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Importance Opioid-related mortality and national prescribing guidelines have led to tapering of doses among patients prescribed long-term opioid therapy for chronic pain. There is limited information about risks related to tapering, including overdose and mental health crisis. Objective To assess whether there are associations between opioid dose tapering and rates of overdose and mental health crisis among patients prescribed stable, long-term, higher-dose opioids. Design, Setting, and Participants Retrospective cohort study using deidentified medical and pharmacy claims and enrollment data from the OptumLabs Data Warehouse from 2008 to 2019. Adults in the US prescribed stable higher doses (mean ≥50 morphine milligram equivalents/d) of opioids for a 12-month baseline period with at least 2 months of follow-up were eligible for inclusion. Exposures Opioid tapering, defined as at least 15% relative reduction in mean daily dose during any of 6 overlapping 60-day windows within a 7-month follow-up period. Maximum monthly dose reduction velocity was computed during the same period. Main Outcomes and Measures Emergency or hospital encounters for (1) drug overdose or withdrawal and (2) mental health crisis (depression, anxiety, suicide attempt) during up to 12 months of follow-up. Discrete time negative binomial regression models estimated adjusted incidence rate ratios (aIRRs) of outcomes as a function of tapering (vs no tapering) and dose reduction velocity. Results The final cohort included 113 618 patients after 203 920 stable baseline periods. Among the patients who underwent dose tapering, 54.3% were women (vs 53.2% among those who did not undergo dose tapering), the mean age was 57.7 years (vs 58.3 years), and 38.8% were commercially insured (vs 41.9%). Posttapering patient periods were associated with an adjusted incidence rate of 9.3 overdose events per 100 person-years compared with 5.5 events per 100 person-years in nontapered periods (adjusted incidence rate difference, 3.8 per 100 person-years [95% CI, 3.0-4.6]; aIRR, 1.68 [95% CI, 1.53-1.85]). Tapering was associated with an adjusted incidence rate of 7.6 mental health crisis events per 100 person-years compared with 3.3 events per 100 person-years among nontapered periods (adjusted incidence rate difference, 4.3 per 100 person-years [95% CI, 3.2-5.3]; aIRR, 2.28 [95% CI, 1.96-2.65]). Increasing maximum monthly dose reduction velocity by 10% was associated with an aIRR of 1.09 for overdose (95% CI, 1.07-1.11) and of 1.18 for mental health crisis (95% CI, 1.14-1.21). Conclusions and Relevance Among patients prescribed stable, long-term, higher-dose opioid therapy, tapering events were significantly associated with increased risk of overdose and mental health crisis. Although these findings raise questions about potential harms of tapering, interpretation is limited by the observational study design.

Importance A 2016 Centers for Disease Control and Prevention prescribing guideline cautioned against higher-dose long-term opioid therapy and recommended tapering daily opioid doses by approximately 10% per week if the risks outweigh the benefits. Warnings have since appeared regarding potential hazards of rapid opioid tapering. Objectives To characterize US trends in opioid dose tapering among patients prescribed long-term opioids from 2008 to 2017 and identify patient-level variables associated with tapering and a more rapid rate of tapering. Design, Setting, and Participants This retrospective cohort study used deidentified medical and pharmacy claims and enrollment records for 99 874 commercial insurance and Medicare Advantage enrollees, representing a diverse mixture of ages, races/ethnicities, and geographical regions across the United States. Adults with stable, higher-dosage (mean, ≥50 morphine milligram equivalents [MMEs]/d) opioid prescriptions for a 12-month baseline period and 2 or more months of follow-up from January 1, 2008, to December 31, 2017, were included in the study. Main Outcomes and Measures Tapering was defined as 15% or more relative reduction in mean daily MME during any of 6 overlapping 60-day windows within a 7-month follow-up period. The rate of tapering was computed as the maximum monthly percentage dose reduction. Results Among the 99 874 participants (53 358 [53.4%] women; mean [SD] age, 57.4 [11.8] years), from 2008 to 2015, the age- and sex-standardized percentage of patients tapering daily opioid doses increased from 12.7% to 16.2% (adjusted incidence rate ratio [aIRR] per year, 1.05 [95% CI, 1.05-1.06]) before increasing to 18.6% in 2016 and 23.1% in 2017 (aIRR in 2016-2017 vs 2008-2015, 1.16 [95% CI, 1.12-1.20]). Patient-level covariates associated with tapering included female sex (aIRR, 1.09 [95% CI, 1.07-1.11]) and higher baseline dose (aIRR for ≥300 MMEs/d vs 50-89 MMEs/d, 2.19 [95% CI, 2.12-2.27]). Among patients tapering daily opioid doses, the mean (SD) maximum dose reduction was 34.0% (27.4%) per month, and 26.5% of patients had a maximum tapering rate exceeding 40% per month (ie, faster than 10% per week). Higher maximum dose reduction rate was associated with age 18 to 34 years (vs older age groups), male sex, a high school education or less (vs more education), small town or rural residence (vs metropolitan, micropolitan, or unknown), a Charlson Comorbidity Index score of 3 or higher (vs 0) (adjusted difference, 1.9% [95% CI, 0.9%-2.9%]), lower baseline doses (50-89 MMEs vs 150-299 or ≥300 MMEs), and a recent drug overdose (adjusted difference, 10.2% [95% CI, 6.8%-13.6%]). Conclusions and Relevance Patients using long-term opioid therapy are increasingly undergoing dose tapering, particularly women and those prescribed higher doses; in addition, dose tapering has become more common since 2016. Many patients undergoing tapering reduce daily doses at a rapid maximum rate.

Purpose Some research has suggested that discussion of prognosis can disrupt the patient-physician relationship. This study assessed whether physician discussion of prognosis is associated with detrimental changes in measures of the strength of the patient-physician relationship. Methods This was a longitudinal cohort study of 265 adult patients with advanced cancer who visited 38 oncologists within community- and hospital-based cancer clinics in Western New York and Northern California. Prognostic discussion was assessed by coding transcribed audio-recorded visits using the Prognostic and Treatment Choices (PTCC) scale and by patient survey at 3 months after the clinic visit. Changes in the strength of the patient-physician relationship were computed as differences in patient responses to The Human Connection and the Perceived Efficacy in Patient-Physician Interactions scales from baseline to 2 to 7 days and 3 months after the clinic visit. Results Prognostic discussion was not associated with a temporal decline in either measure. Indeed, a one-unit increase in PTCC during the audio-recorded visit was associated with improvement in The Human Connection scale at 2 to 7 days after the visit (parameter estimate, 0.10; 95% CI, −0.02 to 0.23) and 3 months after the visit (parameter estimate, 0.18; 95% CI, 0.02 to 0.35) relative to baseline. Standardized effect sizes (SES) associated with an increase of two standard deviations in the PTCC at each time point were consistent with small beneficial effects (SES, 0.14 [95% CI, −0.02 to 0.29] at 2 to 7 days; SES, 0.24 [95% CI, 0.02 to 0.45] at 3 months), and lower bounds of CIs indicated that substantial detrimental effects of prognostic discussion were unlikely. Conclusion Prognostic discussion is not intrinsically harmful to the patient-physician relationship and may even strengthen the therapeutic alliance between patients and oncologists.

