Colonoscopy: Who Gets Treated Where and How Effective is that Treatment?

The Past is Hard to Forget when Evaluating New Dementia Screening Tests | GeriPal - Geriatrics and Palliative Care Blog

If we care about primary care physicians actually using the screening tests we develop, then we should care about their accessibility to those clinicians. To put it simply, the more barriers we put in place, the less likely anyone will use them to assess cognitive status in the elderly.

The prior gold standard for cognitive screening was the mini-mental status exam (MMSE). This test used to be freely available online, in books, and on pocket cards that were distributed to medical students and residents throughout the country. This all changed in March of 2001 when MiniMental, LLC (the current owners of the MMSE copyright) granted Psychological Assessment Resources (PAR) the exclusive rights to publish, license, and manage all intellectual property rights to the MMSE. Suddenly, after decades of neglect, PAR began enforcing the copyright on the MMSE (see "stealth patents"). Now physicians would have to pay about $1 per test, and importantly, another barrier to cognitive screening was erected.

In the wake of the MMSE copyright enforcement, several new and improved cognitive screens began hitting the geriatrics store shelves. One excellent example is the Montreal Cognitive Assessment (MoCA). This is a free, brief, and validated screening tool with high sensitivity and specificity for detecting MCI and dementia (http://www.mocatest.org). It’s easy to use, but does require one to print out the actual test in order to administer it to patients.

What about a test that requires no props and no special forms? This months Archives of Internal Medicine released a study on the Sweet 16. The article describes the creation of this new brief cognitive assessment tool, and its comparison to the MMSE in a cohort of patients. A long story made short: the Sweet 16 was found to be at least equivalent to, and possibly superior to that of the MMSE (at least in this cohort of patients). Some of the results included:

• The average time to complete the test was 1.4 to 2.9 minutes
• When compared to the IQCODE, a Sweet 16 score of less than 14 demonstrated a sensitivity of 80% and a specificity of 70%, whereas an MMSE score of less than 24 showed a sensitivity of 64% and a specificity of 86%.
• When compared with clinical diagnosis, a Sweet 16 score of less than 14 showed a sensitivity of 99% and a specificity of 72% in contrast to an MMSE score with a sensitivity of 87% and a specificity of 89%.

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Cervical Ca Screening Age Limits Questioned

By Charles Bankhead, Staff Writer, MedPage Today

A substantial portion of cervical cancer occurs in women older than 70, raising questions about clinical recommendations to discontinue screening at that age, analysis of an NCI database suggested.

From 2000 to 2006, more than 12% of newly diagnosed cervical cancers were in women ages 70 to 85. The rate was similar to that in age groups more often associated with the disease, according to a study reported here at the Society of Gynecologic Oncology meeting.

Almost 60% of cervical cancer cases in older patients were diagnosed at later disease stages.

That limits their treatment options, said Malgorzata E. Skaznik-Wikiel, MD, of Magee-Womens Hospital in Pittsburgh. "Lack of uniform screening across all at-risk age groups may account for the discrepancy," Skaznik-Wikiel said.
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Bone Mineral Density Screening: Older Women With Normal T-Scores Can Wait For 10 Years

Since 2002, the U.S. Preventive Services Task Force has recommended that women ages 65 and older be routinely screened for osteoporosis and has suggested that a 2-year screening interval might be appropriate. However, what length the screening interval should be is a topic that remains controversial and undecided, with no definitive scientific evidence to provide guidance.

Now a new study led by Margaret L. Gourlay, MD, MPH of the University of North Carolina at Chapel Hill School of Medicine finds that women aged 67 years and older with normal bone mineral density scores may not need screening again for 10 years.

"If a woman's bone density at age 67 is very good, then she doesn't need to be re-screened in two years or three years, because we're not likely to see much change," Gourlay said. "Our study found it would take about 16 years for 10 percent of women in the highest bone density ranges to develop osteoporosis."

Source: Tom Hughes University of North Carolina School of Medicine

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USPSTF Expands Osteoporosis Guidelines from MedPage Today

By Todd Neale, Staff Writer, MedPage Today

Postmenopausal women of any age with a 10-year fracture risk equal to or greater than that of a 65-year-old woman and no other osteoporosis risk factors should be screened for the disease, according to draft guidelines from the U.S. Preventive Services Task Force (USPSTF).

The 2002 USPSTF guidelines recommended routine screening only for women ages 65 and older, as well as women ages 60 to 64 with an increased risk for osteoporotic fractures. The current guidelines contain no recommendation for or against screening in younger women.

