the animal kingdom with high and low dominance for very straightforward evolutionary reasons. Either you want to be big because you're in charge, or you want to close in and hide your vital organs because you're not in charge.
"It does appear that even this minimal manipulation can change people's physiology and psychology and, we hope, lead to very different, meaningful outcomes, whether it's how they perform in a job interview or how they participate in class."
Cuddy acknowledges that there are moderating factors in how easily some groups can use traditional power poses. It would run counter to social norms, for example, if a woman wearing a skirt sat with her feet up on her desk while talking to a colleague.
"I'm not saying it's fair, but there is a different range for women versus men," says Cuddy, who also teaches several HBS Executive Education programs.
Female managers seem to have an intuition about the need to communicate confidence by striking expansive poses through other means. They might use a whiteboard as a prop that they can reach out and rest a hand on—allowing them to take up more space.
"There are implications across cultures as well," she adds. Cuddy believes American poses are bigger and more flamboyant than what would be acceptable in Korea or Japan, for example, and expects to focus on this question in future research.
Warmth versus competence
It ultimately boils down to how we connect to one another. In general, she says, people form impressions of others through a matrix of how much we trust and like them and how much we think they're competent and respect them.
For the most part people underestimate the powerful connection of warmth and overestimate the importance of competence.
"We are influenced, and influence others, through very unconscious and implicit processes," she says. "People tend to spend too much energy focusing on the words they're saying—perfectly crafting the content of the message—when in many cases that matters much less than how it's being communicated. People often are more influenced by how they feel about you than by what you're saying. It's not about the content of the message, but how you're communicating it.
"Many students believe that if they have a great idea, they should be able to magnetize their audience toward them because their audience will recognize the 'greatness' of that idea—that they'll get on board because the idea is so good," she continues.
"I try to show students that it doesn't work that way—you have to go meet people where they are and then all move together.
You have to connect with them before you can lead them."
If understanding how you are influenced and can influence others feels a bit too Machiavellian, Cuddy helps bring it down a notch.
"It's not about politics," she says. "It's about understanding what moves people."
About the author
Julia Hanna is associate editor of the HBS Alumni Bulletin.
Friday, January 7, 2011
Male Circumcision Reduces Risk for HPV Infection in Female Partners
From Medscape Medical News
Emma Hitt, PhD
January 6, 2011 — Male circumcision appears to protect against high-risk human papillomavirus (HPV) infection in female partners, according to the findings of 2 randomized controlled trials carried out in rural Uganda.
Maria J. Wawer, MD, and Aaron A.R. Tobian, MD, from Johns Hopkins University, Baltimore, Maryland, and colleagues reported their findings from the studies, conducted in Rakai, Uganda, online January 7 in The Lancet.
According to the researchers, male circumcision has previously been linked to reduced HPV infection in men and to reduced risk for cervical neoplasia in women with circumcised partners. In the current study, HIV-negative men were randomly assigned to undergo circumcision immediately (intervention) or after a delay of 24 months (control). Their HIV-negative female partners were interviewed, and concurrent self-collected vaginal swabs were tested for high-risk HPV infection.
At 24 months after intervention, more than 1000 women remained enrolled in the study (544 in the intervention group and 488 in the control group). Results showed a significant reduction of 28% in the prevalence of high-risk HPV infection in female partners of circumcised men compared with the control group (27.8% vs 38.7%; prevalence risk ratio, 0.72; 95% confidence interval [CI], 0.60 - 0.85; P = .001).
In addition, male circumcision significantly reduced the incidence of high-risk HPV in women (20.7 vs 26.9 infections per 100 person-years; incidence rate ratio, 0.77; 95% CI, 0.63 - 0.93; P = .008). For women positive for all high-risk HPV genotypes, clearance of infection was also more likely in the intervention group (66% vs 59%; risk ratio, 1.12; 95% CI, 1.02 - 1.22; P = .014), although clearance of the HPV-16 genotype was lower.