Existing guidelines for repeat screening and treatment monitoring intervals regarding the use of dual-energy x-ray absorptiometry (DXA) scans are conflicting or lacking. The Choosing Wisely campaign recommends against repeating DXA scans within 2 years of initial screening. It is unclear how frequently physicians order repeat scans and what clinical factors contribute to their use. To estimate cumulative incidence and predictors of repeat DXA for screening or treatment monitoring in a regional health system. Retrospective longitudinal cohort study A total of 5992 women aged 40–84 years who received initial DXA screening from 2006 to 2011 within a regional health system in Sacramento, CA. Two- and five-year cumulative incidence and hazard rations (HR) of repeat DXA by initial screening result (classified into three groups: low or high risk of progression to osteoporosis, or osteoporosis) and whether women were prescribed osteoporosis drugs after initial DXA. Among women not treated after initial DXA, 2-year cumulative incidence for low-risk, high-risk, and osteoporotic women was 8.0%, 13.8%, and 19.6%, respectively, increasing to 42.9%, 60.4%, and 57.4% by 5 years after initial screening. For treated women, median time to repeat DXA was over 3 years for all groups. Relative to women with low-risk initial DXA, high-risk initial DXA significantly predicted repeat screening for untreated women [adjusted HR 1.67 (95% CI 1.40–2.00)] but not within the treated group [HR 1.09 (95% CI 0.91–1.30)]. Repeat DXA screening was common in women both at low and high risk of progression to osteoporosis, with a substantial proportion of women receiving repeat scans within 2 years of initial screening. Conversely, only 60% of those at high-risk of progression to osteoporosis were re-screened within 5 years. Interventions are needed to help clinicians make higher-value decisions regarding repeat use of DXA scans.

Background: Care teams are increasingly expected to attend to the needs of patient's personal caregivers (e.g., family members). Improving communication among oncologists, patients with advanced cancer, and their personal caregivers might enhance caregivers' experiences of end-of-life (EoL) cancer care and bereavement outcomes. Objective: To explore the effects of the Values and Options in Cancer Care intervention on caregivers' experiences of EoL care and bereavement outcomes. Design: We developed a brief behavioral intervention to improve communication among oncologists, patients with advanced cancer, and their personal caregivers. The intervention was designed to help patients/caregivers ask questions, express concerns, and help oncologists respond effectively. We randomly assigned oncologists (and their patients/caregivers) to the intervention or usual care. Setting/Subjects: Medical oncologists in NY and CA; patients/personal caregivers with advanced cancer. Measurements: Two months after the patient's death, caregivers completed three instruments assessing their experiences of EoL care. Seven months after the patient's death, caregivers completed the Prolonged Grief Disorder-13 (PG-13; primary prespecified outcome), the Purpose-in-Life scale, and scales assessing mental health function, depression, and anxiety. Results: The intervention did not significantly improve caregivers' scores on the PG-13 (p = 0.21), mental health function, depression, or anxiety, but it did improve purpose-in-life scores (p = 0.018). Cohen's d (95% confidence interval) for all three experiences of EoL care outcomes were promising, ranging from 0.22 (−0.19 to 0.63) to 0.39 (−0.07 to 0.86) although none was statistically significant. Conclusion: Preliminary findings show promise that scalable interventions in cancer care settings may improve caregiver experiences with cancer care and some bereavement outcomes.

BACKGROUND In caring for patients with advanced cancer, accurate estimation of survival is important for clinical decision making. The purpose of this study was to assess the accuracy of 2-year survival probabilities estimated by oncologists, patients, and caregivers and to identify demographic and clinical factors associated with prognostic accuracy. METHODS This was a secondary observational analysis of data obtained from a cluster randomized controlled trial. Participants included 38 oncologists, 263 patients with advanced nonhematologic cancer, and 193 of their caregivers from clinics in Sacramento and Western New York. Discrimination within each group (oncologists, patients, caregivers) was evaluated using the C statistic, whereas calibration was assessed by comparing observed to predicted 2-year mortality using the chi-square statistic. RESULTS The median survival from study entry was 18 months, and 41.8% of patients survived for 2 years. C statistics for oncologists, patients, and caregivers were 0.81 (95% CI, 0.76-0.86), 0.62 (95% CI, 0.55-0.68), and 0.72 (95% CI, 0.65-0.78), respectively; oncologists' predictions were better than the predictions of both patients (P = .001) and caregivers (P = .03). Oncologists also had superior calibration: their predictions of 2-year survival were similar to actual survival (P = .17), whereas patients' (P = .0001) and caregivers' (P = .003) predictions diverged significantly from actual survival. Although most oncologists' predictions were classified as realistic (62.0%), approximately one-half of patients' and caregivers' predictions (50.0% and 46.0%, respectively) were unduly optimistic. Among patients, nonwhite race and higher levels of social well-being predicted undue optimism (P

Importance Prostate cancer is the second leading cause of cancer death among US men. Objective To systematically review evidence on prostate-specific antigen (PSA)–based prostate cancer screening, treatments for localized prostate cancer, and prebiopsy risk calculators to inform the US Preventive Services Task Force. Data Sources Searches of PubMed, EMBASE, Web of Science, and Cochrane Registries and Databases from July 1, 2011, through July 15, 2017, with a surveillance search on February 1, 2018. Study Selection English-language reports of randomized clinical trials (RCTs) of screening; cohort studies reporting harms; RCTs and cohort studies of active localized cancer treatments vs conservative approaches (eg, active surveillance, watchful waiting); external validations of prebiopsy risk calculators to identify aggressive cancers. Data Extraction and Synthesis One investigator abstracted data; a second checked accuracy. Two investigators independently rated study quality. Main Outcomes and Measures Prostate cancer and all-cause mortality; false-positive screening results, biopsy complications, overdiagnosis; adverse effects of active treatments. Random-effects meta-analyses were conducted for treatment harms. Results Sixty-three studies in 104 publications were included (N = 1 904 950). Randomization to PSA screening was not associated with reduced risk of prostate cancer mortality in either a US trial with substantial control group contamination (n = 76 683) or a UK trial with low adherence to a single PSA screen (n = 408 825) but was associated with significantly reduced prostate cancer mortality in a European trial (n = 162 243; relative risk [RR], 0.79 [95% CI, 0.69-0.91]; absolute risk reduction, 1.1 deaths per 10 000 person-years [95% CI, 0.5-1.8]). Of 61 604 men screened in the European trial, 17.8% received false-positive results. In 3 cohorts (n = 15 136), complications requiring hospitalization occurred in 0.5% to 1.6% of men undergoing biopsy after abnormal screening findings. Overdiagnosis was estimated to occur in 20.7% to 50.4% of screen-detected cancers. In an RCT of men with screen-detected prostate cancer (n = 1643), neither radical prostatectomy (hazard ratio [HR], 0.63 [95% CI, 0.21-1.93]) nor radiation therapy (HR, 0.51 [95% CI, 0.15-1.69]) were associated with significantly reduced prostate cancer mortality vs active monitoring, although each was associated with significantly lower risk of metastatic disease. Relative to conservative management, radical prostatectomy was associated with increased risk of urinary incontinence (pooled RR, 2.27 [95% CI, 1.82-2.84]; 3 trials; n = 1796) and erectile dysfunction (pooled RR, 1.82 [95% CI, 1.62-2.04]; 2 trials; n = 883). Relative to conservative management (8 cohort studies; n = 3066), radiation therapy was associated with increased risk of erectile dysfunction (pooled RR, 1.31 [95% CI, 1.20-1.42]). Conclusions and Relevance PSA screening may reduce prostate cancer mortality risk but is associated with false-positive results, biopsy complications, and overdiagnosis. Compared with conservative approaches, active treatments for screen-detected prostate cancer have unclear effects on long-term survival but are associated with sexual and urinary difficulties.