An additional change from the 2002 guidelines is a mention of men, albeit only to say that evidence is insufficient to assess the balance of benefits and harms of screening in older men. The updated guidance is still in draft form and will be available on the Agency for Healthcare Research and Quality's website for four weeks to receive public comments. After consideration of feedback, the final recommendations will be released.
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Vital Signs: Colorectal Cancer Screening Among Adults Aged 50--75 Years --- United States, 2008

ABSTRACT  Background: Colorectal cancer (CRC) remains the second leading cause of cancer deaths in the United States and the leading cause of cancer deaths among nonsmokers. Statistical modeling indicates that, if current trends in health behaviors, screening, and treatment continue, U.S. residents can expect to see a 36% decrease in the CRC mortality rate by 2020, compared with 2000.

Methods: Every 2 years, CDC uses Behavioral Risk Factor Surveillance System data to estimate up-to-date CRC screening prevalence in the United States. Adults aged ≥50 years were considered to be up-to-date with CRC screening if they reported having a fecal occult blood test (FOBT) within the past year or lower endoscopy (i.e., sigmoidoscopy or colonoscopy) within the preceding 10 years. Prevalence was calculated for adults aged 50--75 years based on current U.S. Preventive Services Task Force recommendations.

Results: For 2008, the overall age-adjusted CRC screening prevalence for the United States was 62.9% among adult respondents aged 50--75 years, increased from 51.9% in 2002. Among the lowest screening prevalences were those reported by persons aged 50--59 years (53.9%), Hispanics (49.8%), persons with lower income (47.6%), those with less than a high school education (46.1%), and those without health insurance (35.6%).

Conclusions: CRC screening rates continue to increase in the United States. Underscreening persists for certain racial/ethnic groups, lower socioeconomic groups, and the uninsured.

Implications for Public Health Practice: Health reform is anticipated to reduce financial barriers to CRC screening, but many factors influence CRC screening. The public health and medical communities should use methods, including client and provider reminders, to ensure test completion and receipt of follow-up care. Public health surveillance should be expanded and communication efforts enhanced to help the public understand the benefits of CRC screening.
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• 10,000-plus in U.S. die for lack of cancer screens: CDC (reuters.com)
• Colon Cancer Screening Rates Improve (online.wsj.com)
• Colon cancer screenings up, breast rate stalled (msnbc.msn.com)
• Patient Hand-Holding Boosts Colon Cancer Screenings (abcnews.go.com)

Vital Signs: Breast Cancer Screening Among Women Aged 50--74 Years --- United States, 2008

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Breast cancer remains the most commonly diagnosed cancer and the second leading cause of cancer deaths among women in the United States. In 2006 (the most recent data available), approximately 191,410 women were diagnosed with invasive breast cancer, and 40,820 women died (1). The incidence and mortality have been declining since 1996 at a rate of approximately 2% per year (2), possibly as a result of widespread screening with mammography and the development of more effective therapies (3). Mammography use declined slightly in 2004, but rose again in 2006 (4,5). This Vital Signs report updates mammography screening prevalence in the United States, using data from the 2008 Behavioral Risk Factor Surveillance System (BRFSS).
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Elder Abuse e-Bulletin

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This edition of the Elder Abuse E-Bulletin focuses on elder abuse screening and assessment. The abuse and neglect of older adults is a serious and prevalent problem that is often not readily identified by service providers, community or family members. This e-bulletin provides an overview of screening and assessment issues and highlights new research and tools that aim to increase elder abuse detection, intervention and prevention. The Elder Abuse E-bulletin is a quarterly e-newsletter for those interested in addressing and preventing the abuse of older adults in Canada. It is produced by the Public Health Agency of Canada (PHAC), as part of its role under the Government of Canada's Federal Elder Abuse Initiative (FEAI). For more information on the Government of Canada’s elder abuse initiatives, visit seniors.gc.ca or call 1-800-O-Canada (1-800-622-6232). For people using a teletypewriter device (TTY), call 1-800-926-9105. We want to hear from you. Please send your comments and feedback to our editor at ncfv-cnivf@phac-aspc.gc.ca.
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• Even at Home; Security is a Growing Concern for the Elderly (prweb.com)
• Elder Abuse: 3 Nursing Home Patients Killed by 'Chemical Restraints' (abcnews.go.com)

Mammograms and Severe Dementia - The New Old Age Blog - NYTimes.com

By PAULA SPAN

I’m trying, with some difficulty, to imagine myself as a quite elderly woman in her 80’s, someone with such advanced cognitive impairment that I can correctly answer fewer than a third of the questions on a commonly used test. I might not know who the president is, or what day or date it is; I might not be able to remember a few nouns the test giver just recited. Asked the question, “What is the object used to cut paper?,” I might not be able to come up with the word scissors.