The authors suggest that reduced penile HPV carriage may explain the way in which circumcision helps prevent HPV infection in women.
Study limitations include the inability to obtain samples from 20% of the women enrolled in each group because of temporary stock shortages. This reduced the sample size and the power of the study. In addition, study participants were HIV-negative and in steady partnerships; therefore, the results may only be applicable to low-risk, monogamous individuals. Finally, follow-up data were obtained annually, and so do not account for incident cases that occurred and resolved during the year.
"Our findings indicate that male circumcision should now be accepted as an efficacious intervention for reducing the prevalence and incidence of HPV infections in female partners," write Dr. Wawer, Dr. Tobian and colleagues.
According to the researchers, decreased incidence and prevalence of high-risk HPV infection is likely to reduce the long-term risk for cervical cancer for women with circumcised male partners. "However, our results indicate that protection is only partial; the promotion of safe sex practices is also important," they add.
In an editorial, Anna R. Giuliano, PhD; Alan G. Nyitray, PhD; and Ginesa Albero from the Department of Cancer Epidemiology and Genetics, H. Lee Moffitt Cancer Center, Tampa, Florida, recount the historical association of circumcision and reduced incidence of cervical cancer. Commending the work of Dr. Wawer, Dr. Tobian, and colleagues, they state that "these data, from the most rigorous of study designs, support original observations for a preventive role of male circumcision in cervical cancer."
They mention several caveats, however, to drawing this conclusion, "First, the reduction in high-risk HPV infection in women was limited to about 25%. Second, a clinical endpoint such as high-grade cervical dysplasia (cervical intraepithelial neoplasia grade 2/3) was not assessed. Third, clearance of HPV-16 was lower in the intervention group than in the control group."
The study was supported by the Bill and Melinda Gates Foundation, the National Institutes of Health, and the Fogarty International Center. One author reports receiving research funding from Roche Molecular Diagnostics, the company that manufactures the HPV genotyping test used in this study. The other study authors have disclosed no relevant financial relationships. Each of the editorialists has received financial support from Merck & Co, GlaxoSmithKline, and/or Roche.
Lancet. Published online January 7, 2011.
Emma Hitt, PhD
January 6, 2011 — Male circumcision appears to protect against high-risk human papillomavirus (HPV) infection in female partners, according to the findings of 2 randomized controlled trials carried out in rural Uganda.
Maria J. Wawer, MD, and Aaron A.R. Tobian, MD, from Johns Hopkins University, Baltimore, Maryland, and colleagues reported their findings from the studies, conducted in Rakai, Uganda, online January 7 in The Lancet.
According to the researchers, male circumcision has previously been linked to reduced HPV infection in men and to reduced risk for cervical neoplasia in women with circumcised partners. In the current study, HIV-negative men were randomly assigned to undergo circumcision immediately (intervention) or after a delay of 24 months (control). Their HIV-negative female partners were interviewed, and concurrent self-collected vaginal swabs were tested for high-risk HPV infection.
At 24 months after intervention, more than 1000 women remained enrolled in the study (544 in the intervention group and 488 in the control group). Results showed a significant reduction of 28% in the prevalence of high-risk HPV infection in female partners of circumcised men compared with the control group (27.8% vs 38.7%; prevalence risk ratio, 0.72; 95% confidence interval [CI], 0.60 - 0.85; P = .001).
In addition, male circumcision significantly reduced the incidence of high-risk HPV in women (20.7 vs 26.9 infections per 100 person-years; incidence rate ratio, 0.77; 95% CI, 0.63 - 0.93; P = .008). For women positive for all high-risk HPV genotypes, clearance of infection was also more likely in the intervention group (66% vs 59%; risk ratio, 1.12; 95% CI, 1.02 - 1.22; P = .014), although clearance of the HPV-16 genotype was lower.
The authors suggest that reduced penile HPV carriage may explain the way in which circumcision helps prevent HPV infection in women.