Patients and physicians report that communication about chronic pain and opioids is often challenging, but there is little empirical research on whether patient-physician communication about pain affects patient and physician visit experience. This study video recorded 86 primary care visits involving 49 physicians and 86 patients taking long-term opioids for chronic musculoskeletal pain, systematically coded all pain-related utterances during these visits using a custom-designed coding system, and administered previsit and postvisit questionnaires. Multiple regression was used to identify communication behaviors and patient characteristics associated with patients' ratings of their visit experience, physicians' ratings of visit difficulty, or both. After adjusting for covariates, 2 communication variables-patient-physician disagreement and patient requests for opioid dose increases-were each significantly associated with both worse ratings of patient experience and greater physician-reported visit difficulty. Patient desire for increased pain medicine was also significantly positively associated with both worse ratings of patient experience and greater physician-reported visit difficulty. Greater pain severity and more patient questions were each significantly associated with greater physician-reported visit difficulty, but not with patient experience. The association between patient requests for opioids and patient experience ratings was wholly driven by 2 visits involving intense conflict with patients demanding opioids. Patient-physician communication during visits is associated with patient and physician ratings of visit experience. Training programs focused on imparting communication skills that assist physicians in negotiating disagreements about pain management, including responding to patient requests for more opioids, likely have potential to improve visit experience ratings for both patients and physicians.

Objective Assess patient-physician agreement on management goals for chronic musculoskeletal pain and its associations with patient and physician visit experiences. Materials and methods Pre-visit and post-visit questionnaires for 87 primary care visits that involved patients taking opioids for chronic musculoskeletal pain and primary care resident physicians. After each visit, patients and physicians independently ranked 5 pain treatment goals from most to least important. Results In total, 48% of patients ranked reducing pain intensity as their top priority, whereas 22% ranked finding a diagnosis as most important. Physicians ranked improving function as the top priority for 41% of patients, and ranked reducing medication side effects as most important for 26%. The greatest difference between patient and physician rankings was for reducing pain intensity. In regression analyses, neither overall agreement on goals (ie, the physician's first or second priority included the patient's top priority) nor difference in patient versus physician ranking of pain intensity was significantly associated with patient-reported visit experience (β for overall agreement, -0.08; 95% confidence interval [CI], -0.45 to 0.30; P=0.69; β for intensity, -0.06; 95% CI, -0.17 to 0.04; P=0.24) or physician-reported visit difficulty (β for overall agreement, 1.92; 95% CI, -2.70 to 6.55; P=0.41; β for intensity, 0.42; 95% CI, -0.87 to 1.71; P=0.53). Discussion Patients and physicians prioritize substantially different goals for chronic pain management, but there is no evidence that agreement predicts patient experience or physician-reported visit difficulty. Primary care physicians may have adapted to new recommendations that emphasize functional goals and avoidance of long-term opioid therapy, whereas patients continue to focus on reducing pain intensity.

Objective To develop and validate Medicare claims-based approaches for identifying abnormal screening mammography interpretation. Data Sources Mammography data and linked Medicare claims for 387,709 mammograms performed from 1999 to 2005 within the Breast Cancer Surveillance Consortium (BCSC). Study Design Split-sample validation of algorithms based on claims for breast imaging or biopsy following screening mammography. Data Extraction Methods Medicare claims and BCSC mammography data were pooled at a central Statistical Coordinating Center. Principal Findings Presence of claims for subsequent imaging or biopsy had sensitivity of 74.9 percent (95 percent confidence interval [CI], 74.1–75.6) and specificity of 99.4 percent (95 percent CI, 99.4–99.5). A classification and regression tree improved sensitivity to 82.5 percent (95 percent CI, 81.9–83.2) but decreased specificity (96.6 percent, 95 percent CI, 96.6–96.8). Conclusions Medicare claims may be a feasible data source for research or quality improvement efforts addressing high rates of abnormal screening mammography.

BackgroundScreening mammography has lower sensitivity and specificity in women with dense breasts, who experience higher breast cancer risk.PurposeTo perform a systematic review of reproducibility of Breast Imaging Reporting and Data System (BI-RADS) density categorization and test performance and clinical outcomes of supplemental screening with breast ultrasonography, magnetic resonance imaging (MRI), and digital breast tomosynthesis (DBT) in women with dense breasts and negative mammography results.Data sourcesMEDLINE, PubMed, EMBASE, and Cochrane database from January 2000 to July 2015.Study selectionStudies reporting BI-RADS density reproducibility or supplemental screening results for women with dense breasts.Data extractionQuality assessment and abstraction of 24 studies from 7 countries; 6 studies were good-quality.Data synthesisThree good-quality studies reported reproducibility of BI-RADS density; 13% to 19% of women were recategorized between "dense" and "nondense" at subsequent screening. Two good-quality studies reported that sensitivity of ultrasonography for women with negative mammography results ranged from 80% to 83%; specificity, from 86% to 94%; and positive predictive value (PPV), from 3% to 8%. The sensitivity of MRI ranged from 75% to 100%; specificity, from 78% to 94%; and PPV, from 3% to 33% (3 studies). Rates of additional cancer detection with ultrasonography were 4.4 per 1000 examinations (89% to 93% invasive); recall rates were 14%. Use of MRI detected 3.5 to 28.6 additional cancer cases per 1000 examinations (34% to 86% invasive); recall rates were 12% to 24%. Rates of cancer detection with DBT increased by 1.4 to 2.5 per 1000 examinations compared with mammography alone (3 studies). Recall rates ranged from 7% to 11%, compared with 7% to 17% with mammography alone. No studies examined breast cancer outcomes.LimitationsGood-quality evidence was sparse. Studies were small and CIs were wide. Definitions of recall were absent or inconsistent.ConclusionDensity ratings may be recategorized on serial screening mammography. Supplemental screening of women with dense breasts finds additional breast cancer but increases false-positive results. Use of DBT may reduce recall rates. Effects of supplemental screening on breast cancer outcomes remain unclear.Primary funding sourceAgency for Healthcare Research and Quality.

Background The breast cancer detection rate is a benchmark measure of screening mammography quality, but its computation requires linkage of mammography interpretive performance information with cancer incidence data. A Medicare claims-based measure of detected breast cancers could simplify measurement of this benchmark and facilitate mammography quality assessment and research. Objectives To validate a claims-based algorithm that can identify with high positive predictive value (PPV) incident breast cancers that were detected at screening mammography. Research design Development of a claims-derived algorithm using classification and regression tree analyses within a random half-sample of Medicare screening mammography claims followed by validation of the algorithm in the remaining half-sample using clinical data on mammography results and cancer incidence from the Breast Cancer Surveillance Consortium (BCSC). Subjects Female fee-for-service Medicare enrollees aged 68 years and older who underwent screening mammography from 2001 to 2005 within BCSC registries in 4 states (CA, NC, NH, and VT), enabling linkage of claims and BCSC mammography data (N=233,044 mammograms obtained by 104,997 women). Measures Sensitivity, specificity, and PPV of algorithmic identification of incident breast cancers that were detected by radiologists relative to a reference standard based on BCSC mammography and cancer incidence data. Results An algorithm based on subsequent codes for breast cancer diagnoses and treatments and follow-up mammography identified incident screen-detected breast cancers with 92.9% sensitivity [95% confidence interval (CI), 91.0%-94.8%], 99.9% specificity (95% CI, 99.9%-99.9%), and a PPV of 88.0% (95% CI, 85.7%-90.4%). Conclusions A simple claims-based algorithm can accurately identify incident breast cancers detected at screening mammography among Medicare enrollees. The algorithm may enable mammography quality assessment using Medicare claims alone.

