Established in 1927 by the American College of Physicians


3 April 2012 Annals of Internal Medicine Tip Sheet

Annals of Internal Medicine is published by the American College of Physicians on the first and third Tuesday of every month. These highlights are not intended to substitute for articles as sources of information. For a copy of an article, call 215-351-2653 or e-mail Angela Collom at

1. Mammography Screening Leads to Overdiagnosis of Breast Cancer

Women undergo mammography screening to detect cancer in its early stages. Theoretically, early detection saves lives. However, newer research is questioning whether finding cancer early is better. Researchers in Norway sought to determine the percentage of overdiagnosis of breast cancer attributable to mammography screening. Overdiagnosis is considered the detection of cancer that would not go on to cause symptoms or death. In Norway, mammography screening was rolled out over a decade, one geographic region at a time, making it an ideal environment for the research. The number of breast cancer cases found in screened women was compared with that in matched unscreened women. A total of 39,888 women with invasive breast cancer were included in the analysis, 7,793 of whom were diagnosed after the screening program started. Investigators estimated that 15 – 25 percent of cases of breast cancer detected represented overdiagnosis. The authors of an accompanying editorial write about the under recognized harms of overdiagnosis. The anxiety of false-positive results eventually goes away, but women who are diagnosed with cancer that otherwise would not have progressed are forever altered by that diagnosis. The authors recommend “watch-and-wait” strategies with non-invasive, early-state tumors. However, they recognize that this approach may be difficult for women to support. Until better screening tools are developed, women should be educated that some cancers detected by mammography represent over diagnosis.

2. International Network of Experts Proposes Minimum Standards for Guideline Development

Evidence-based clinical practice guidelines help to inform and direct patient care. With an increasing number of guidelines being developed (sometimes contradictory), it is important for health care providers to be able to discern which guidelines are high-quality, and therefore should be trusted. The Guidelines International Network (G-I-N) is an international, multidisciplinary group of active guideline developers that includes 93 organizations and 92 individual members representing 45 countries. The G-I-N sought to form a consensus about minimum standards for guideline development that are both rigorous and feasible for even modestly funded groups to implement. The authors reviewed the current literature to identify components of guideline development critical to developing high-quality guidelines. The group also considered practical issues related to implementation and global adaptation. Based on their research, G-I-N identified 11 key components of high-quality and trustworthy guidelines: 1) composition of a guideline development panel that is diverse, and includes relevant stakeholders; 2) firm establishment of a decision-making process for reaching consensus; 3) disclosure of conflicts of interest; 4) identification of the guideline objective and scope; 5) detailed description of guideline development methods; 6) adherence to systematic reviews of evidence; 7) description of recommendation including benefits, harms, and costs; 8) rating of the evidence; 9) external review by stakeholders; 10) inclusion of an expiration date and/or description of process for updating; and 11) disclosure of financial support. “Having this article published in Annals of Internal Medicine is an important step because the journal is internationally recognized as publishing only high-quality guidelines,” said lead author Amir Qaseem, MD, PhD, MHA, FACP, Director of Clinical Policy at the American College of Physicians. “It is hoped that this article promotes discussion and eventual agreement on a set of international standards for guideline development.”

3. A Video Intervention Increases Consent to Donate Organs Among Ethnic Groups

Currently more than 100,000 people are on the active waiting list for organ transplantation – a figure that grows by 50,000 each year. Because of the significant gap between supply and demand, many patients will die while waiting for an organ. Ethnic groups are hit especially hard by this shortage, as they make up 50 percent of the waiting list, but only 30 percent of donors. Researchers sought to determine if a brief video intervention could increase consent to donate. Participants at 12 Ohio Bureau of Motor Vehicles offices were randomly assigned to either view an iPod video addressing ethnic group concerns about organ donation (n=443) or to receive written information only about organ donation (n=509). They found that blacks and whites who watched the video were more likely to identify themselves as organ donors on their driver’s licenses, learner’s permits, or state identification cards than patrons who did not view the video. Because tens of millions of people obtain driver’s licenses annually, this type of intervention could substantially increase the number of potential organ donors in the U.S.