470 - Colorectal Cancer Screening, RSV in Adults, OutSMART an Elephant?

From the New England Journal of Medicine 

1)  Colonoscopy Screening and Colorectal Cancer Mortality 

The authors of this pragmatic controlled trial randomized the entire eligible population (aged 55-64) in the countries of Poland, Norway, and Sweden to an invitation to colonoscopy screening or no screening. Keep in mind that an invitation to colonoscopy screening is all we really do in primary care practice when we discuss this test with our patients and refer them. The authors calculated (and recruited) an adequate sample size, had centralized morbidity and mortality data from the European health registries, standardized the high quality of the colonoscopy examinations, adjusted for any confounding screening programs that were instituted during the study, and followed up any polyps found at the recommended intervals. 

The investigators obtained data from ~84,500 patients (89% of the ~95,000 invited). They did an “intention-to-screen” analysis for the primary outcome, as well as a “per protocol” analysis, which estimated what would have happened if everyone assigned to colonoscopy got one. Only 42% of the invited group completed a colonoscopy over a follow up of 10 years. Those invited to colonoscopy did have a decreased incidence of colorectal cancer (0.98% vs. 1.20%, risk ratio (RR) 0.82, 95% confidence interval [CI] 0.70 to 0.93, number needed to screen was 455). However, the invited group did not have a decreased risk of colorectal cancer death (0.28% vs. 0.31%, RR 0.90, 95% CI 0.64 to 1.16).  There was no difference in overall mortality at 10 years. 

The per-protocol analysis estimated a decreased 10-year risk of colorectal cancer (0.84% vs. 1.22%, RR 0.69, 95% CI 0.55 to 0.83) and a significantly decreased risk of colorectal cancer death (0.15% vs. 0.30%, RR 0.50, 95% CI 0.27 to 0.77).  The authors note, as limitations, the smaller-than-usual incidence of colorectal cancer in the study population and the 42% colonoscopy rate among those invited. 

John’s Comments: 

I realize that this is an unpopular opinion, but I do not think colonoscopy is a useful screening test, and this study provides some support to that argument. This study is limited by its inclusion of an older screening cohort, given what we know about the changing epidemiology of colorectal cancers toward a younger population. However, the “intention to treat” nature of the primary analysis helps us understand the real-world effectiveness of colonoscopy screening. Estimating what “would have” happened (a “per protocol analysis”) if everyone got the intervention is of limited value. Screenings are supposed to be simple, minimally invasive tests that are acceptable to patients and lead to more invasive, definitive testing only as needed. Colonoscopy does not meet those goals and has only limited evidence of mortality reduction in cohort studies, while fecal occult blood testing and even office-based sigmoidoscopy have demonstrated colorectal cancer mortality benefit in controlled trials. FIT-DNA testing has no direct evidence of colorectal cancer or related mortality reduction at all. 

All that said, it is still the USPSTF recommendation to get one of these tests for routine colorectal cancer screening.  Work with your patients to be sure you select the one they’ll do!

Reference: 

Bretthauer M, Løberg M, Wieszczy P, et al. Effect of Colonoscopy Screening on Risks of Colorectal Cancer and Related Death. N Engl J Med. Published online October 9, 2022. Link.

From the Literature, FDA, and Question from a Reader

2) Testing for Respiratory Syncytial Virus (RSV) in Adults

Question:

When would it be indicated to test for Respiratory Syncytial Virus (RSV) in adults?

Answer:

The month of October presented a unique challenge in many parts of the country with significant increases in infections with COVID, influenza, and RSV happening simultaneously in both children and adults (what some news outlets have named the “tripledemic”). 

This specific question resulted from utilization of the Alinity m Resp-4-Plex, a multiplexed polymerase chain reaction (PCR) test which has received Emergency Use Authorization for use with anterior nasal or nasopharyngeal swab specimens collected from individuals suspected of respiratory viral infection consistent with COVID-19.  It tests for viral infection due to SARS-CoV-2, Respiratory Syncytial Virus (RSV) and influenza A and B, since these infections can have similar clinical presentations and distinguishing between them could potentially impact treatment.

Although virtually all children have been infected with RSV by two years of age, previous infection with RSV does not appear to protect against reinfection.  Even in those with high titers of specific antibody, repeat infections can occur, particularly in children.  Infections occur in adults as well, and they typically present with cough, coryza, rhinorrhea, and conjunctivitis, though sinus and ear involvement often occur as well.  Sore throat, myalgias, and high fever are not as common, which can help distinguish these infections clinically from both the Omicron variant of COVID-19 and influenza.  RSV is an often-unrecognized cause of lower respiratory tract infection (LRTI) in older adults and those who are immunocompromised.   

Transmission of RSV is primarily by self-inoculation of nasopharyngeal or ocular mucous membranes after contact with virus-containing secretions or fomites.  However, large droplet aerosol transmission has also been implicated.  The virus can survive for several hours on hands and fomites, making hand washing and contact precautions important measures to prevent health care-associated spread.