Study limitations include the inability to obtain samples from 20% of the women enrolled in each group because of temporary stock shortages. This reduced the sample size and the power of the study. In addition, study participants were HIV-negative and in steady partnerships; therefore, the results may only be applicable to low-risk, monogamous individuals. Finally, follow-up data were obtained annually, and so do not account for incident cases that occurred and resolved during the year.
"Our findings indicate that male circumcision should now be accepted as an efficacious intervention for reducing the prevalence and incidence of HPV infections in female partners," write Dr. Wawer, Dr. Tobian and colleagues.
According to the researchers, decreased incidence and prevalence of high-risk HPV infection is likely to reduce the long-term risk for cervical cancer for women with circumcised male partners. "However, our results indicate that protection is only partial; the promotion of safe sex practices is also important," they add.
In an editorial, Anna R. Giuliano, PhD; Alan G. Nyitray, PhD; and Ginesa Albero from the Department of Cancer Epidemiology and Genetics, H. Lee Moffitt Cancer Center, Tampa, Florida, recount the historical association of circumcision and reduced incidence of cervical cancer. Commending the work of Dr. Wawer, Dr. Tobian, and colleagues, they state that "these data, from the most rigorous of study designs, support original observations for a preventive role of male circumcision in cervical cancer."
They mention several caveats, however, to drawing this conclusion, "First, the reduction in high-risk HPV infection in women was limited to about 25%. Second, a clinical endpoint such as high-grade cervical dysplasia (cervical intraepithelial neoplasia grade 2/3) was not assessed. Third, clearance of HPV-16 was lower in the intervention group than in the control group."
The study was supported by the Bill and Melinda Gates Foundation, the National Institutes of Health, and the Fogarty International Center. One author reports receiving research funding from Roche Molecular Diagnostics, the company that manufactures the HPV genotyping test used in this study. The other study authors have disclosed no relevant financial relationships. Each of the editorialists has received financial support from Merck & Co, GlaxoSmithKline, and/or Roche.
Lancet. Published online January 7, 2011.
Wednesday, January 5, 2011
Cryotherapy is More Effective than Salicylic Acid for Common Warts
From Journal Watch > Journal Watch (General)
Bruce Soloway, MD
Cutaneous warts are seen often in primary care, particularly among children, but a recent Cochrane review (Cochrane Database Syst Rev 2006; 3:CD001781) was inconclusive on the relative merits of the two most common treatments, salicylic acid and cryotherapy.
Dutch researchers randomized 250 patients (43% were younger than 12 years) who were recruited from 30 primary care practices with one or more new cutaneous warts (<1 cm diameter) to receive cryotherapy with liquid nogen every 2 weeks, daily self-applications of 40% salicylic acid gel, or no treatment for 13 weeks.
Half the patients had predominantly common warts (mainly on the hands), and half had predominantly plantar warts. Among patients with predominantly common warts, warts were significantly more likely to resolve completely with cryotherapy than with salicylic acid or no treatment (49% vs. 15% and 8%, respectively). Patients with predominantly plantar warts had similar cure rates regardless of treatment (30%, 33%, and 23%, respectively) and were more likely to be completely cured if they were younger than 12 years (50% vs. 3%) or if their warts had been present for <6 months (46% vs. 10%). Cryotherapy caused more local side effects than salicylic acid, but more patients who received cryotherapy were satisfied with their treatment.
Comment
This pragmatic primary care–based trial suggests that cryotherapy is the preferred treatment for common warts. Persistent plantar warts in adolescents and adults are unlikely to respond to brief therapy with either cryotherapy or salicylic acid.
Bruce Soloway, MD
Cutaneous warts are seen often in primary care, particularly among children, but a recent Cochrane review (Cochrane Database Syst Rev 2006; 3:CD001781) was inconclusive on the relative merits of the two most common treatments, salicylic acid and cryotherapy.
Dutch researchers randomized 250 patients (43% were younger than 12 years) who were recruited from 30 primary care practices with one or more new cutaneous warts (<1 cm diameter) to receive cryotherapy with liquid nogen every 2 weeks, daily self-applications of 40% salicylic acid gel, or no treatment for 13 weeks.