Purpose: To determine how often primary care physicians address patient-level health behavioral constructs that are associated with colorectal cancer (CRC) screening and whether physician counseling addressing constructs is associated with favorable changes in patients’ attitudes, beliefs, intentions, and subsequent screening. Methods: We conducted a prospective cohort study of patients eligible for CRC screening and attending routine appointments within two academic primary care clinics (50 patients, 20 primary care clinicians). Patients completed validated measures of behavioral constructs associated with CRC screening (benefits, barriers, susceptibility, self-efficacy, intention, and stage of readiness) before and after their visits. Audio-recorded discussions of CRC screening were coded for conversation addressing constructs. Bivariate and regression analyses estimated associations between discussions that did and did not address constructs and, after the visit, measures of perceived benefits, barriers, susceptibility, self-efficacy, intention, and completion of CRC screening within 6 months. Results: Physicians discussed CRC screening during 38 encounters (76%) and addressed behavioral constructs during 26 (52%). Relative to visits without CRC screening discussion, visits with discussion were associated with increased perceived susceptibility ( 0.39; 95% CI, 0.09 – 0.68) and screening intention ( 0.42; 95% CI, 0.11– 0.73) after the visit but no significant change in perceived benefits, barriers, or self-efficacy. Within 6 months, 17 of 38 patients (45%) who discussed screening completed screening compared with 0 of 12 patients who did not discuss screening (P .001). Associations between discussions and outcomes were similar whether or not counseling addressed behavioral constructs. Conclusions: These findings suggest that physician counseling is associated with increased patient perception of CRC susceptibility, greater screening intention, and completion of screening regardless of whether counseling addresses behavioral constructs. (J Am Board Fam Med 2011;24:673– 681.)

Computer-aided detection (CAD) is applied during screening mammography for millions of US women annually, although it is uncertain whether CAD improves breast cancer detection when used by community radiologists.We investigated the association between CAD use during film-screen screening mammography and specificity, sensitivity, positive predictive value, cancer detection rates, and prognostic characteristics of breast cancers (stage, size, and node involvement). Records from 684 956 women who received more than 1.6 million film-screen mammograms at Breast Cancer Surveillance Consortium facilities in seven states in the United States from 1998 to 2006 were analyzed. We used random-effects logistic regression to estimate associations between CAD and specificity (true-negative examinations among women without breast cancer), sensitivity (true-positive examinations among women with breast cancer diagnosed within 1 year of mammography), and positive predictive value (breast cancer diagnosed after positive mammograms) while adjusting for mammography registry, patient age, time since previous mammography, breast density, use of hormone replacement therapy, and year of examination (1998-2002 vs 2003-2006). All statistical tests were two-sided.Of 90 total facilities, 25 (27.8%) adopted CAD and used it for an average of 27.5 study months. In adjusted analyses, CAD use was associated with statistically significantly lower specificity (OR = 0.87, 95% confidence interval [CI] = 0.85 to 0.89, P.001) and positive predictive value (OR = 0.89, 95% CI = 0.80 to 0.99, P = .03). A non-statistically significant increase in overall sensitivity with CAD (OR = 1.06, 95% CI = 0.84 to 1.33, P = .62) was attributed to increased sensitivity for ductal carcinoma in situ (OR = 1.55, 95% CI = 0.83 to 2.91; P = .17), although sensitivity for invasive cancer was similar with or without CAD (OR = 0.96, 95% CI = 0.75 to 1.24; P = .77). CAD was not associated with higher breast cancer detection rates or more favorable stage, size, or lymph node status of invasive breast cancer.CAD use during film-screen screening mammography in the United States is associated with decreased specificity but not with improvement in the detection rate or prognostic characteristics of invasive breast cancer.

PURPOSE Although screening with fecal occult blood testing (FOBT) reduces colorectal cancer (CRC) mortality, its effectiveness may diminish if patients do not adhere with repeated screenings. Among patients who had previously engaged in FOBT screening, we assessed subsequent adherence with FOBT screening. METHODS We assessed longitudinal adherence with biennial FOBT screening (every other year) within a cohort of patients enrolled in an integrated Washington State health plan. Among 11,110 patients who participated in FOBT screening during a 2-year baseline period (2000–2001), we ascertained CRC screening use during a subsequent 2-year observation period (2002–2003). We used multinomial logistic regression to identify patient characteristics associated with higher incidence of repeat CRC screening (with or without FOBT) relative to patients who received no CRC screening. RESULTS Despite prior participation in FOBT screening, less than one-half of patients (44.4%; 95% CI, 42.9%–45.8%) completed FOBT screening during the 2-year observation period. Although 8.8% of patients (95% CI, 8.0%–9.7%) received other CRC tests without FOBT during the observation period, nearly one-half, 46.8% (95% CI, 45.3%–48.4%), received no CRC screening. After adjustment for other patient characteristics, receipt of a preventive health examination was strongly associated with FOBT adherence relative to no CRC screening (adjusted relative rate ratio = 11.16; 95% CI, 9.61–12.96). CONCLUSIONS Longitudinal adherence with FOBT screening was low in this insured population, potentially compromising its effectiveness in population CRC mortality reduction. Interventions to promote adherence may be necessary to achieve high effectiveness in population-based FOBT screening programs.

Objective: Colorectal cancer (CRC) screening is commonly initiated during primary care visits. Thus, at the population level, limited primary care attendance may constitute a substantial barrier to CRC screening uptake. Within a defined population, we quantified the percent of CRC screening underuse that is potentially explained by low use of primary care visits. Methods: Among 48,712 adults ages 50 to 78 years eligible for CRC screening within a Washington state health plan, we estimated the degree to which a lack of CRC screening in 2002 to 2003 (fecal occult blood testing, sigmoidoscopy, or colonoscopy) was attributable to low primary care use, expressed as the population attributable risk percent (PAR%) associated with 0 to 3 primary care visits during the 2-year period. Results: In analyses adjusted for age, comorbidity, nonprimary care visit use, and prior preventive service use, low primary care use in 2002 to 2003 was strongly associated with a lack of CRC screening among both women and men. However, a majority of unscreened women and men had ≥4 primary care visits. Thus, whether low primary care use was defined as 0, 0 to 1, 0 to 2, or 0 to 3 primary care visits, the PAR% associated with low primary care use was large in neither women (range, 3.0-6.8%) nor men (range: 5.6-11.5%). Conclusions: Health plan outreach efforts to encourage primary care attendance would be unlikely to substantially increase population uptake of CRC screening. In similar settings, resources might be more fruitfully devoted to the optimization of screening delivery during primary care visits that patients already attend. (Cancer Epidemiol Biomarkers Prev 2009;18(2):640–5)

