489 - Weight Mgt. Interventions, Prostate CA Dx, Springing Forward

From the Literature

1)  Weight Management Interventions in Primary Care

The US Preventive Services Task Force (USPSTF) recommends, for adults with a body mass index (BMI) over 30 kg/m², offering or referring for “intensive multicomponent behavioral interventions.” The USPSTF usually recommends interventions that can be delivered in primary care or referred to from primary care. However, there was a clear recognition in this recommendation that “intensive and multicomponent” interventions are most often delivered outside primary care with a varied role for the primary care clinician. Most of the effective interventions reviewed in that recommendation were 12 months in duration, involved a number of different specialists and several types of interventions (diet, education, physical activity, etc.).

The reviewers of a recent systematic review took at different tack, positing that primary care is an ideal place to intervene to promote weight loss. Studies included in this review examined interventions delivered mostly in the primary care setting, by a primary care clinician or clinician staff member. The review met the standard validity criteria for a comprehensive search, explicit inclusion/exclusion criteria, quality assessment of the included articles, and an assessment of heterogeneity in the meta-analysis. The primary outcome studied was weight change at 12 months, while weight change at 24 months was studied secondarily.

The reviewers found twenty-seven studies (N = 8000 subjects) for the primary outcome (12 months) and thirteen (N = 5011) for weight change at 24 months. The trials were mainly from the US and Europe, with 65% women, a mean BMI of 35 and a mean age of 48 years. Weight loss interventions in primary care resulted in a mean of 2.3 kg of weight loss (95% confidence interval (CI) −3.0 to −1.6 kg, P<0.001) over control. At 24 months, these interventions led to a loss of 1.8 kg (95% CI −2.8 to −0.8 kg, P<0.001) over control. Non-medical (e.g., health coaches) or “other” practitioner (e.g., dietitians or unclear)-led interventions resulted in greater weight loss than general practitioner or nurse-led interventions.

The risk of bias was low in 9 trials, but unclear or high in 25 trials. A subgroup analysis of results by study risk of bias did not reveal any differences in the outcomes based on quality grouping. There was significant heterogeneity in both outcomes (69-88%).

The authors note that they did not control for the number of contacts between intervention and control groups, or between the different provider types, which could have explained some of the effect seen.

John’s Comments:

This review included low-quality studies and had significant heterogeneity, so I don’t think there’s anything here to suggest a big change from the USPSTF recommendation. Behavioral interventions for weight loss take time and frequent contacts, which primary care clinicians may not be able to provide alone.  We should still strive to find effective (or maybe create) multi-component weight loss programs for our patients and follow alongside them providing supplemental weight loss counseling and support.

References:

·       US Preventive Services Task Force. Behavioral Weight Loss Interventions to Prevent Obesity-Related Morbidity and Mortality in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;320(11):1163-1171. Link

·       Madigan CD, Graham HE, Sturgiss E, et al. Effectiveness of weight management interventions for adults delivered in primary care: systematic review and meta-analysis of randomised controlled trials. BMJ. 2022;377:e069719. Link

From the Literature

2)  Prostate Cancer Diagnosis Update – Systematic vs. Targeted Bx 

Appropriate screening for prostate cancer remains a controversial issue. The high rate of overdiagnosis is regarded as the main obstacle to the recommendation of population-based screening for prostate cancer.   The cause of overdiagnosis is the high prevalence of small, low-grade prostate cancers in the adult population; approximately 50% of men older than 60 years of age have such tumors.  These tumors are often indolent in nature and show slow or no progression. In addition, the PSA test has low specificity. The positive predictive value of a PSA level of 3 ng per milliliter or greater as an indicator of a significant lesion (Gleason score of 3+4 or greater) is estimated to be 16%.  Thus, in a screening program that involves systematic biopsy, a significant majority of patients without clinically significant cancer will undergo systematic biopsy that will accidentally detect clinically insignificant cancers, potentially causing much unnecessary morbidity due to both the biopsy itself, potential subsequent treatment, and psychological impact. 

Targeted biopsy of suspected lesions that are shown on MRI has been suggested as a means of reducing overdiagnosis of prostate cancer; this approach has been shown to be noninferior to systematic biopsy in patients with elevated PSA.  However, there is not a worldwide consensus as to whether systematic biopsy can be omitted as the present “standard of care.”  This recently published study set out to address that question. 

Participants included 17,980 men with a PSA level ≥ 3 ng/mL who underwent MRI of the prostate.  One third of the participants were randomly assigned to a reference group that underwent systematic biopsy as well as targeted biopsy of suspicious lesions shown on MRI.  The remaining participants were assigned to the experimental group and underwent MRI-targeted biopsy only. The primary outcome was clinically insignificant prostate cancer, defined as a Gleason score of 3+3.  The secondary outcome was clinically significant prostate cancer, defined as a Gleason score of at least 3+4. Safety was also assessed.                        