Half the patients had predominantly common warts (mainly on the hands), and half had predominantly plantar warts. Among patients with predominantly common warts, warts were significantly more likely to resolve completely with cryotherapy than with salicylic acid or no treatment (49% vs. 15% and 8%, respectively). Patients with predominantly plantar warts had similar cure rates regardless of treatment (30%, 33%, and 23%, respectively) and were more likely to be completely cured if they were younger than 12 years (50% vs. 3%) or if their warts had been present for <6 months (46% vs. 10%). Cryotherapy caused more local side effects than salicylic acid, but more patients who received cryotherapy were satisfied with their treatment.
Comment
This pragmatic primary care–based trial suggests that cryotherapy is the preferred treatment for common warts. Persistent plantar warts in adolescents and adults are unlikely to respond to brief therapy with either cryotherapy or salicylic acid.
Tuesday, January 4, 2011
Community-Based Study Shows Colonoscopy Is Effective
From Medscape Medical News > Oncology
Zosia Chustecka
January 3, 2011 — A new community-based study from Germany confirms that colonoscopy is an effective tool for preventing colorectal cancer (CRC), according to an editorial accompanying the study published in the January 4 issue of the Annals of Internal Medicine.
In Germany, colonoscopy has been the primary screening method offered to people 55 years and older since 2002, explain the authors, headed by Hermann Brenner, MD, MPH, from the German Cancer Research Center in Heidelberg. The introduction of colonoscopy was accompanied by "major efforts" in training and quality assurance measures, they note.
In this setting of high-quality colonoscopy, they conducted a population-based case–control study comparing 1688 patients and 1932 control subjects.
They found that for individuals who had undergone colonoscopy in the previous 10 years, the overall risk for any colorectal cancer was reduced by 77%.
As has been seen in previous studies, there was a larger reduction in the risk for left-sided colorectal cancer (84%) than in right-sided colorectal cancer (56%). Both of these reductions were "significant," they note.
These results show a greater risk reduction than has been reported recently in other studies, Dr. Brenner and colleagues note. Although the original trial that led to the adoption of colonoscopy — the National Polyp Study, published in 1993 — reported up to a 90% reduction in the risk for CRC, more recent population studies from Germany and Canada have reported reductions of only 30% to 50%.
In addition, this latest study shows a substantial reduction in the risk for right-sided CRC, Dr. Brenner and colleagues point out. This is in contrast to the lack of effect seen in a recent study from Canada (based on administrative claims), which found no protection from deaths from right-sided cancer (JAMA. 2008;299:1027-1035). However, the reduction in right-sided CRC seen in the German study showed an age gradient; in patients aged younger than 60 years, the reduction was modest (26%) and statistically nonsignificant, the authors point out.
The new results "vindicate colonoscopy as an effective prevention tool," writes David Weinberg, MD, MSc, from the Fox Chase Cancer Center in Philadelphia, Pennsylvania, in an accompanying editorial.
They also offer reassurance that colonoscopy can provide substantial protection against both right- and left-sided CRC, he adds. Although it does appear that colonoscopy is "less effective" in the right colon, this is not the same as "ineffective," he points out.
Colonoscopy Most Popular Method in the United States
Colonoscopy has become a standard — and for some the preferred — method of screening for CRC, Dr. Weinberg explains. It is certainly the most popular method in the United States, he adds, where more than 14 million colonoscopies are performed annually.
In contrast, other screening methods, such as flexible sigmoidoscopy and fecal occult blood testing, are performed with decreasing frequency in the United States, despite their lower costs and a stronger evidence base demonstrating their effectiveness, he notes.
Against this backdrop, there has been "recent and unwelcome news that colonoscopy may not protect against CRC as effectively as we would like to think," Dr. Weinberg notes.
These latest results from Germany provide reassurance that colonoscopy is effective, he writes. The study was methodologically rigorous, and the protective effect against CRC was "impressive." The protective effect was seen in both sexes and all ages, and even in patients with a family history of CRC, who are presumably at higher risk.
