441 - Screening for Prostate Cancer, Rosacea Tx, Finding Joy in Medicine?

From the Literature

1)  Screening Guidelines and Prostate Cancer (PCa)

The history of USPSTF recommendations for PCa screening goes back 26 years:

·         1996 – D recommendation (against) for digital rectal examination, PSA, and US.

·         2002 – I statement (insufficient evidence).

·         2008 – D recommendation for PSA, men 75 years and older, I statement for others.

·         2012 – D recommendation for all men.

·         2018 (current) – C recommendation (small net benefit) for men 55-69 years, D recommendation for men 70 years and older.

A group of urologists and cancer epidemiologists at UCLA have just published an analysis of trends in metastatic prostate cancer (mPC) incidence from before and after the 2008 and 2012 USPSTF D recommendations. They used a well-established National Cancer Institute cancer registry– the Surveillance, Epidemiology, and End Results (SEER) 18 - to examine the rates of mPC in men 45 years and older from 2004 to 2018. Using several methods to enhance the validity of the comparisons, they found that in men 75 years or older, there was a notable increase in mPC starting in 2011 (58 cases/100,000 in 2011 to 89 cases/100K in 2018, a relative increase of 53%) whereas prior to 2011, cases had been decreasing (67 cases per 100K in 2004 to 58 cases/100K). In men from 45-74 years, the difference was smaller, (11.8 cases per 100K in 2010 vs. 17.3 cases/100K in 2018, a 41% relative increase). These changes were consistent when non-Hispanic whites and blacks were analyzed separately, but Hispanic rates of mPC began rising in 2007 with a steady slope through 2012. The researchers also used the American Joint Committee on Cancer staging system outcomes for the analyses and obtained similar results for all groups.

The authors conclude that there is an association of rising mPC rates with the 2008 and 2012 USPSTF D recommendations and recommend further study beyond 2018 as well as examination of mortality data when available. The authors note that a change in tumor biology is unlikely to account for such dramatic short-term trend changes.

John’s Comments:

First, just to be clear, neither the USPSTF nor the American Urologic Association recommends routine prostate cancer screening above age 69, and the American Cancer Society does not recommend screening for anyone in whom life expectancy is less than 10 years. The “75 and over” data seems to be used in this article mainly to demonstrate the influence of a D recommendation. Second, I thought this article was going to do a lot more finger-pointing than it did, but it was a conservative treatment of this controversial subject. There are still some unexplained findings here that did not get much attention in the article: the fact that mPC incidence started to rise in the 1-2 years prior to the 2012 recommendation, and a rise of mPC in Hispanic men starting in 2007.

The most important limitation of this study, in my opinion, is the lack of recognition of the USPSTF’s primary perspective – the balance between benefits and harms of screening. This article contains only a single sentence acknowledging overdiagnosis and overtreatment (OD/OT).  Yet, data from the major screening trials shows between a 21% and 50% OD/OT rate with PSA screening.  This OD/OT will have resulted in transrectal biopsies, hormone therapy, radiation therapy, and radical prostatectomy for many of the patients, with the resultant outcomes of erectile dysfunction, incontinence, and other harms.  In addition, not every screen-detected cancer is cured. Out of 1000 men offered screening for prostate cancer, an estimated 1 life will be saved, and 3 men will avoid mPC, but 5 will still die of prostate cancer despite treatment.

It is this balance of benefits vs. harms that is important to assess and maintain when considering screening programs, and articles that present data from only one side of that equation do not achieve that balance. It may happen that, as diagnostic and treatment methods improve to avoid harms (including OD/OT), prostate cancer screening will be recommended more broadly. Retrospective analyses like this one are important to consider and learn from but are of limited use in assessing the quality of guideline recommendations made in a different time and context.

Disclaimer: I was on the USPSTF from 2016-2020 and participated in the 2018 recommendation deliberation.

References:

·         Desai MM, Cacciamani GE, Gill K, et al. Trends in Incidence of Metastatic Prostate Cancer in the US. JAMA Network Open. 2022;5(3):e222246. Link

·         Hoffman RM. Striking the Right Balance With Prostate Cancer Screening. JAMA Netw Open. 2022;5(3):e222174. Link

·         Is Prostate Cancer Screening Right for You? - U.S. Preventive Services Task Force, accessed 3/21/22. Link

From the Guidelines and British Association of Dermatology (BAD)

2)  Treatment of Rosacea

Rosacea is a chronic facial skin condition of unknown etiology characterized by marked involvement of the central face with transient or persistent erythema, inflammatory papules or pustules, telangiectasia, or connective tissue hyperplasia.  It is diagnosed by a compatible history and physical examination. Though precise prevalence is difficult to estimate due to variations in presentation, some studies indicate it may be up to 5% of the adult population.  Co-morbid depression has been estimated in up to 65% of patients.  Intervention is not curative but can help control symptoms.   

While a US guideline for the treatment of rosacea was last published in 2014, a more recent guideline was published by the British Association of Dermatology in 2021 using the GRADE methodology.  It should be noted that there were no primary care clinicians represented in the group.  Notable recommendations include:

General recommendations (GPP = Good Practice Point):

·         Advise limited exposure to known aggravating factors such as alcohol, sun exposure, hot drinks and spicy food.