Background In 1998, Medicare initiated universal coverage for colorectal cancer (CRC) screening via fecal occult blood testing (FOBT) and sigmoidoscopy. In mid-2001, universal coverage was advanced to screening colonoscopy. This study sought to determine whether trends in CRC testing differed among racial/ethnic, age, or gender subgroups of the Medicare population. Methods In 2006, claims from 1995 to 2003 were analyzed for annual 5% random samples of fee-for-service Medicare enrollees living in Surveillance, Epidemiology, and End Results (SEER) regions to calculate the annual, age-standardized percentages of subjects who received FOBT, sigmoidoscopy, or colonoscopy. Logistic regression then modeled trends in annual test use within racial/ethnic, age, and gender subgroups across three Medicare coverage periods (precoverage [1995–1997]; limited coverage [1998–mid-2001]; and full coverage [mid-2001–2003]). Results The annual use of FOBT and sigmoidoscopy declined from 1995 to 2003 in all racial/ethnic groups, but the relative decline in sigmoidoscopy use was greater among whites compared to nonwhites. In contrast, colonoscopy use increased substantially in all racial/ethnic groups. However, relative to the precoverage period among whites, the full-coverage period was associated with significantly greater colonoscopy use among whites (OR=2.14; 95% CI=2.09, 2.19) than blacks (OR=1.86; 95% CI=1.75, 1.96); Asian/Pacific Islanders (OR=1.73; 95% CI=1.62, 1.86); or Hispanics (OR=1.65; 95% CI=1.49, 1.81). The use of colonoscopy during the full-coverage period was also differentially greater among enrollees aged Conclusions Colonoscopy is supplanting sigmoidoscopy as a CRC test among Medicare enrollees, while FOBT use is in decline. The transition from sigmoidoscopy to colonoscopy has occurred more quickly among white than nonwhite Medicare enrollees.

BACKGROUND Computer-aided detection identifies suspicious findings on mammograms to assist radiologists. Since the Food and Drug Administration approved the technology in 1998, it has been disseminated into practice, but its effect on the accuracy of interpretation is unclear. METHODS We determined the association between the use of computer-aided detection at mammography facilities and the performance of screening mammography from 1998 through 2002 at 43 facilities in three states. We had complete data for 222,135 women (a total of 429,345 mammograms), including 2351 women who received a diagnosis of breast cancer within 1 year after screening. We calculated the specificity, sensitivity, and positive predictive value of screening mammography with and without computer-aided detection, as well as the rates of biopsy and breast-cancer detection and the overall accuracy, measured as the area under the receiver-operating-characteristic (ROC) curve. RESULTS Seven facilities (16%) implemented computer-aided detection during the study period. Diagnostic specificity decreased from 90.2% before implementation to 87.2% after implementation (P

Study Design. Systematic review. Objective. To quantify variability in undesirable outcomes among studies of lumbar interbody fusion using stand-alone cage devices, and to determine whether author conflicts of interest contribute to variability. of Background Data. Promising early studies of lumbar fusion with stand-alone cage devices led to rapid uptake of the technique, but some surgeons later expressed reservations regarding efficacy and safety. Methods. We systematically identified studies of lumbar interbody fusion with stand-alone cage devices that reported at least one undesirable outcome among 10 or more adult subjects. We performed meta-analyses of rates of 7 prespecified outcomes (nonunion, reoperation, major vessel injury, retrograde ejaculation, neurologic injury, dural injury, and infection). Heterogeneity in outcome rates was quantified as I 2 (the proportion of variance due to differences among studies rather than random variation). Random-effects meta-regression identified sources of observed heterogeneity, including potential conflicts of interest. Results. We identified 30 eligible studies, including a total of 3228 subjects. A potential conflict of interest was identified in 18 (60%). We observed marked heterogeneity in rates of nonunion, reoperation, and neurologic injury (I 2 > 85%; P < 0.001), and substantial heterogeneity in rates of dural injury (I 2 = 63%; P< 0.01) and major vessel injury (I 2 a= 38%; P = 0.09). Among 24 studies reporting fusion status after 6 months of follow-up, nonunion rates ranged from 2.3% to 83.3% (median, 8.3%) and exceeded 45% in 4 studies. Potential author conflict of interest was associated with significantly lower rates of nonunion (P = 0.001). Heterogeneity in rates of other undesirable outcomes was not significantly associated with author conflicts of interest or other study characteristics. Conclusion. We quantified substantial unexplained variation in reported complication rates of undesirable outcomes of lumbar interbody fusion with stand-alone cage devices. Authors with potential conflicts of interest, however, reported significantly lower rates of nonunion.

Background"Difficult visits" are common in primary care and may contribute to primary care provider (PCP) career dissatisfaction and burnout. Patient requests occur in approximately half of primary care visits and may be a source of clinician-patient miscommunication or conflict, contributing to perceived visit difficulty.ObjectiveWe aimed to determine associations between types of patient requests and PCP-perceived visit difficulty.DesignThis was an observational study, nested in a multicenter randomized trial of depression engagement interventions.SubjectsWe included 824 patient visits within 135 PCP practices in Northern California occurring from June 2010 to March 2012.Main measuresPCP-perceived visit difficulty was quantified using a three-item scale (relative visit difficulty, amount of effort required, and amount of time required; Cronbach's α = 0.81). Using linear regression, the difficulty scale (score range 0-2 from least to most difficult) was modeled as a function of: patient requests for diagnostics tests, pain medications, and specialist referrals; PCP perception of likely depression or likely substance abuse; patient sociodemographics, comorbidity, depression; PCP characteristics and practice setting.ResultsPatients requested diagnostic tests, pain medications, and specialist referrals in 37.2, 20.0 and 30.0% of visits, respectively. After adjustment for patient medical and psychiatric complexity, perceived difficulty was significantly higher when patients requested diagnostic tests [parameter estimate (PE) 0.11, (95% CI: 0.03, 0.20)] but not when patients requested pain medications [PE -0.04 (95% CI: -0.15, 0.08)] or referrals [PE 0.04 (95% CI: -0.07, 0.25)].ConclusionsPCP-perceived visit difficulty is associated with patient requests for diagnostic tests, but not requests for pain medications or specialist referrals. In this era of "choosing wisely," PCPs may be challenged to respond to diagnostic test requests in an evidence-based manner, while maintaining the provider-patient relationship and PCP career satisfaction.

The United States Preventive Services Task Force (USPSTF) recommends screening for osteoporosis with dual-energy x-ray absorptiometry (DXA) for women aged ≥ 65 years and younger women with increased risk. "Choosing Wisely" initiatives advise avoiding DXA screening in women younger than 65 years without osteoporosis risk factors.We aimed to determine the extent to which DXA screening is used in accordance with USPSTF recommendations within a regional health system.This was a retrospective longitudinal cohort study within 13 primary care clinics in the Sacramento, CA region.The study included 50,995 women aged 40-85 years without prior osteoporosis screening, diagnosis, or treatment attending primary care visits from 2006 to 2012, observed for a mean of 4.4 years.We examined incidence of DXA screening. Covariates included age, race/ethnicity, and osteoporosis risk factors (body mass index 20, glucocorticoid use, secondary osteoporosis, prior high-risk facture, rheumatoid arthritis, alcohol abuse, and current smoking).Among previously unscreened women for whom the USPSTF recommends screening, 7-year cumulative incidence of DXA screening was 58.8 % among women aged 60-64 years with ≥ 1 risk factor (95 % CI: 51.9-65.8 %), 57.8 % for women aged 65-74 years (95 % CI: 55.6-60.0 %), and 42.7 % for women aged ≥ 75 years (95 % CI: 38.7-46.7 %). Among women for whom the USPSTF does not recommend screening, 7-year cumulative incidence was 45.5 % among women aged 50-59 years (95 % CI 44.1-46.9 %) and 58.6 % among women aged 60-64 years without risk factors (95 % CI 55.9-61.4 %).DXA screening was underused in women at increased fracture risk, including women aged ≥ 65 years. Meanwhile, DXA screening was common among women at low fracture risk, such as younger women without osteoporosis risk factors. Interventions may be needed to augment the value of population screening for osteoporosis.

PURPOSE We sought to determine the association between timely receipt of diabetes-related preventive services and the longitudinal pattern of outpatient service use as characterized by a novel taxonomy that prioritized visits based on the Oregon State Prioritized Health Services List. METHODS We performed a cross-sectional analysis of mail survey and automated health care data for a population-based sample of patients with diabetes enrolled in a health maintenance organization in Washington State (N = 4,463). Outcomes included American Diabetes Association–recommended preventive services, including regular hemoglobin A1C (HbA1C) monitoring, retinal examination, and microalbuminuria screening. Patients with fewer than 8 visits during the 2-year study period were considered infrequent users, while patients with 8 or more visits were classified as lower-priority users if most visits were for conditions of relatively low rank on the Oregon list and as higher-priority users otherwise. RESULTS After adjustment for social, demographic, and clinical factors, and depression, infrequent users had significantly reduced odds of receiving at least 1 HbA1C test (odds ratio [OR] = 0.35, 95% confidence interval [CI], 0.24–0.51), retinal examination (OR = 0.74, 95% CI, 0.63–0.86), and microalbuminuria screening (OR = 0.75, 95% CI, 0.58–0.96) relative to higher-priority users during the previous year. Lower-priority users also had relatively reduced odds of receiving at least 1 HbA1C test (OR = 0.59, 95% CI, 0.35–1.01), retinal examination (OR = 0.68, 95% CI, 0.56–0.84), and microalbuminuria screening (OR = 0.79, 95% CI, 0.57–1.09) despite attending a similar mean number of total visits as higher-priority users. CONCLUSIONS Patients who attend relatively few outpatient visits or who attend more frequent visits for predominantly lower-priority conditions are more likely to receive substandard preventive care for diabetes.

Since 2001, Medicare has reimbursed computer-aided detection (CAD) during screening mammography. The CAD software tool is used by radiologists to identify lesions suggestive of malignant disease. Research suggests that CAD use increases the rate of false-positive findings of screening mammography and the detection of ductal carcinoma in situ (DCIS).1 Increased DCIS detection could lead to overdiagnosis of breast cancer, particularly among older women at risk for competing causes of death. We estimated the fraction of diagnostic tests, DCIS treatments, and costs attributable to CAD dissemination within the Medicare population, among whom the risk for overdiagnosis may be elevated.

Background: Although most American women regularly receive screening clinical breast examination (CBE), little is known about CBE accuracy in community practice. We sought to estimate the rate of cancer detection (sensitivity) of screening CBE performed by community-based clinicians on women who ultimately died of breast cancer, as well as to identify factors associated with accurate detection. Subjects and Methods: We evaluated CBE accuracy among asymptomatic female health plan enrollees in fi ve states (WA, OR, CA, MA, and MN) who received a CBE within 1 year of breast cancer diagnosis and who died of breast cancer within 15 years of diagnosis (N = 485). Sensitivity was estimated as the proportion whose exam was abnormal. Bivariate and logistic regression analyses identifi ed patient characteristics associated with cancer detection. Results: An abnormality was noted on screening CBE in one of fi ve women who ultimately succumbed to breast cancer (sensitivity = 21.6%; 95% confi dence interval [CI] = 18.1% to 25.6%). The odds of a true-positive screening CBE (sensitivity) were decreased among women using estrogen (odds ratio [OR] = 0.23; 95% CI = 0.07 to 0.80), receiving a Pap smear during the same visit as CBE (OR = 0.45; 95% CI = 0.27 to 0.72), and with increasing chronic disease comorbidity ( P trend = .08). Conclusion: Screening CBE as performed in the community may be insuffi ciently sensitive to detect most lethal breast cancers. Low sensitivity of screening CBE in community practice may be partly attributable to its performance alongside time- consuming clinical tasks such as Pap smear screening or chronic illness care. [J Natl Cancer Inst Monogr 2005;35:67 – 71]

While reviewing abstracts in my role as an Evidence Based Medicine editor, I recently encountered a seemingly strange randomised trial of sitagliptin, one of the new dipeptidyl peptidase-4 (DPP-4) inhibitor antidiabetic drugs. Appearing in the New England Journal of Medicine , the trial evaluated the impact of sitagliptin on cardiovascular outcomes in patients with non-ideally controlled type 2 diabetes with established cardiovascular disease, concluding that sitagliptin was both non-inferior and non-superior to placebo in this high-risk group.1 As a primary care physician, my hope for diabetic patients of mine is that a new medication, such as sitagliptin, would be superior to placebo in reducing their high cardiovascular risk. However, in this high-risk population with prevalent cardiovascular disease, sitagliptin seemed to have no impact on cardiovascular outcomes over the median 3-year follow-up of the trial, so the clinical implications of the findings for my patients seemed dubious. I wondered why a trial demonstrating the non-inferiority of sitagliptin to placebo merited appearance in the world's highest impact general medical journal. Of course, a trial such as this—the Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS)—has a broader audience than front-line physicians. Indeed, on closer inspection, one suspects that …

More so than most other diseases, effective control of type 2 diabetes (DM) requires that patients are actively engaged in the self-management of their health. In this paper we define and characterize the elements of self-management and review the published literature for the evidence of the benefit of interventions that support patient self-management.

TPS1594Background: Currently in the United States, the majority of women are recommended to undergo annual mammographic screening for breast cancer starting at age 40, regardless of personal risk. ...

textabstractBackground: Estimates of risk for radiation-induced breast cancer from mammography screening have not considered variation in dose exposure or diagnostic work-up after abnormal screening results. Objective: To estimate distributions of radiation-induced breast cancer incidence and mortality from digital mammography screening while considering exposure from screening and diagnostic mammography and dose variation among women. Design: 2 simulation-modeling approaches. Setting: U.S. population. Patients: Women aged 40 to 74 years. Intervention: Annual or biennial digital mammography screening from age 40, 45, or 50 years until age 74 years. Measurements: Lifetime breast cancer deaths averted (bene-fits) and radiation-induced breast cancer incidence and mortality (harms) per 100 000 women screened. Results: Annual screening of 100 000 women aged 40 to 74 years was projected to induce 125 breast cancer cases (95% CI, 88 to 178) leading to 16 deaths (CI, 11 to 23), relative to 968 breast cancer deaths averted by early detection from screening. Women exposed at the 95th percentile were projected to develop 246 cases of radiation-induced breast cancer leading to 32 deaths per 100 000 women. Women with large breasts requiring extra views for complete examination (8% of population) were projected to have greater radiation-induced breast cancer risk (266 cancer cases and 35 deaths per 100 000 women) than other women (113 cancer cases and 15 deaths per 100 000 women). Biennial screening starting at age 50 years reduced risk for radiation-induced cancer 5-fold. Limitation: Life-years lost from radiation-induced breast cancer could not be estimated. Conclusion: Radiation-induced breast cancer incidence and mortality from digital mammography screening are affected by dose variability from screening, resultant diagnostic work-up, initiation age, and screening frequency. Women with large breasts may have a greater risk for radiation-induced breast cancer. Primary Funding Source: Agency for Healthcare Research and Quality, U.S. Preventive Services Task Force, National Cancer Institute.