Now, I’m trying to imagine technicians undressing me and getting me set up for a mammogram, a screening test whose purpose I may not understand. I’m betting the test would cause some discomfort (ask me how I know). I might also find it frightening, disorienting, threatening. It’s unlikely to do me any good, and it could do me some harm.

This is not an imaginary scenario.

Epidemiologists at the University of California, San Francisco have been analyzing the Medicare records of women over 70, focusing on a sample of 355 with severe cognitive impairment but no history of breast cancer. They’ve come up with a classic good news/bad news picture.
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Health Business Blog: More on the overuse of mammography in elderly women

by David E. Williams
A 2001 article from the Journal of General Internal Medicine (Screening Mammography for Frail Older Women; What are the Burdens?)followed the paths of 216 frail, elderly women who had undergone screening mammography.

The recent debate following the US Preventive Services Task Force recommendations on the age to begin routine mammography screening has focused heavily on the benefits of screening and the potential harm from discouraging screening. I’d like to see the debate broadened to include a frank discussion of the potential harm from too much screening. Excessive screening and associated harm to the frail elderly population is one aspect of that story.
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• Mammograms May Be Overused in Women with Dementia (nlm.nih.gov)

Doctors called on to screen all adults for depression :: American Medical News

By Kevin B. O'Reilly

All adults should be screened for depression, and primary care physicians should do the screening, according to a position statement issued in October by the American College of Preventive Medicine.
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Screening for Prostate Cancer among Men 75 Years of Age or Older

New England Journal of Medicine Volume 359:2515-2516 December 11, 2008 Number 24 Michael J. Barry, M.D. Prostate-cancer screening with the prostate-specific antigen (PSA) test remains one of the most controversial issues in modern medicine. The U.S. Preventive Services Task Force (USPSTF), an independent group of experts supported by the Agency for Healthcare Research and Quality under a mandate from Congress, recently revised its recommendations regarding prostate-cancer screening. The USPSTF concluded that "the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years," but it now "recommends against screening for prostate cancer in men age 75 years or older."1 In its 2002 statement, the task force did not recommend for or against screening in either age group. The implication of the new recommendation for medical practice is that clinicians should discuss the potential benefits and known harms of screening with men between 50 and 74 years of age, but not necessarily with older men. Why change the recommendation for men 75 or older, at least given the continuing dearth of evidence from randomized trials that addresses the tradeoff between the benefits and harms of prostate-cancer screening in men of any age? The task force believes that at least a moderate amount of evidence now makes it possible to conclude that the known harms of screening outweigh the possible benefits for this age group. Link to full article

Formative Research on Lung Cancer Screening

Proposed Project: Formative Research on Lung Cancer Screening--New--Division of Cancer Prevention and Control (DCPC), National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention (CDC).

The value of screening for lung cancer is a topic of scientific debate with important medical and economic consequences. Although chest x-rays (CXR) have been widely used for lung cancer screening, studies have shown that CXR with or without sputum cytology does not reduce mortality from lung cancer. Studies are currently underway to provide more information about the effectiveness of other types of screening tests, such as computed tomography (CT) scans and spiral CT scans. CDC proposes to conduct formative research to gather information from adult health care consumers and primary care physicians about experiences and practices related to lung cancer screening. Information will be collected over a two-year period. Of particular interest are long-term heavy smokers aged 40-70 who are considered high-risk for lung cancer. Information to be collected concerns their knowledge, attitudes, and behaviors related to preventive lung cancer screening and testing.

Written screening tests confuse some patients

A pair of studies suggests that these tools may be limited by deficiencies in literacy and numeracy.


By Victoria Stagg Elliott, AMNews staff in American Medical News, Nov. 3, 2008

The usefulness of having patients complete written screening tests while in the waiting room may be limited by a lack of understanding of the questions, according to a pair of papers presented at the American College of Surgeons 94th Annual Clinical Congress in San Francisco, Oct. 12-16.


"There is a true epidemic of health illiteracy in this country. Do not assume that your patients are literate with either prose or numeracy," said Viraj A. Master, MD, PhD, one of the authors and an assistant professor of urology at Emory University School of Medicine in Atlanta.

Colonoscopies Not Recommended After Age 75

Posted by Jacob Goldstein in the Wall Street Journal Health Blog The utility of cancer screening over the course of a lifetime follows a sort of bell curve. Now federal guidelines suggest that most people can stop getting colonoscopies after age 75.

Stop prostate exams at age 75, federal panel recommends

By Thomas H. Maugh II and Denise Gellene, Los Angeles Times Staff Writers August 5, 2008 Men over the age of 75 should no longer be screened for prostate cancer because the potential harm from the test results -- both physical and psychological -- outweighs any potential benefit from treatment, a federal panel said Monday. Related Document: Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement