Annals
Established in 1927 by the American College of Physicians

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17 November 2009 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 1-800-523-1546, ext. 2656, or 215-351-2656, or visit www.annals.org. Past highlights are accessible as well.

1. Annals of Internal Medicine Publishes New USPSTF Breast Cancer Screening Guidelines

Task Force Recommends Against Routine Mammography Screening for Women Before Age 50, Suggests Screening End at Age 74

In an update to its 2002 recommendations, the U.S. Preventive Services Task Force (USPSTF) now recommends against routine breast cancer screening for women under the age of 50. Women between the ages of 40 and 49 at high risk for breast cancer should talk to their doctor about the best time to start regular, biennial screening mammography. These recommendations appear in the November 17 issue of Annals of Internal Medicine, the flagship journal of the American College of Physicians.

In addition to revising the age at which mammography screening should begin, the USPSTF also suggests changing the screening interval from one year to two, up to the age of 74. There is insufficient evidence to determine the screening benefits and harms for women aged 75 or older.

The Task Force recommends against teaching breast self-examination, as adequate evidence suggests that teaching self-examination does not reduce breast cancer mortality. USPSTF researchers also conclude that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination for women 40 and over. This recommendation is a change from the 2002 statement, which suggested mammography screening, with or without clinical breast examination, every one to two years for women aged 40 years or older.

According to the available evidence, screening with film mammography reduces breast cancer mortality, especially for women aged 50 to 74 years, with the greatest benefit seen in women aged 60 to 69. Among women 75 and older, evidence of the benefits of mammography is lacking.

The USPSTF did not recommend one form of mammography over another. According to its recommendation, the current evidence is insufficient to assess additional benefits and harms of either digital mammography or magnetic resonance imaging instead of film mammography as screening modalities for breast cancer.

To update the 2002 recommendation statement, researchers systematically reviewed published evidence of the efficacy of five screening modalities in reducing mortality from breast cancer: film mammography, clinical breast examination, breast self-examination, digital mammography, and magnetic resonance imaging. In addition, the Task Force commissioned two studies related to breast cancer screening: a targeted systematic evidence review of six selected questions relating to the benefits and harms of screening; and a decision analysis that used population modeling techniques to compare the expected health outcomes and resource requirements of starting and ending mammography screening at different ages and using annual versus biennial screening intervals.

2. Hand-held Computer May Help Improve Pulmonary Embolism Diagnosis

Pulmonary embolism is a life-threatening condition most often caused by a blood clot breaking off from a vein and entering the circulatory system. While evidence-based guidelines exist to help physicians safely and efficiently evaluate patients with suspected pulmonary embolism, testing often differs from what is suggested. Researchers sought to determine if a computer program for use on a mobile, handheld device could improve diagnostic decision-making. During a pre-intervention phase involving 20 centers and 1,103 patients, health care providers grew accustomed to inputting clinical data into handheld devices and investigators assessed baseline testing. Then, the 20 centers were randomized to make diagnostic decisions based on the handheld devices (10 centers, 753 patients) or based on posters and pocket cards that clearly stated evidence-based guidelines (10 centers, 1,015 patients). The researchers concluded that use of an electronic decision support system available on handheld computers significantly improved diagnostic decision making over paper guidelines, increasing the proportion of patients who received appropriate diagnostic work-up by