BACKGROUND: The Medicare population has documented racial/ethnic disparities in colorectal cancer (CRC) screening, but it is unknown whether these disparities differ across geographic regions. METHODS: Among Medicare enrollees within 8 US states, we ascertained up-to-date CRC screening on December 31, 2003 (fecal occult blood testing in the prior year or sigmoidoscopy or colonoscopy in the prior 5 years). Logistic regression models tested for regional variation in up-to-date status among white versus different nonwhite populations (blacks, Asian/Pacific Islanders [APIs], Hispanics). We estimated regression-adjusted region-specific prevalence of up-to-date status by race/ethnicity and compared adjusted white versus nonwhite up-to-date prevalence across regions by using generalized least squares regression. RESULTS: White versus nonwhite up-to-date status varied significantly across regions for blacks (P = .01) and APIs (P < .001) but not Hispanics (P = .62). Whereas the white versus black differences in proportion up-to-date were greatest in Atlanta (Georgia), rural Georgia, and the San Francisco Bay Area of California (range, 10%-16% differences, blacks

Background: Billing data, such as Medicare claims, are a potential data source for evaluative studies of new digital mammography technologies, such as digital mammography and computer-aided detection (CAD). Objective: To assess the internal validity of procedure codes on Medicare claims for screening mammography interpreted with either digital mammography or CAD. Study Design: We assessed agreement of procedure coding for digital versus film mammography and CAD use versus nonuse for mammograms with claims appearing in two independent Medicare claims files (the Carrier Claims and Outpatient files). Subjects and Setting: Women enrolled in fee-for-service Medicare who received screening mammography in 2001 to 2003 within Surveillance, Epidemiology, and End Results regions, representing 25% of the U.S. population (n = 35,642 women who received 57,632 total mammograms). Measures: Coding agreement beyond chance (κ), overall, and by year. Results: Overall coding agreement was excellent for both digital versus film mammography [κ = 0.81 (95% confidence interval, 0.80-0.83)] and for CAD use versus nonuse [κ = 0.82 (95% confidence interval, 0.81-0.83)]. However, in 2001, agreement was only moderate (κ = 0.51 for digital versus film and κ = 0.50 for CAD use versus nonuse) but increased to higher levels in 2002 and 2003 (κ > 0.80 for both technologies). Conclusions: High internal agreement in procedure codes for digital mammography technologies is consistent with accurate coding on Medicare claims after 2001, although external validation remains desirable. (Cancer Epidemiol Biomarkers Prev 2009;18(8):2186–9)

Background Although interpretive performance varies substantially among radiologists, such variation has not been examined among mammography facilities. Understanding sources of facility variation could become a foundation for improving interpretive performance. Methods In this cross-sectional study conducted between 1996 and 2002, we surveyed 53 facilities to evaluate associations between facility structure, interpretive process characteristics, and interpretive performance of screening mammography (ie, sensitivity, specificity, positive predictive value [PPV1], and the likelihood of cancer among women who were referred for biopsy [PPV2]). Measures of interpretive performance were ascertained prospectively from mammography interpretations and cancer data collected by the Breast Cancer Surveillance Consortium. Logistic regression and receiver operating characteristic (ROC) curve analyses estimated the association between facility characteristics and mammography interpretive performance or accuracy (area under the ROC curve [AUC]). All P values were two-sided. Results Of the 53 eligible facilities, data on 44 could be analyzed. These 44 facilities accounted for 484 463 screening mammograms performed on 237 669 women, of whom 2686 were diagnosed with breast cancer during follow-up. Among the 44 facilities, mean sensitivity was 79.6% (95% confidence interval [CI] = 74.3% to 84.9%), mean specificity was 90.2% (95% CI = 88.3% to 92.0%), mean PPV1 was 4.1% (95% CI = 3.5% to 4.7%), and mean PPV2 was 38.8% (95% CI = 32.6% to 45.0%). The facilities varied statistically significantly in specificity (P < .001), PPV1 (P < .001), and PPV2 (P = .002) but not in sensitivity (P = .99). AUC was higher among facilities that offered screening mammograms alone vs those that offered screening and diagnostic mammograms (0.943 vs 0.911, P = .006), had a breast imaging specialist interpreting mammograms vs not (0.932 vs 0.905, P = .004), did not perform double reading vs independent double reading vs consensus double reading (0.925 vs 0.915 vs 0.887, P = .034), or conducted audit reviews two or more times per year vs annually vs at an unknown frequency (0.929 vs 0.904 vs 0.900, P = .018). Conclusion Mammography interpretive performance varies statistically significantly by facility.

Background: Increased health care use by pain patients is largely due to conditions other than their identified pain condition, but the kinds of services accounting for increased service use are poorly understood. This study assesses reasons for health care visits of pain patients versus controls, and compares characteristics of pain patients who differ in frequency and priority of service use. Methods: The study samples included consecutive, primary care back pain (N = 807), headache (N = 831), and temporomandibular disorder pain (N = 372) patients who were interviewed by telephone. Subsequently, age-sex matched controls with a primary care visit in the 6 months before the matched case's pain visit were identified. Over the following 3 years, diagnostic codes for health care visits were classified based on the Oregon Prioritized List of Health Services and case-control differences in major classes of care were compared. Pain patients differing in frequency and priority of service use were compared on measures of pain severity, chronicity, and psychosocial dysfunction. Results: Pain patients' increased health care use was sustained over 3 years. Increased utilization was largely due to symptomatic and ill-defined conditions, lower priority chronic disease, lower and higher priority acute disease, and mental health care. About one-half of the pain patients (vs. one-third of the controls) were frequent health care users. About one-third of the pain patients (vs. one-sixth of the controls) were frequent users who predominately used medical care for lower priority conditions, and this difference accounted for most of the case-control difference in the prevalence of high users. Pain patients with frequent health care use had more severe pain and greater psychosocial dysfunction than pain patients with less frequent health care use. Among frequent users, pain patients who predominately used services for lower priority conditions did not differ on measures of pain severity, chronicity, or somatization when compared with frequent users who typically used services for higher priority conditions. Conclusions: The kind of problems explaining heightened service use of pain patients is more varied and complex than previously understood. These results call for increased attention to the implications of health care providers responding to presenting complaints as if each were a unique problem, without bringing continuity or an integrating perspective to patients' overall experience and management of illness.