Nonetheless, there are several questions and issues that remain. Colonoscopy is operator dependent, and there is consistent evidence that gastroenterologists, as opposed to practitioners from other backgrounds, miss fewer lesions, Dr. Weinberg notes. There is also research showing that the ability to detect polyps and other lesions depends on the quality of the laxative preparation, he explains. Preparations that work best should become the standard, although any regimen remains a challenge for older sicker patients, he acknowledges.
Colonoscopy is more expensive and carries a higher risk than other CRC screening methods, so there are appropriate concerns about its "value," he writes.
"It is unrealistic to expect that colonoscopy to prevent all cases of CRC," Dr. Weinberg writes. "Physicians need to inform patients that colonoscopy offers very good, but not perfect, protection," he concludes.
The study was funded by the German Research Council and German Federal Ministry of Education and Research. Dr. Weinberg has disclosed no relevant financial relationships.
Ann Intern Med. 2011:154;22-30, 68-69.
Zosia Chustecka
January 3, 2011 — A new community-based study from Germany confirms that colonoscopy is an effective tool for preventing colorectal cancer (CRC), according to an editorial accompanying the study published in the January 4 issue of the Annals of Internal Medicine.
In Germany, colonoscopy has been the primary screening method offered to people 55 years and older since 2002, explain the authors, headed by Hermann Brenner, MD, MPH, from the German Cancer Research Center in Heidelberg. The introduction of colonoscopy was accompanied by "major efforts" in training and quality assurance measures, they note.
In this setting of high-quality colonoscopy, they conducted a population-based case–control study comparing 1688 patients and 1932 control subjects.
They found that for individuals who had undergone colonoscopy in the previous 10 years, the overall risk for any colorectal cancer was reduced by 77%.
As has been seen in previous studies, there was a larger reduction in the risk for left-sided colorectal cancer (84%) than in right-sided colorectal cancer (56%). Both of these reductions were "significant," they note.
These results show a greater risk reduction than has been reported recently in other studies, Dr. Brenner and colleagues note. Although the original trial that led to the adoption of colonoscopy — the National Polyp Study, published in 1993 — reported up to a 90% reduction in the risk for CRC, more recent population studies from Germany and Canada have reported reductions of only 30% to 50%.
In addition, this latest study shows a substantial reduction in the risk for right-sided CRC, Dr. Brenner and colleagues point out. This is in contrast to the lack of effect seen in a recent study from Canada (based on administrative claims), which found no protection from deaths from right-sided cancer (JAMA. 2008;299:1027-1035). However, the reduction in right-sided CRC seen in the German study showed an age gradient; in patients aged younger than 60 years, the reduction was modest (26%) and statistically nonsignificant, the authors point out.
The new results "vindicate colonoscopy as an effective prevention tool," writes David Weinberg, MD, MSc, from the Fox Chase Cancer Center in Philadelphia, Pennsylvania, in an accompanying editorial.
They also offer reassurance that colonoscopy can provide substantial protection against both right- and left-sided CRC, he adds. Although it does appear that colonoscopy is "less effective" in the right colon, this is not the same as "ineffective," he points out.
Colonoscopy Most Popular Method in the United States
Colonoscopy has become a standard — and for some the preferred — method of screening for CRC, Dr. Weinberg explains. It is certainly the most popular method in the United States, he adds, where more than 14 million colonoscopies are performed annually.
In contrast, other screening methods, such as flexible sigmoidoscopy and fecal occult blood testing, are performed with decreasing frequency in the United States, despite their lower costs and a stronger evidence base demonstrating their effectiveness, he notes.
Against this backdrop, there has been "recent and unwelcome news that colonoscopy may not protect against CRC as effectively as we would like to think," Dr. Weinberg notes.
These latest results from Germany provide reassurance that colonoscopy is effective, he writes. The study was methodologically rigorous, and the protective effect against CRC was "impressive." The protective effect was seen in both sexes and all ages, and even in patients with a family history of CRC, who are presumably at higher risk.
