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Information sourced from Journal Watch:

Fecal Occult Blood Tests Can Do More Harm Than Good in the Elderly

Among elderly men, 87% with the worst life expectancy and 65% with the best life expectancy experienced more burden than benefit from fecal occult blood testing.

The U.S. Preventive Services Task Force recommends that colorectal cancer (CRC) screening be discontinued after age 85 and that decisions to perform screening be individualized for patients aged 75 to 85. Several other guidelines recommend against CRC screening if individual life expectancy is <10 years, but supporting evidence is mostly from short-term follow-up studies.

To assess the benefit versus burden of fecal occult blood test (FOBT) screening in the elderly, researchers conducted a 7-year longitudinal study involving 212 patients (age range, 70–84; 99.5% men) who received positive FOBT results at four Veterans Affairs medical centers. Net benefit was defined as detection of CRC or "significant adenoma" (adenoma ≥1 cm, 3 or more adenomas, or an adenoma with villous features), followed by treatment and survival for ≥5 years. Net burden encompassed false-positive tests, deaths within 5 years of FOBT screening, and undetected cancers when patients declined follow-up. Researchers analyzed benefit status by life expectancy, which they classified as follows, using the Charlson-Deyo comorbidity index (CCI) as a measure of comorbidity:

• Best: age range, 70–79 and CCI, 0 (life expectancy, >10 years)
• Average: age range, 70–84 and CCI, 1–3; or age ≥80 and CCI, 0 (life expectancy, 5–10 years)
• Worst: age range, 70–84 and CCI ≥4; or age ≥85 and CCI ≥1 (life expectancy, <5 years)

Of all participants, 16% experienced net benefit from FOBT screening, and 70% experienced net burden; benefit status was indeterminate in 14%. The percentage of patients who experienced a net burden varied by life expectancy: best, 65%; average, 70%; and worst, 87%. Net benefit also varied by life expectancy: best, 20%; average, 15%; and worst, 10%.

Comment: This study is somewhat hampered by ambiguous definitions of screening burdens. For example, a net burden from FOBT screening in patients who had cancer but did not undergo colonoscopy would seem to result from failure to follow up the positive screening test, not the screening test itself. Appropriate follow-up would have shifted a net burden to a net benefit. Also, although a positive FOBT without a follow-up colonoscopy in a person without cancer might constitute a net burden, the burden seems minimal. Nevertheless, the study provides some quantitative data on CRC screening benefit by patient life expectancy. These issues might be even more relevant to colonoscopy screening, since the costs and risks of colonoscopy and polypectomy are incurred at the initial decision to screen. However, with FOBT screening, a positive test can still be followed by a decision to forgo colonoscopy if substantial morbidities or advanced age are factors. In that case, of course, the initial decision to perform the FOBT was probably inappropriate.

— Douglas K. Rex, MD

Published in Journal Watch Gastroenterology June 3, 2011

Citation:
Kistler CE et al. Long-term outcomes following positive fecal occult blood test results in older adults: Benefits and burdens. Arch Intern Med 2011 May 9; [e-pub ahead of print]. [Medline® Abstract]

Copyright © 2011. Massachusetts Medical Society. All rights reserved.

The above message comes from Journal Watch, who is solely responsible for its content.

Rastreio das Hepatites

Reproduzo aqui um email enviado por Michael Duncan, sobre Screening das Hepatites:


O UptoDate resume as principais recomendações nos EUA sobre rastreamento para hepatite C. Não tem artigo específico para rastreamento de hepatite B, mas no capítulo de rastreamento para DSTs, eles listam como indicações para o seu rastreamento:

Hepatitis B — Hepatitis B is efficiently transmitted by percutaneous or mucous membrane exposure to infected blood or body fluids that contain blood. Hepatitis B screening (hepatitis B surface antigen with anti-HBc or anti-HBs) should be offered to patients with multiple sex partners, MSM, and injection drug users. If the patient is susceptible, vaccination should be offered.

Para a hepatite C, dão mais informações:

Several organizations have provided guidelines for who should be tested. Despite having reviewed similar data and including experts, the various guidelines do not all agree. The following summarizes recommendations from the major organizations.

United States Preventive Services Task Force — The United States Preventive Services Task Force (USPSTF) recommends against routine screening for hepatitis C virus (HCV) infection in asymptomatic adults who are not at increased risk for infection [1]. In addition, they found insufficient evidence to make a recommendation for or against routine screening in adults at high risk for HCV infection. In making this recommendation the USPSTF notes potential harms of screening and treatment including labeling of the patient, adverse treatment effects, and unnecessary liver biopsies.

This recommendation should be interpreted as suggesting the need for additional research [2]. A response from the Centers for Disease Control and Prevention to the USPSTF recommendation emphasizes that medical and public health professionals should continue the practice of screening persons for risk factors, and offering testing to those at increased risk [3].

Centers for Disease Control and Prevention — The Centers for Disease Control and Prevention recommend that testing for HCV should be routine in patients at increased risk for infection, including those who (www.cdc.gov/mmwr/pdf/rr/rr5203.pdf and http://www.cdc.gov.libproxy.lib.unc.edu/mmwr/preview/mmwrhtml/rr5912a1.htm):

• Ever injected illegal drugs
• Received clotting factors made before 1987
• Received blood/organs before July 1992
• Were ever on chronic hemodialysis
• Have evidence of liver disease (elevated alanine aminotransferase [ALT] level)
• Are infected with HIV

Testing should also be performed based upon the need for exposure management including:

• Healthcare, emergency, and public safety workers after needle stick/mucosal exposure to HCV-positive blood
• Children born to HCV-positive women

Routine testing is not recommended (unless an additional risk factor is identified) in:

• Healthcare, emergency medical, and public safety workers
• Pregnant women
• Household (non-sexual) contacts of HCV-positive persons
• The general population

The need for testing is uncertain in the following groups:

• Recipients of transplanted tissue after 1992
• Intranasal cocaine or other non-injecting illicit drug users
• Those with a history of tattooing, body piercing
• Those with a history of sexually transmitted diseases or multiple sex partners
• Long-term steady sexual partners of HCV-positive persons

National Institutes of Health — The National Institutes of Health (NIH) consensus guidelines are similar to those of the CDC. In addition to the CDC guidelines, the NIH guidelines recommended screening individuals who:

• Received a blood transfusion or organ transplantation prior to 1990 (rather than 1992)
• Have had multiple sexual partners
• Are spouses or household contacts of HCV-infected patients
• Share instruments for intranasal cocaine use

American Association for the Study of Liver Diseases — A 2009 practice guideline issued by the American Association for the Study of Liver Diseases (AASLD) recommends testing for the following groups [4]:

• Those who have injected illicit drugs in the recent and remote past, including those who injected only once and do not consider themselves to be drug users
• Those with conditions associated with a high prevalence of HCV including patients with HIV infection, those with hemophilia who received clotting factor concentrates before 1987, persons who were ever on hemodialysis, and those with unexplained abnormal aminotransferase levels
• Prior recipients of transfusions or organ transplants before July 1992, including those who were notified that they received blood from a donor who later tested positive for HCV infection
• Children born to HCV-infected mothers
• Healthcare, emergency and public safety workers after a needle stick injury or mucosal exposure to HCV-positive blood
• Current sexual partners of HCV-infected persons

Authors' recommendations — Our general approach is consistent with the guidelines recommended by the AASLD. Notably, the presence of an abnormal serum ALT level, any history of injection drug use, or a history of blood transfusion before 1992 identified 85 percent of HCV RNA positive participants between the ages 20 to 59 in the most recent National Health and Nutrition Examination Survey in the United States [5].

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