Lung cancer screening based on gains in life expectancy could maximize the benefits of screening programs
Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information.
1. Lung cancer screening based on gains in life expectancy could maximize the benefits of screening programs
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Selecting candidates for lung cancer screening based on their gains to life expectancy could help to maximize the benefits and minimize the harms of screening programs in the United States. This approach would recommend screening for ever-smokers who have both high lung cancer risk and long life-expectancy. Findings from a modeling study are published in Annals of Internal Medicine.
Current lung cancer screening guidelines from the US. Preventive Services Task Force (USPSTF) recommend CT screening for ever-smokers aged 55-80 who smoked within the past 15 years and have 30 or more pack-years of exposure. Risk-based screening has been shown to prevent more lung cancer deaths than current guidelines and are under consideration by the Task Force. However, risk-based screening may not be optimal because it tends to select older ever-smokers with shorter life expectancies due to comorbidities who would also have increased harms from screening. A screening program based on years of life gained may have a better balance of benefits and harms.
Researchers from the National Cancer Institute used data from the National Health Interview Survey (NHIS) to develop and validate an individualized prediction model for overall mortality and for gains to individual life expectancy from undergoing 3 rounds of CT screening in U.S. ever smokers aged 40 to 84 years. The analysis included data for 131,000 participants representing about 60 million US ever-smokers during 1997 to 2015. Comparative analysis showed that risk-based and life-gained-based strategies provide substantially greater life extension and death prevention than current USPSTF recommendations. Additionally, the analysis showed that, compared with risk-based selection, life gained-based selection of ever-smokers resulted in the greatest gains in life-expectancy and identified a population of moderately high-risk smokers who would also greatly benefit from screening but would otherwise be missed by risk-based or USPSTF recommendations. However, risk-based selection prevented more lung cancer deaths. For this reason, a life-gained-based screening approach also should consider the number of prevented deaths, the balance of benefits and harms, program efficiency, and costs.
Notes and media contacts: For embargoed PDFs please contact Angela Collom at [email protected] To speak with the lead author, Li C. Cheung, PhD, please contact the NCI press office: [email protected] or 240-760-6600.
2. Empirical antibiotics could mean the difference between life and death in Lyme carditis
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Public health officials are reminding physicians that early recognition and treatment of Lyme carditis could mean the difference between life and death. They report two cases where patients with unrecognized Lyme carditis subsequently died from their illness. Previously, only nine cases of fatal Lyme carditis were reported in the medical literature. Their case reports are published in Annals of Internal Medicine.
Carditis is a rare manifestation of Lyme disease that can usually be treated successfully with a short course of antibiotics. However, it can present with many symptoms, and its severity can change rapidly and unpredictably.
Public health officials report two cases where patients from high Lyme-endemic areas presented with acute, severe symptoms consistent with Lyme carditis. In both cases, testing was ordered, but antibiotics were not initiated while awaiting test results. Before proper treatment could be administered, both patients had died. According to the authors, clinicians should follow consensus guidelines which recommend simultaneous initiation of empirical antibiotic therapy when Lyme disease tests are ordered if Lyme carditis is suspected because severe illness can develop quickly.
3. International experts update international consensus recommendations on nonvariceal gastrointestinal bleeding
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An international multidisciplinary group convened to update 2010 guidelines for the management of patients with nonvariceal upper gastrointestinal bleeding. Their recommendations, the new International Consensus Recommendations on the Management of Patients with Nonvaricial Upper Gastrointestinal Bleeding (UGIB), are published in Annals of Internal Medicine.
The researchers, led by a team at McGill University, derived their recommendations from evidence summarized in previous recommendations, as well as systematic reviews and trials identified from a series of literature searches of several electronic bibliographic databases from inception to April 2018. They used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to identify which studies to include in their analysis, which is the most rigorous system worldwide for developing guidelines.
Similar to previous guidelines, the update focuses on resuscitation and risk assessment; pre-endoscopic, endoscopic, and pharmacologic management; and secondary prophylaxis for recurrent UGIB. Recommendations include:
- For patients with acute UGIB and hemodynamic instability, resuscitation should be initiated.
- Use a Glasgow Blatchford score of 1 or less to identify patients at very low risk for rebleeding who may not require hospitalization.
- Use a hemoglobin threshold of 80 g/L for patients without cardiovascular disease and a higher threshold for those with cardiovascular disease.
- Employ endoscopy within 24 hours of presentation for patients with acute upper GI bleeding.
- Use high-dose proton-pump inhibitor (PPI) therapy for 3 days in patients with bleeding ulcers with high-risk stigmata who had successful endoscopy.
- For these high-risk patients, continued oral PPI therapy is suggested twice daily through 14 days, then once daily for a total duration that depends on the nature of the bleeding lesion.
- Prescribe PPI therapy for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis.
A complete summary of recommendations is included in a guideline table. According to the author of an accompanying editorial from University Clinic Hospital, University of Zaragoza, recommendations for managing patients receiving antiplatelets or anticoagulants and for the appropriate use of new therapeutic endoscopic techniques should be particularly helpful to clinicians.
Also new in this issue:
Cases in Precision Medicine: The Role of Tumor and Germline Genetic Testing in Breast Cancer Management
Jonah Tischler, BA; Katherine D. Crew, MD, MS; and Wendy K. Chung, MD, PhD
Cases in Precision Medicine