Nonetheless, there are several questions and issues that remain. Colonoscopy is operator dependent, and there is consistent evidence that gastroenterologists, as opposed to practitioners from other backgrounds, miss fewer lesions, Dr. Weinberg notes. There is also research showing that the ability to detect polyps and other lesions depends on the quality of the laxative preparation, he explains. Preparations that work best should become the standard, although any regimen remains a challenge for older sicker patients, he acknowledges.
Colonoscopy is more expensive and carries a higher risk than other CRC screening methods, so there are appropriate concerns about its "value," he writes.
"It is unrealistic to expect that colonoscopy to prevent all cases of CRC," Dr. Weinberg writes. "Physicians need to inform patients that colonoscopy offers very good, but not perfect, protection," he concludes.
The study was funded by the German Research Council and German Federal Ministry of Education and Research. Dr. Weinberg has disclosed no relevant financial relationships.
Ann Intern Med. 2011:154;22-30, 68-69.
Wednesday, December 29, 2010
The Latest STD Treatment Guidelines
From Centers for Disease Control and Prevention (CDC): Expert Commentary
Kimberly Workowski, MD
Infectious Diseases Specialist in the Division of STD Prevention at the Centers for Disease Control and Prevention and lead author of the recently-released 2010 STD Treatment guidelines
Over the next few minutes, I will highlight new information from the 2010 STD guidelines. These guidelines are intended to assist the clinician with the management of persons who have, or are at risk for, sexually transmitted diseases. Although these guidelines emphasize treatment, prevention strategies and diagnostic evaluation are also discussed.
Some of the key changes include the prevention and treatment of HPV, gonorrhea, and lymphogranuloma venereum proctocolitis.
These guidelines highlight expanded prevention recommendations for sexually transmitted infections, including preexposure vaccination for human papillomavirus virus (HPV).Preexposure vaccination is one of the most effective methods to prevent transmission of HPV. There are 2 HPV vaccines licensed for females aged 9 through 26 years to prevent cervical precancer and cancer: the quadrivalent HPV vaccine Gardasil® and the bivalent HPV vaccine Cervarix®. Gardasil will also prevent genital warts. Routine vaccination of females aged 11 or 12 years is recommended with either vaccine, as is the catch-up vaccination for females aged 13 through 26 years. Gardasil may also be given to males aged 9 through 26 years to prevent genital warts.
Neisseria gonorrhoeae, or GC, has developed resistance to many classes of antimicrobials recommended for treatment. Quinolone-resistant Neisseria gonorrhoeae strains are now widely disseminated throughout the United States and the world, and as a result, quinolones are not recommended for the treatment of gonorrhea. Although currently recommended regimens are effective for gonorrhea within the United States, the susceptibility of gonococcal isolates to cephalosporins has been decreasing and treatment failures with oral cephalosporins have been documented in Southeast Asia. Based on prior experience with quinolone-resistant N gonorrhoeae, it is probable that such isolates may spread to the Unites States.
Due to these reports, ceftriaxone 250 mg intramuscularly or cefixime 400 mg orally are recommended for urogenital infection.
Since many with gonorrhea are coinfected with chlamydia, therapy with azithromycin or doxycycline is recommended.
Lymphogranuloma venereum proctocolitis (LGV) is being increasingly recognized especially among HIV-positive men who have sex with men. In persons with painful perianal ulcers or those detected on anoscopy, presumptive therapy should include treatment for LGV, which is doxycycline 100 mg twice daily for 21 days.
A new patient-applied treatment for genital warts is available. The treatment of 15% sinecatechins ointment should be applied by the patient 3 times daily until complete clearance of the warts.
There is also a new alternative treatment for bacterial vaginosis: 2 g of tinidazole taken daily for 3 days or 1 g taken daily for 5 days. For episodic outbreaks of herpes simplex virus, an additional treatment option is 500 mg of famciclovir followed by 2 days of 250 mg taken twice daily. There are also some data that moxifloxacin -- 400 mg daily for 7 days -- is effective in nongonococcal urethritis treatment failures due to Mycoplasma genitalium.
