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17 September 2013 Annals of Internal Medicine Tip Sheet

Below is information about articles being published in the September 17 issue of Annals of Internal Medicine. The information is not intended to substitute for the full article as a source of information. Annals of Internal Medicine attribution is required for all coverage. /p>

1. Survey: Unfounded fear of recurrence prompts young breast cancer patients to remove healthy breasts

Despite evidence that contralateral prophylactic mastectomy (CPM) does not improve survival rates, an increasing number of young women with breast cancer elect to remove their healthy breast to avoid recurrence and improve survival. Researchers surveyed 123 women aged 40 or younger without known bilateral breast cancer who reported having bilateral mastectomy. The purpose of the survey was to better understand how women approach the decision to have CPM. The survey included questions about the women’s health history, reason for choosing CPM, and knowledge and perceptions about breast cancer. Most of the women (n = 97) had stage I or stage II breast cancer and 60 percent of tumors were estrogen receptor-positive. Almost all (98 percent) of the women surveyed indicated that desires to decrease their risk for contralateral breast cancer (CBC) prompted their decision to remove the healthy breast. Although 94 percent of the women surveyed said they chose bilateral mastectomy to increase survival, only 18 percent reported thinking that CPM improved survival rates. Almost all of the women surveyed overestimated the actual risk of CBC. While physicians were identified as the most important sources of information about breast cancer, only one-third of the women cited a desire to follow a physician’s recommendations as an extremely or very important factor in their decision. The authors suggest that this survey underscores a need for better risk communication strategies that help patients make decisions based on evidence.

2. Varenicline proves safe and effective for smoking cessation in patients with current or past depression

Varenicline is safe and effective to help smokers with current or past major depression quit smoking. Approximately half of smokers seeking treatment have a history of depression. This is a clinically important relationship because depression and smoking are among the leading causes of disability and death in the world and having depression makes quitting smoking more difficult. Varenicline has proven more effective than bupropion for smoking cessation, but because of its mechanism of action, there are concerns about the safety of varenicline in patients with psychiatric disorders. In a phase 4* double-blind, randomized trial, 525 adult smokers with stably treated current or past major depression and no recent cardiovascular events were assigned to either varenicline, 1 mg twice daily, or placebo for 12 weeks, followed by 40 weeks of no treatment. Patients were evaluated for smoking abstinence and changes in mood and anxiety levels. The researchers found that patients in the varenicline group were about twice as likely to quit smoking than those in the placebo group, with the effects persisting throughout the 40-week follow-up phase. There were no clinically relevant differences in mood, anxiety, or overall worsening of depression in either group. The verenicline group had more adverse events including nausea, headache, abnormal dreams, irritability, and insomnia.

*Phase 4 trials are conducted after an intervention has already been approved and marketed. These trials are used to evaluate long-term safety and effectiveness, and can also help to determine optimal use.

3. ACP policy paper shares principles for organizing clinical care teams based on patient needs

A new policy paper from the American College of Physicians (ACP) sets the framework for a team-based model of health care. Principles Supporting Dynamic Clinical Care Teams outlines more than a dozen principles for creating more nimble, adaptable partnerships that encourage teamwork, collaboration, and smooth transitions of responsibility to ensure the best possible care for patients. While reaffirming its support of the Joint Principles of the Patient-Centered Medical Home in the paper, ACP said it recognizes that the current model of health care delivery will need to change to meet the coming demand of patients. Highly-functioning teams typically assign responsibility and authority for distinct organizational domains to the person or persons most appropriate for the tasks required, the paper says. Clinical care teams will vary in their composition depending on the medical specialty (e.g., internal medicine or cardiology), the clinical setting (inpatient, outpatient, small practice, large institution) and will vary in their function depending on leadership, institutional policies, available team members, even individual talents and characteristics of specific team members. Optimal effectiveness of clinical care teams requires a culture of trust, shared goals, effective communication, and mutual respect for the distinctive skills, contributions, and roles of each team member. “These principles offer a framework for an evolving, updated approach to health care delivery, providing policy guidance that can be useful to clinical teams themselves in organizing their care processes and clinician responsibilities consistent with professionalism,” Molly Cooke MD, FACP, president of ACP pointed out.

Note: This paper will be published early online with three editorials. Full text of the policy paper and editorials are available to reporters under embargo. The URL for this paper will be live on September 16 at 5:00 p.m. and may be included in news articles.