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14 April 2015 Annals of Internal Medicine Tip Sheet

Below is information about articles being published in 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.

1. Task Force weighs evidence on diabetes screening

Researchers for the U.S. Preventive Services Task Force (USPSTF) have completed a systematic evidence review to inform an upcoming update of Task Force recommendations on screening asymptomatic, nonpregnant adults for type 2 diabetes. The review is published in Annals of Internal Medicine.

Approximately 21 million persons in the U.S. received a diabetes diagnosis in 2010 and an estimated 8 million cases went undiagnosed. Screening asymptomatic persons for diabetes may lead to earlier identification and earlier or more-intensive treatments, potentially improving health outcomes. Researchers reviewed studies published from 2007 through October 2014 to assess the benefits and harms of screening for type 2 diabetes, impaired fasting glucose, or impaired glucose tolerance among asymptomatic adults. The evidence suggests that screening asymptomatic, nonpregnant adults for type 2 diabetes could help to delay progression to diabetes by identifying those who could benefit from treatment of impaired fasting glucose and impaired glucose tolerance. However, screening did not improve mortality rates after 10 years of follow up.

In 2008, the USPSTF recommended that physicians should screen for type 2 diabetes in asymptomatic adults with treated or untreated sustained blood pressure greater than 135/80 mm Hg. This recommendation was based on the ability of screening to identify persons with diabetes and evidence that more-intensive blood pressure treatment was associated with reduced risk for cardiovascular events, including cardiovascular mortality, in patients with diabetes and hypertension. Since then, evidence shows that an intensive multifactorial intervention for screen-detected diabetes aimed at decreasing glucose and lipid levels and blood pressure was not associated with a reduction in risk for all-cause or cardiovascular mortality or morbidity compared with standard treatment. The USPSTF posted draft recommendations for public comment in October 2014. The Task Force is currently incorporating public comment to finalize those recommendations for future release.

2. Survey: Proposed regulations may contradict patient attitudes towards medical research

Take the patient survey

Results of a web-based survey suggest that patients prefer to be asked for permission to participate in observational and randomized research evaluating usual medical practices. However, patient attitudes regarding consent and risk disclosure may be in opposition to regulatory guidance being drafted by the U.S. Office for Human Research Protections (OHRP).

Researchers surveyed 1,095 U.S. adults sampled from an online panel and an online convenience river sample to determine their attitudes about risks and preferences for notification and consent for research on medical practices. The survey results suggest strong support for research that compares usual clinical practices to determine the best ways of treating a particular condition and willingness to participate in such research. Respondents favored being asked for permission to participate in research, regardless of whether it affects treatment decisions. The patients were willing to make tradeoffs between imposing full consent requirements if more elaborate notification or approaches to consent would prevent research from being conducted. These results seem to be in opposition to proposed OHRP guidance. The research is being published in Annals of Internal Medicine.

3. Cancer experts: Too many patients being screened, diagnosed, and treated

Cancer experts from Memorial Sloan Kettering Cancer Center in New York and Tufts Medical Center in Boston, write that too many people are being screened, diagnosed, and treated for disease because they mistakenly believe they are at higher risk than they actually are. The authors call this the “Lake Wobegon Effect” after the fictional Midwestern town of above-average citizens featured in Garrison Keillor’s A prairie Home Companion. Their commentary is published in Annals of Internal Medicine.

The authors argue that prostate cancer is a perfect example of the Lake Wobegon Effect and how it leads to overdiagnosis. Prostate cancer screening programs assume that all men are at average risk, when risk can be very strongly separated depending on PSA levels. For example, men in the top quartile of PSA levels at age 60 have a 20-times greater risk for prostate cancer death than those with lower PSA levels. Screening only men at high risk, rather than screening all men, drastically reduces screening harms in terms of overdiagnosis, but retains 100 percent of the screening benefits in terms of mortality reductions. The authors suggest that having a better understanding of the Lake Wobegon Effect will help physicians focus screening programs on patients who have the most to gain.