The complete treatment guidelines can be viewed and downloaded at cdc.gov/std/treatment/2010.
Kimberly Workowski, MD
Infectious Diseases Specialist in the Division of STD Prevention at the Centers for Disease Control and Prevention and lead author of the recently-released 2010 STD Treatment guidelines
Over the next few minutes, I will highlight new information from the 2010 STD guidelines. These guidelines are intended to assist the clinician with the management of persons who have, or are at risk for, sexually transmitted diseases. Although these guidelines emphasize treatment, prevention strategies and diagnostic evaluation are also discussed.
Some of the key changes include the prevention and treatment of HPV, gonorrhea, and lymphogranuloma venereum proctocolitis.
These guidelines highlight expanded prevention recommendations for sexually transmitted infections, including preexposure vaccination for human papillomavirus virus (HPV).Preexposure vaccination is one of the most effective methods to prevent transmission of HPV. There are 2 HPV vaccines licensed for females aged 9 through 26 years to prevent cervical precancer and cancer: the quadrivalent HPV vaccine Gardasil® and the bivalent HPV vaccine Cervarix®. Gardasil will also prevent genital warts. Routine vaccination of females aged 11 or 12 years is recommended with either vaccine, as is the catch-up vaccination for females aged 13 through 26 years. Gardasil may also be given to males aged 9 through 26 years to prevent genital warts.
Neisseria gonorrhoeae, or GC, has developed resistance to many classes of antimicrobials recommended for treatment. Quinolone-resistant Neisseria gonorrhoeae strains are now widely disseminated throughout the United States and the world, and as a result, quinolones are not recommended for the treatment of gonorrhea. Although currently recommended regimens are effective for gonorrhea within the United States, the susceptibility of gonococcal isolates to cephalosporins has been decreasing and treatment failures with oral cephalosporins have been documented in Southeast Asia. Based on prior experience with quinolone-resistant N gonorrhoeae, it is probable that such isolates may spread to the Unites States.
Due to these reports, ceftriaxone 250 mg intramuscularly or cefixime 400 mg orally are recommended for urogenital infection.
Since many with gonorrhea are coinfected with chlamydia, therapy with azithromycin or doxycycline is recommended.
Lymphogranuloma venereum proctocolitis (LGV) is being increasingly recognized especially among HIV-positive men who have sex with men. In persons with painful perianal ulcers or those detected on anoscopy, presumptive therapy should include treatment for LGV, which is doxycycline 100 mg twice daily for 21 days.
A new patient-applied treatment for genital warts is available. The treatment of 15% sinecatechins ointment should be applied by the patient 3 times daily until complete clearance of the warts.
There is also a new alternative treatment for bacterial vaginosis: 2 g of tinidazole taken daily for 3 days or 1 g taken daily for 5 days. For episodic outbreaks of herpes simplex virus, an additional treatment option is 500 mg of famciclovir followed by 2 days of 250 mg taken twice daily. There are also some data that moxifloxacin -- 400 mg daily for 7 days -- is effective in nongonococcal urethritis treatment failures due to Mycoplasma genitalium.
The complete treatment guidelines can be viewed and downloaded at cdc.gov/std/treatment/2010.
Tuesday, December 28, 2010
Little Screening of Kids for Obesity Complications
From Reuters Health Information
By Frederik Joelving
NEW YORK (Reuters Health) Dec 23 - Only a minority of obese youths are screened for diabetes, liver problems and high cholesterol, electronic medical records from an Ohio healthcare system show.
Researchers say the findings are a call for action, since such complications could be part of the reason why heavy kids appear to have shorter lives.
Other experts, however, say there is no proof that stepping up routine screening tests will improve the prospects for the more than one in six American youngsters who are obese.