Are we overdiagnosing breast cancer? Cancer screening is intuitively appealing. Common sense would dictate that early detection is good. If you had a silent, potential-life-threatening cancer, wouldn't you want to know as early as possible, when treatment might have the greatest chance of cure? Many would say, “Of course!” Some are even willing to pay a lot of money to have whole-body cancer screening with computed tomography—all for the sake of early detection.1 Enthusiasm for cancer screening, however, may be based on misperceptions about the natural history of cancer and the benefits of early detection (see box). Indeed, some cancers may grow so slowly that they are unlikely to be diagnosed during one's lifetime, and others may regress. Detection of such cancers by screening, overdiagnosis , can lead to unnecessary, invasive treatment. Overdiagnosis is thought to occur frequently in prostate cancer and neuroblastoma screening.2,3 While concerns have been raised about overdiagnosis of ductal carcinoma in situ (DCIS) with screening mammography,4 little is known about the extent of …

BACKGROUND Despite uncertain benefits and harms, screening computed tomography (CT) is being marketed to consumers in the U.S. One plausible harm is the detection and treatment of renal carcinoma cases that otherwise would have remained clinically silent during the patient's lifetime. METHODS After estimating the prevalence of preclinical renal carcinoma using meta-analysis of five series of asymptomatic, middle-aged Americans who received CT screening, the authors divided the prevalence by U.S. incidence rates of clinical renal carcinoma among persons of similar age. This calculation would estimate the mean duration of the detectable preclinical period (the “sojourn time”) of renal carcinoma if the incidence of preclinical and clinical renal carcinoma were equivalent. RESULTS The 5 series included 16,174 screenees (mean age range, 58–64 years; 61% male). The prevalence of asymptomatic renal carcinoma ranged from 0.11% to 0.76%; the pooled prevalence was 0.21% (95% confidence interval, 0.14–0.28%). The estimated mean sojourn time for renal carcinoma was between 3.7 years and 5.8 years among middle-aged Americans. CONCLUSIONS Because most renal carcinomas grow slowly during the preclinical period, the authors' estimated mean sojourn time did not seem unduly long. Therefore, the incidence rate of clinical renal carcinoma most likely is a reasonable surrogate for the incidence rate of preclinical renal carcinoma, implying that most renal carcinomas detected by CT screening among middle-aged Americans are likely to progress to clinical diagnosis. Cancer 2004;100:986–90. © 2004 American Cancer Society.

Commentary on: Oken MM, Hocking WG, Kvale PA, et al. Screening by chest radiograph and lung cancer mortality: the Prostate, Lung, Colorectal, and Ovarian (PLCO) randomized trial. JAMA 2011;306:1865–73.[OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] In the 1970s and 1980s, randomised controlled trials of lung cancer screening with chest radiography and sputum cytology found no lung cancer mortality reduction among high-risk patients.1 Evidence-based guidelines have since recommended against lung cancer screening, although many physicians still endorse screening for high-risk patients, such as chronic smokers.2 The Mayo Lung Study, for example, compared screening with chest radiography and sputum cytology every 4 months to no screening among male, chronically heavy smokers over a 6-year period. Although screening was associated with higher incidence of lung cancer, no benefits in lung cancer mortality were observed, and the extra incidence was most likely attributable to overdiagnosis. Early trials, however, may have … [1]: {openurl}?query=rft.jtitle%253DJAMA%26rft_id%253Dinfo%253Adoi%252F10.1001%252Fjama.2011.1591%26rft_id%253Dinfo%253Apmid%252F22031728%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1001/jama.2011.1591&link_type=DOI [3]: /lookup/external-ref?access_num=22031728&link_type=MED&atom=%2Febmed%2F17%2F5%2F149.atom [4]: /lookup/external-ref?access_num=000296376200020&link_type=ISI

Commentary on: SK Smith, L Trevena, JM Simpson, et al.. A decision aid to support informed choices about bowel cancer screening among adults with low education: randomised controlled trial.BMJ2010;341:c5370.

In the past decade, 2 technologies have transformed screening methods in the United States. First, digital mammography has supplanted film-screen mammography as the predominant method of image acquisition and storage. Second, most radiologists now use computer algorithms, or computer-aided detection (CAD), to mark and reassess potentially suspicious lesions that may have been missed on initial mammogram review. In 2001, Congress extended Medicare coverage to CAD, and CAD has since diffused widely into U.S. practice (1–3). In Europe, where double-reading by 2 radiologists is common, some have proposed replacing the second reader with CAD (4). Despite broad uptake, the effectiveness and clinical utility of CAD in screening mammography remains controversial. In individual radiology practices, CAD adoption has been associated with greater rate of cancer detection, along with commensurate increases in false-positive rates (5–9), and within 3 British health system breast screening centers, outcomes were similar whether mammograms were double-read or interpreted by a single reader using CAD (10). However, in some practices, CAD adoption has been associated with little, if any, clinical effect (11, 12). The clinical effect of CAD may be heterogeneous across practices (13) or radiologists (14). In addition, CAD may differentially facilitate detection of noninvasive breast cancer, or ductal carcinoma in situ (DCIS), rather than invasive breast cancer (6–8, 15– 18). Because randomized clinical trials suggest that the effect of mammography on breast cancer mortality derives chiefly from detecting invasive cancer (19, 20), it is crucial to delineate the effect of CAD on the detection of invasive and noninvasive breast cancer. In multicenter studies, CAD has not been associated with a clear improvement in the diagnosis of invasive breast cancer (15, 16) despite greater false-positive (15, 16) and biopsy rates (15). However, because breast cancer is uncommon, studies to date may have had insufficient sample sizes of participants with cancer to precisely estimate the association of CAD with detection of invasive versus noninvasive breast cancer or its association with invasive breast cancer stage, size, or lymph node status, all of which are important predictors of breast cancer survival. As stated in a U.S. Preventive Services Task Force evidence review, new digital technologies, such as CAD, “have become widely used in the United States without definitive studies of their effect on screening” (21). Ideally, clinical trials would compare breast cancer outcomes among women screened with CAD versus without CAD, but such trials would require long-term follow-up of very large samples (22). To our knowledge, no such trials are planned or ongoing. However, now that CAD has diffused into clinical practice in the United States, the linked SEER (Surveillance, Epidemiology and End Results)–Medicare data enable a large-sample, population-based observational study of the clinical effect of CAD within the Medicare population. Although evaluation of CAD among both younger and older women having screening is desirable, the SEER–Medicare data offer sample sizes and analytic precision that cannot otherwise be achieved. Therefore, we assessed associations between CAD use during screening mammography received by Medicare enrollees and the incidence of invasive breast cancer and DCIS; invasive breast cancer stage, size, and lymph node status; and subsequent diagnostic testing among women without breast cancer.

Background Patients and physicians strongly endorse the importance of preventive or periodic health examinations (PHEs). However, the extent to which PHEs contribute to the delivery of cancer screening is uncertain. Methods In a retrospective cohort study, we determined the association between receipt of a PHE and cancer testing in a population-based sample of enrollees in a Washington State health plan who were aged 52 to 78 years and eligible for colorectal, breast, or prostate cancer screening in 2002-2003 (N = 64 288). Outcomes included completion of any colorectal cancer testing (fecal occult blood testing, sigmoidoscopy, colonoscopy, or barium enema), screening mammography, and prostate-specific antigen testing. Results More than half (52.4%) of the enrollees received a PHE during the study period. After adjusting for demographics, comorbidity, number of outpatient visits, and historical preventive service use before January 1, 2002, receipt of a PHE was significantly associated with completion of colorectal cancer testing (incidence difference, 40.4% [95% confidence interval (CI), 39.4%-41.3%]; relative incidence, 3.47 [95% CI, 3.34-3.59]), screening mammography [incidence difference, 14.2% [95% CI, 12.7%-15.7%]; relative incidence, 1.23 [95% CI, 1.20-1.25]), and prostate-specific antigen testing (incidence difference, 39.4% [95% CI, 38.3%-40.5%]; relative incidence, 3.06 [95% CI, 2.95-3.18]). Conclusions Among managed care enrollees eligible for cancer screening, PHE receipt is associated with completion of colorectal, breast, and prostate cancer testing. In similar populations, the PHE may serve as a clinically important forum for the promotion of evidence-based colorectal cancer and breast cancer screening and of screening with relatively less empirical support, such as prostate cancer screening.