A total of 66 of the 11,986 participants in the experimental group (0.6%) received a diagnosis of clinically insignificant prostate cancer, as compared with 72 of 5994 participants (1.2%) in the reference group (P<0.001). The relative risk of clinically significant prostate cancer in the experimental group as compared with the reference group was 0.81 (95% CI, 0.60 to 1.1). Clinically significant cancer that was detected only by systematic biopsy was diagnosed in 10 participants in the reference group; all cases were of intermediate risk and involved mainly low-volume disease that was managed with active surveillance. Serious adverse events were rare (<0.1%) in the two groups.

The authors concluded that the avoidance of systematic biopsy in favor of MRI-directed targeted biopsy for screening and early detection in persons with elevated PSA levels reduced the risk of overdiagnosis by half at the cost of delaying detection of intermediate-risk tumors in a small proportion of patients.

Mark’s Comments:

The challenges of prostate cancer screening, diagnosis, and treatment continue and demonstrate the incredible dynamic tension that exists as we try to maximize diagnosing and treating clinically significant disease in the population who will most benefit while minimizing both overdiagnosis and treatment harm.  What has become clear is that trade-offs appear inevitable at present, emphasizing the importance of involving men in dialogue and educating them from the very start of the screening discussion. 

Many efforts are ongoing to recalibrate diagnostic strategies to make them both safer and more precise, including those described in this article.  Other strategies include the use of age-restricted eligibility for more focused diagnostic interventions, age-specific PSA thresholds for additional workup by age, the use of life-expectancy predictions in screening treatment decisions, the use of serum or urine biomarkers as second-line triage tests before MRI is performed, and the use of transperineal biopsy versus transrectal biopsy techniques.  It will be important that we who practice primary care medicine stay up on these advances so we can continue to best help guide our patients.   

References:

Hugosson J, et al. Prostate Cancer Screening with PSA and MRI Followed by Targeted Biopsy Only.  N Engl J Med December 8, 2022; 387:2126-2137.   Link

From PeerRxMed ( www.PeerRxMed.org )

3)  How Will You Spring Forward in the Coming Months?

"Though I do not believe that a plant will spring up where no seed has been, I have great faith in a seed... Convince me that you have a seed there, and I am prepared to expect wonders." — Henry David Thoreau

I don’t know about you, but I’m quite grateful that spring has finally arrived.   This change of seasons provides a dramatic and symbolic contrast from the colder more monotone backdrop of winter to the warmer, lighter, burst-of-color palette of spring, and with it, a chance to do some personal and professional reflection.  Two traditional activities of spring provide a wonderful anchor for that reflection if you are willing.

Spring Cleaning: 

With warmer weather, spring provides an opportunity to do some cleaning, both inside and out.  Inside, one can pack up or give away those things no longer needed and open the windows to “air out” the house.  Outside, one can clean up the debris accumulated over fall and winter and put a fresh coat of paint on those places weathered by years of exposure.  For your reflection, consider how some internal and external “spring cleaning” of your life might be useful as you begin to prepare for the next few months.  What habits or patterns have you accumulated that you no longer need or have outgrown?  What is “cluttering up” your life in terms of overcommitments or mindless activity?  What parts of you need some “sprucing up” through a change in pattern of diet, exercise, sleep, or even making an appointment for routine medical care?

Spring Planting: 

Spring is also the season for tilling and enriching the soil, then planting seeds.  It provides the opportunity to look into the future and act now in preparation for the time of future “harvest.”  As you prepare yourself spring, consider what type of seeds would you like to plant in your personal and professional life that could lead to a bountiful harvest in the next 4-6 months if you follow through with providing them water and sunlight.  Is there a specific “crop” you need to attend to?  What resources do you need to ensure your growth goes as planned? 

Recall that a vital component of the PeerRxMed process is the quarterly “up to 90 minutes every 90 days” check-in (what I call PRx90) intended to provide a deliberate space for reconnecting with ourselves and our PeerRxMed partner.  Here’s a reminder of that Process .  As spring begins, it’s time to schedule that quarterly meeting once again.  To help guide that dialogue, consider the questions above as well as a few others below:   

·       What have you learned about yourself over the past 3 months?

·       What are your top personal/professional goals and priorities over the next three months?  What is one that will cause disappointment if you have not accomplished it when we meet again in 3 months?

·       When’s your next vacation / adventure / break?  What will you do that will be fun for you?

The transition of seasons provides an incredible opportunity to pause and ponder, and then to create a plan for the coming months.  Don’t squander this opportunity.  It will be a “spring forward” that won’t require an act of Congress – only some action from you in the form of cleaning, and planting ….

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Mark and John

Carilion Clinic Department of Family and Community Medicine

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Email: mhgreenawald@carilionclinic.org