The new study, published online December9th in Obesity, found that among nearly 70,000 children and adolescents with data on height and weight, 13% were obese. But among those with a diagnosis of obesity, only 30% had liver function tests, 41% had their cholesterol and other lipids checked, and 52% had blood glucose tests. Only 22% were screened for all three obesity-related conditions
The numbers did climb over the past decade, the researchers found, but appeared to level off around 2004 and may even be declining.
"Lack of knowledge of current guidelines likely contributes to underscreening, as guidelines have varied throughout the study period, beginning with vague recommendations in 1998 to more complete guidelines published in 2005 and 2007," Dr. Lacey Benson, of the Denver Children's Hospital, and her colleagues write.
"After an obese child is diagnosed with obesity, diagnosis should be followed by an assessment for obesity-related conditions that may require treatment or further intervention," they add.
But not all guidelines agree.
The U.S. Preventive Services Task Force recommends screening for obesity itself and suggests targeting diet and physical activity to help kids lose weight.
But according to the task force, there aren't enough data to show that benefits of further screening tests outweigh the harms -- or are worth the extra cost, for that matter. The drugs used to correct potential problems all have side effects, for instance, such as the muscle pain and occasional liver damage caused by statins.
"There is so much uncertainty about the long-term impacts -- benefits and harms -- of putting kids on statins for decades," said Dr. David Grossman, a member of the USPSTF.
"We do know that you can have some impact on lipid levels, but whether or not that improves outcomes and quality of life, or whether or not you could wait until later to start treatment, that is unclear," he added. "Some people are willing to make that assumption, but our standard is such that we need to prove it."
In the meantime, Dr. Grossman said, the decision to do lab tests should be an individual one, taking into consideration each person's symptoms as well as disease among close relatives.
SOURCE: http://link.reuters.com/vac92r
Obesity 2010.
By Frederik Joelving
NEW YORK (Reuters Health) Dec 23 - Only a minority of obese youths are screened for diabetes, liver problems and high cholesterol, electronic medical records from an Ohio healthcare system show.
Researchers say the findings are a call for action, since such complications could be part of the reason why heavy kids appear to have shorter lives.
Other experts, however, say there is no proof that stepping up routine screening tests will improve the prospects for the more than one in six American youngsters who are obese.
The new study, published online December9th in Obesity, found that among nearly 70,000 children and adolescents with data on height and weight, 13% were obese. But among those with a diagnosis of obesity, only 30% had liver function tests, 41% had their cholesterol and other lipids checked, and 52% had blood glucose tests. Only 22% were screened for all three obesity-related conditions
The numbers did climb over the past decade, the researchers found, but appeared to level off around 2004 and may even be declining.
"Lack of knowledge of current guidelines likely contributes to underscreening, as guidelines have varied throughout the study period, beginning with vague recommendations in 1998 to more complete guidelines published in 2005 and 2007," Dr. Lacey Benson, of the Denver Children's Hospital, and her colleagues write.
"After an obese child is diagnosed with obesity, diagnosis should be followed by an assessment for obesity-related conditions that may require treatment or further intervention," they add.
But not all guidelines agree.
The U.S. Preventive Services Task Force recommends screening for obesity itself and suggests targeting diet and physical activity to help kids lose weight.
But according to the task force, there aren't enough data to show that benefits of further screening tests outweigh the harms -- or are worth the extra cost, for that matter. The drugs used to correct potential problems all have side effects, for instance, such as the muscle pain and occasional liver damage caused by statins.
"There is so much uncertainty about the long-term impacts -- benefits and harms -- of putting kids on statins for decades," said Dr. David Grossman, a member of the USPSTF.
"We do know that you can have some impact on lipid levels, but whether or not that improves outcomes and quality of life, or whether or not you could wait until later to start treatment, that is unclear," he added. "Some people are willing to make that assumption, but our standard is such that we need to prove it."
In the meantime, Dr. Grossman said, the decision to do lab tests should be an individual one, taking into consideration each person's symptoms as well as disease among close relatives.
SOURCE: http://link.reuters.com/vac92r
Obesity 2010.
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