In the US, RSV typically causes seasonal outbreaks from October or November to April or May, with a peak in January or February.  During the coronavirus disease 2019 (COVID-19) pandemic, mitigation measures were associated with marked reductions in non-COVID-19 respiratory infections in children, including RSV, during the winter season in 2020 and 2021.  However, with relaxation of mitigation measures, interseasonal RSV activity has increased, as well as the early surge being experienced this year. 

While RSV can more commonly cause serious morbidity and mortality from LRTI in children under the age of 2, it can also do so for infected adults > 50, particularly those with underlying medical conditions, and for the immunocompromised. 

For infected adults, treatment is symptomatic and supportive, though glucocorticoids and bronchodilators may be beneficial in the management of RSV-associated bronchial reactivity in older children and adults, particularly those with pre-existing asthma.  Although there are no approved treatments for RSV in adults, decisions regarding treatment of RSV infection in immunocompromised patients should be individualized. The optimal treatment is uncertain. Interventions that have been associated with reduced rates of progression from upper to lower respiratory tract infection or decreased mortality in observational studies include single agent or combination therapy with ribavirin, intravenous immune globulin, palivizumab (Synagis), and/or glucocorticoids. 

Mark’s Comments:

So why, then, would one test an adult for RSV in the ambulatory setting?  Two main clinical scenarios come to mind for me:  First, if they are immunocompromised themselves and secondly, if they live in proximity with a child who is immunocompromised.  “What’s the harm?”, one might ask.  While there is no apparent clinical harm, there is a cost differential in testing, which is always an important consideration and even more so in our present economic environment.  And, of course, patient portals have painfully proven that more information is not always better.  Those of us who have been tasked with trying to explain an “abnormal” mean corpuscular hemoglobin concentration (MCHC) or estimated glomerular filtration rate (eGFR) can certainly attest to that.

From PeerRxMed ( www.PeerRxMed.org )

3)  You’ll Never OutSMART the Heart of an Elephant

In last week's blog, we continued the journey of trying to understand why it is often so difficult to travel “the longest yard” – the distance between our knowledge (head), our beliefs (heart) and our action (hands) – when it comes to behavior change, and agreed that just because we “should” or even “need” to do something doesn’t mean this automatically translates into action.  

But why?  We’re rational creatures, right?  It just can’t be that hard to start something that may be helpful or stop something that may be harmful, whether (in my case) it be saying no to a cookie or a keynote.  Well, it turns out that “Just Do It” may be a good slogan for selling sneakers, but when it comes to changing our behavior, something larger seems to be at play.  That “something” appears to have the power of an elephant when it comes to influencing whether or not we change.   

In his 2006 book The Happiness Hypothesis, psychologist Jonathan Haidt proposed that when it comes to behavior change, we have 2 competing forces vying for control;  one he called the “rider” (rational/analytical) and the other the “elephant” (emotional).   In this analogy, the rider sees and directs the journey, and the elephant provides the power.  Chip and Dan Heath extended this analogy in their 2010 book Switch: How to Change Things When Change is Hard by emphasizing that while the rider might appear to be in control, ultimately, it is the elephant who really is.   So, as they travel down the path together (behavior change gap), when there is a disagreement, the elephant will invariably win.

These authors emphasize something that is often forgotten or underemphasized when it comes to behavior change – the role of emotion (what I call “heart”).   This absence is demonstrated in the widely utilized SMART Goal Setting  acronym (specific / measurable / achievable  / relevant / time-bound), which is incomplete in that it gives the impression that the “rider” is not only in control, but that the “elephant” is simply “along for the ride”  

But the elephant is not that easily ignored. It is no mistake that the word emotion derives from the Latin derivation of the word movere (move, stir, provoke) combined with the prefix “e” (out).  Ultimately, despite our best thought-out plans, it is emotion that will move us out of our present state and catalyze behavior change (or not).  The things that engender positive emotions in us tend to be things that we find inspiring or energizing and can often be powerful motivators for us to change.  An example in my own life was my recovery from a severe back injury in 2019 and the vision of my being able to stand-up paddleboard again that ignited my determination through months of pain and grueling physical therapy.  Recognizing that it’s often easier to build upon something than reinvent it, I have taken to encourage the setting of “I’M SMARTER” goals in my coaching and leader development work, with the SMART rider sandwiched between the “elephant attributes” of Inspiring and Motivating on one end and Energizing and Rewarding on the other.  I’d be glad to share more details with any who are interested.

How about you? Where is your “elephant heart” undermining your plans for behavior change?  Perhaps it’s time to get your rational plans and emotional drivers aligned by considering not just your "what" but your "why," and really start moving down your desired path.  Well, not so fast.  It turns out that even that alignment is not sufficient to most effectively travel the final “two feet” of the longest yard (“heart to hands”).  Next week we’ll explore how collaboration between you and your PeerRxMed partner and others can help you progress along that journey by significantly closing that final gap.  In the meantime, keep “feeding” your elephant large quantities of vision and inspiration in order to prepare for the upcoming journey of change.

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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