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How often should you have a mammogram? Breast density and risk can inform decision

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1. Breast density and risk may be useful for guiding mammography screening frequency
Abstract: http://www.annals.org/article.aspx?doi=10.7326/M16-0476
Editorial: http://www.annals.org/article.aspx?doi=10.7326/M16-1791
URLs go live when the embargo lifts

Women between the ages of 50 and 74 may benefit from more or less frequent mammography screening than is generally recommended, depending on breast density and risk. For average-risk women with lower breast density, which comprises a large proportion of the population, triennial screening offers about the same or better balance of benefits and harms as biennial screening and is also cost-effective. Higher-risk women with dense breasts may fare better with annual screening. Findings from a collaborative modeling study are published in Annals of Internal Medicine.

Accepted clinical guidelines recommend biennial mammography screening for women aged 50 to 74. These recommendations also advocate shared decision making regarding screening frequency that takes into consideration an individual woman's preferences, risk level, and breast density. However, there is limited data available to guide clinicians and women in making these decisions.

Researchers from the Cancer Intervention and Surveillance Modeling Network, collaborating with the Breast Cancer Surveillance Consortium (BCSC), used three well-established models to evaluate outcomes using various screening intervals for digital mammography among subgroups of women based on age, risk, and breast density. The outcomes were projected for women 50 or older who were deciding whether to initiate (or continue) biennial screening until age 74 or to have annual or triennial screening. The models showed that average-risk women with lower breast density could safely and effectively extend their screening interval to once every three years, which could reduce false-positives, biopsies, and overdiagnosis with minimal effect on breast cancer deaths averted. Women at higher risk for breast cancer and with dense breasts would reap greater benefit from annual screening. The authors suggest that these findings could be useful for guiding shared decision making and tailoring screening intervals.

Note: For an embargoed PDF, please contact Cara Graeff. To reach the lead author, Dr. Amy Trentham-Dietz, please contact Susan Smith at [email protected] or 608-890-5643.

2. Preoperative patient frailty a good predictor of long-term mortality in older patients
Abstract: http://www.annals.org/article.aspx?doi=10.7326/M16-0652
Editorial: http://www.annals.org/article.aspx?doi=10.7326/M16-1866
URLs go live when the embargo lifts

Frailty status, assessed using tools that measure mobility, disability, and nutritional status, may predict mortality 6 or more months after major cardiac surgery and functional decline after more minor cardiac procedures. A systematic evidence review is published in Annals of Internal Medicine.

Identifying patients who are most or least likely to benefit from surgical procedures remains a significant challenge. Frailty is one of the factors that affect outcomes in older patients. As such, experts have developed several instruments to measure frailty by assessing gait speed, grip strength, or deficit accumulation. However, there is no consensus on how to best measure this vulnerability.

Researchers reviewed published studies to evaluate the evidence for 9 frailty instruments used to predict mortality, functional status, or major adverse cardiovascular and cerebrovascular events (MACCEs) in older adults undergoing cardiac surgical procedures and 13 instruments to measure the same in patients undergoing minimally invasive procedures. Despite the various ways of measuring frailty, the researchers found strong evidence that it predicts mortality at 6 months or later after major or minimally invasive procedures. Some evidence indicated that frailty may predict functional decline, poor quality of life, or lack of symptomatic benefit after minimally invasive procedures.

The authors of an accompanying editorial suggest that these findings can improve care for older surgical patients by helping to inform decisions about surgery for both the patient and clinician. Once the decision to have surgery is made, patients and their caregivers can be better prepared for possible outcomes.

Note: For an embargoed PDF, please contact Cara Graeff. The lead author, Dr. Dae Hyun Kim, can be reached through Kelly Lawman at [email protected] or 617-667-7305.

3. Fecal transplantation seems highly curative for recurrent C. diff, but questions remain
Abstract: http://www.annals.org/article.aspx?doi=10.7326/M16-0271
Editorial: http://www.annals.org/article.aspx?doi=10.7326/M16-1784
URLs go live when the embargo lifts

In a randomized, controlled, double-blind clinical trial, fecal microbiota transplantation using donor stool seemed to be safe and was more efficacious than transplantation using the patient's own stool in curing multiply recurrent Clostridium difficile (C. diff) infection. However, results varied widely by study site, raising questions about the benefits and risk of the procedure. The findings are published in Annals of Internal Medicine.

C. diff is the most common health care-associated infection in U.S. hospitals. Antibiotics are frequently ineffective and recurrences are common. Fecal transplantation restores the normal composition of gut microbiota and is recommended when antibiotics fail to clear the infection after a third episode of infection. However, the evidence for fecal transplantation rests largely on case series and several open-label clinical trials.

Researchers assigned 46 patients with three or more recurrences of C. diff to receive fecal microbiota transplantation with donor stool or their own stool administered by colonoscopy at two academic medical centers – Montefiore Medical Center in the Bronx, New York, and The Miriam Hospital in Providence, Rhode Island. Overall, 91 percent of patients in the donor stool group achieved clinical cure compared with 63 percent receiving their own stool. However, cure rates in patients receiving their own stool were 90 percent in the New York medical center and about 43 percent at the Rhode Island medical center.

The author of an accompanying editorial suggests that these "striking" findings may be due to differences in patient characteristics including, locale, length of time between initial diagnosis and transplantation, and the type of antibiotic used, among other factors. More research is needed to answer some of the questions raised by this randomized trial.

Note: For an embargoed PDF, please contact Angela Collom. The lead author, Dr. Colleen Kelly, please contact Elena Falcone-Relvas at [email protected] or 401-793-7484.

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