·         When characterizing, include the objective clinical signs and the subjective symptoms experienced by the patient with rosacea.  Diagnostic phenotypes include characteristic fixed centrofacial erythema or phymatous changes. Other features include flushing, papules or pustules, telangiectasia, ocular changes, burning or stinging sensations, oedema and dryness.

·         Take into account the older classification system for rosacea, which was based on clinical signs: erythematotelangiectatic, papulopustular, phymatous or ocular. Characterize the clinical subtypes and symptoms of rosacea affecting the person according to these clinical signs.

·         Whenever possible, avoid long-term use of oral antibiotics.  The optimal duration of antibiotic therapy is not known.  A lack of response after 2–3 months of antibiotic therapy is a good guide.  When antibiotics are working, the pros and cons of longer-term treatment need to be evaluated carefully.

·         Advise that some find it beneficial to wash their skin with emollients, moisturize regularly and use appropriate sun protection.

·         Consider the need to screen for depression and/or anxiety. 

Topical therapies:

·         Offer either metronidazole, azelaic acid or ivermectin as first-line topical options with papulopustular rosacea. (Strong recommendation)

·         Consider topical brimonidine or oxymetazoline to treat facial erythema. (Weak)

Systemic therapies:

·         Offer an oral antibiotic as a first-line treatment option for more severe papulopustular rosacea. Options include: azithromycin, clarithromycin, doxycycline 40 mg (modified release) daily, doxycycline 100 mg daily, erythromycin, tetracycline. (Strong)

·         Consider intermittent courses of low-dose isotretinoin(e.g. 0.25 mg kg) with persistent and severe disease. 

Ocular therapies:

·         Advise those with ocular rosacea to minimize exposure to aggravating factors such as air conditioning, excessive central heating, smoky atmospheres and periocular cosmetics. (Strong)

·         Identify and modify/eliminate medications that could be triggering eye dryness (e.g. antidepressants and anxiolytics). (Strong)

·         Refer to an ophthalmologist if (i) experiencing eye discomfort, sticky eye discharge persisting for >12 months despite frequent (>6 times daily) topical lubricant use and adequate lid hygiene; or (ii)experiencing symptoms such as reduced vision, pain on eye movement and pain that keeps the patient awake at night.

Mark’s Comments:

Having 2 recent patients with significant rosacea reminded me that we’ve never covered this over the first 9 years of Take 3, so it was time.  And though we don’t usually highlight guidelines from other countries, the process for this guideline was similar to those used within the US for guideline development.

References:

·         Hampton PJ et al.  British Association of Dermatologists guidelines for the management of people with rosacea 2021.  British Journal of Dermatology (2021)185: 725–735.  Link

·         National Rosacea Society:  https://www.rosacea.org/

From PeerRxMed (www.PeerRxMed.org)

3) Finding Joy in Medicine?  Start By Celebrating Those Baby Steps!

It takes time and effort to free ourselves of the scarcity story that most of us have learned along the way – the idea that happiness is a competition, and that someone else is grabbing all the joy. — Sharon Salzberg, teacher and author

At first, I didn’t recognize her as she walked toward me and took off her mask.  Indeed, had she not been beaming, I might have worried that something terrible had happened.  Instead, and counter to the experience of many, it turned out she had intentionally lost over 60 pounds during the course of the pandemic, and even though I had cared for her as a patient for many years, a very different “version” of her was present before me. 

“How did you do it?” I asked a bit skeptically, remembering all those I cared for who had lost weight, only to regain it again.  Her expression became more forlorn.  “It wasn’t easy. ‘Baby steps,’ I kept telling myself.  And while I feel incredible, being the ‘new me’ hasn’t always been easy.  At times some of my friends and even my husband, who has gained weight, seem ambivalent or even envious rather than happy for me.” 

In that moment, I recalled our visit 3 years before when she and her husband both excitedly shared about the “first steps” of their only child during a well-child visit and my rather muted, unenthusiastic, “Oh, that’s great” (but thinking “I’m really busy”) response.  How easily I had forgotten the thrill I experienced with the first steps of each of my own children.  Seizing the 2^nd chance, I exclaimed, “This is a big deal!  I’m proud for you.” 

Her smile returned.  “Thanks,” she said.  “I know they’re excited for me too.  But I get it.  They each would have liked to lose some weight as well.”   To which I offered, “Perhaps you could have your husband come see me so I can help him with his health goals.”     

Sympathetic joy is the ability to be happy for and celebrate the happiness and good fortune of others, regardless of our own circumstances.  Brain science research has shown that such expressions of joy can activate our reward system, increase feelings of happiness, and improve our sense of connection with others.  In fact, this ability is so powerful that the Buddha declared it one of the four highest qualities of the heart.

In fairness to this patient’s friends and husband (and myself), expressing sympathetic joy can feel a bit “wobbly” at first, like those first steps of a child, and is often accompanied by some stumbles.  But it can become more natural by regularly noticing and acknowledging what brings others delight, and those opportunities abound.  So remember, whether baby or giant, every “first step” is a big deal.  Afterall, joy awaits … and that’s always worth celebrating together – one step (or pound) at a time.

Reference:

Want to increase your capacity for sympathetic joy?  Take this quiz to learn more:  Quiz

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org