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Men between the ages of 50 and 69 should discuss the limited benefits and substantial harms of the prostate-specific antigen (PSA) test with their doctor before undergoing screening for prostate cancer, according to new recommendations by the American College of Physicians (ACP). Only men between the ages of 50 and 69 who express a clear preference for screening should have the PSA test. According to the authors, men can change their minds at any time by asking for screening that they have previously declined or discontinuing screening that they have previously requested. ACP recommends against prostate cancer screening for average risk men younger than 50, or older than 69. For men younger than 50, the harms such as erectile dysfunction and urinary incontinence may carry more weight relative to any potential benefit. Men with a life expectancy of less than 10 to 15 years should not be tested because the harms of prostate cancer screening outweigh the benefits for this population. The guidance statement includes talking points for physicians to help them explain the benefits and harms of prostate cancer screening and treatment. The authors recommend that physicians explain to patients that there are substantial harms associated with cancer screening and treatment, such as problems interpreting the test result; risks associated with biopsy (small risk of infection, significant bleeding, or hospitalization); and risks associated with surgery or radiation for cancer (small risk of death, loss of sexual function, and urinary incontinence). To inform the recommendation, researchers from ACP’s Clinical Guidelines Committee conducted a rigorous review of available guidelines from other organizations. ACP believes that it is more valuable to provide clinicians with a rigorous review of available guidelines rather than develop a new guideline on the same topic when multiple guidelines are available on a topic, or when existing guidelines conflict. The goal of the evidence review is to develop a clear guide for internists and other clinicians to follow when making decisions about screening for prostate cancer.
Representatives from the New York City Department of Health and Mental Hygiene and the head of the American College of Emergency Physicians (ACEP) share opposing viewpoints on the recently released New York City Emergency Department Discharge Opioid Prescribing Guideline. According to Alex M. Rosenau, DO, CPE, FACEP, President-elect of the ACEP, the guidelines may be missing the mark by targeting emergency room physicians. The new guidelines, which were promoted heavily by New York City Mayor Bloomberg’s office, recommend that public hospital emergency department physicians prescribe no more than three days’ supply of opioids upon discharge. But Dr. Rosenau points out that emergency physicians write less than 5 percent of the immediate release opioid prescriptions and a very small a proportion of the extended/long acting opioids. He says there are many legitimate reasons for prescribing pain medications for more than three days and the guideline may hurt more than help by causing additional visits to the ER while patients await follow-up care. These additional visits will add to the crowding problem in the ER. Authors at NYC’s Department of Health say the guideline is welcome support for emergency physicians who are accountable to patients seeking opioids for pain relief. These doctors have a desire and obligation to help their patients, but they recognize that misuse, addiction, and death are real and common dangers of prescribing opioids. The authors cite evidence that long-term use of opioids for non-cancer pain is unsupported. There is no good evidence that opioids control pain or improve function over the long-term. However, one study shows that opioid use results in addiction for more than one-third of chronic pain patients. The authors say that mayoral backing of the new prescribing guidelines gives physicians the support they need to promote safer opioid prescribing practices. The full guideline can be viewed at www.annals.org.
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