507 - Colon CA Screening , Lipid Screening in Youth, Living The Questions

From the American College of Physicians (ACP)

1)  New Perspectives on Colorectal Cancer Screening

Most everyone agrees that screening for colorectal cancer - the second leading cause of cancer death in the US - is generally a useful thing. Currently, there are several guidelines that recommend CRC screening, but the exact ages of recommendation and the screening test recommendations differ among them. The US Preventive Services Task Force (USPSTF) and American Cancer Society (ACS) guidelines are in alignment at recommending screening between 50-75 without reservation, but with a qualified (ACS) or Grade B (USPSTF) recommendation based on the strength of evidence for age 45-50, and an individualized recommendation based on health status for patients aged 75-85. Both organizations recommend any of the most widely available colorectal cancer screening tests (excluding blood testing).

The American College of Physicians (ACP) makes guidelines on certain clinical topics, but where there are “several conflicting clinical guidelines…available,” they will issue guidance statements in which they critically appraise the guidelines and their supporting evidence and recommend strategies for reconciling and implementing the guidelines. The authors are careful to say that these guidance statements are meant to assist with clinical implementation of guidelines and are not to be used as the basis for quality measures.

The ACP has created a guidance statement on colorectal cancer screening using the USPSTF’s evidence review and statistical modeling study as its evidence. They focus this guidance on average-risk adults only. The ACIP guidance ends up with several important differences from the other guidelines. I have made notes under each recommendation.

1: Clinicians should start screening for colorectal cancer (CRC) in asymptomatic average risk adults at age 50 years

·         Note: The major start and end dates for the recommendations are still 50-75. And it is argued that lots of potential lives are saved, maybe more, if we do a better job screening this population more fully and not extend the age range.

2: Clinicians should consider not screening asymptomatic average-risk adults between the ages of 45 to 49 years. Clinicians should discuss the uncertainty around benefits and harms of screening in this population.

·         Note: The ACP bases this recommendation mainly on a lower prevalence of CRC in this age group and a lack of direct evidence for this age group (the USPSTF made this recommendation based mainly on statistical modeling).

3: Clinicians should stop screening for colorectal cancer in asymptomatic average risk adults older than 75 years or in asymptomatic average-risk adults with a life expectancy of 10 years or less

·         Note: The ACP does not recommend extending to healthy individuals up to age 85 due to a poor life years gained-to-colonoscopy ratio in the modeling study.

4a. Clinicians should select a screening test for colorectal cancer in consultation with their patient based on a discussion of benefits, harms, costs, availability, frequency, and patient values and preferences.

·         Note: Not much different here, but there is concern that clinicians don’t often have these discussions.

4b. Clinicians should select among a fecal immunochemical or high-sensitivity guaiac fecal occult blood test every 2 years, colonoscopy every 10 years, or flexible sigmoidoscopy every 10 years plus a fecal immunochemical test every 2 years as a screening test for colorectal cancer.

·         Note: The ACP sticks with trial evidence here – some FOBT and FIT studies used 2-year intervals and no difference was seen between 1 and 2 year intervals.

4c. Clinicians should not use stool DNA, computed tomography colonography, capsule endoscopy, urine, or serum screening tests for colorectal cancer.

·         Note: FIT-DNA (Cologuard) is NOT included due to a high false positive rate and lack of trial evidence for stool DNA testing. CT colonography and the others are left off due to lack of trial evidence.

John’s Comments:

This is a provocative guidance statement, given the relative harmony of the ACS and USPSTF guidelines and the notable disagreements in the ACP version. As is the case with most guidelines, organizations are all using the same data, but arrive at different guidance because they bring different rules, thresholds, and values to the table. The ACP has largely decided not to use the modeling studies that the USPSTF and ACS did in developing their recommendation. At Carilion, our Department‘s guidelines focus on recommending FIT testing (yearly) or colonoscopy (every 10 years) as the primary screening methods, but will count other tests.

References:

·         Qaseem A, Harrod CS, Crandall CJ, Wilt TJ. Screening for Colorectal Cancer in Asymptomatic Average-Risk Adults: A Guidance Statement From the American College of Physicians.  Ann Intern Med. Published online August 2023. Link

·         Qaseem A, Kansagara D, Lin JS, Mustafa RA, Wilt TJ. The Development of Clinical Guidelines and Guidance Statements by the Clinical Guidelines Committee of the American College of Physicians: Update of Methods. Ann Intern Med. 2019;170(12):863-870. Link

From the USPSTF

2)  Screening for Lipid Disorders in Children and Adolescents

Familial hypercholesterolemia (FH) and multifactorial dyslipidemia are 2 conditions that cause abnormally high lipid levels in children, which can lead to premature cardiovascular events (eg, myocardial infarction and stroke) and death in adulthood. The prevalence of FH in US children and adolescents ranges from 0.2 - 0.4% (1 of every 250 to 500 children and adolescents). Multifactorial dyslipidemia is much more common than FH, with prevalence in children and adolescents ranging from 7.1 – 9.4%. 

Familial hypercholesterolemia is a genetic disorder of cholesterol metabolism characterized by very high levels of low-density lipoprotein cholesterol (LDL-C) early in life. This cumulative exposure to abnormal lipid levels over time can lead to early atherosclerotic changes and premature cardiovascular morbidity and mortality. Diagnosis of FH is variably defined but generally includes substantially elevated lipid levels, a monogenic mutation, or both.

Multifactorial dyslipidemia is a condition of elevated lipid levels primarily associated with environmental factors such as excessive intake of saturated fat, sedentary lifestyle, and obesity; polygenic variants with small additive effects may also contribute to the condition. Abnormal lipid values associated with multifactorial dyslipidemia are generally lower than those associated with FH.

Since 2011, the American Academy of Pediatrics has recommended universal lipid screening between ages 9-11 (Grade B – Strongly Recommend) and again between ages 17-21 (Grade B – Recommend).  This universal approach was recommended because studies showed that using only a selective screening approach based on family history would potentially miss 30-60% of children and adolescents with substantial elevations of cholesterol.  In 2016 the USPSTF concluded that there was insufficient evidence to recommend for or against routine screening for lipid disorders in children and adolescents (I Recommendation). 

Despite the AAP recommendation now spanning more than a decade, lipid screening practices in US pediatric populations vary. Recent studies investigating screening practices in large US health care organizations found universal screening rates of 2% to 9% in children aged 9 to 11 years. Higher weight status, non-White race or ethnicity, and the presence of comorbid conditions were associated with higher screening rates in these studies.

The USPSTF recently reviewed the evidence regarding universal screening for lipid disorders in children and adolescents and concluded again that the current evidence is insufficient and the balance of benefits and harms for screening for lipid disorders in asymptomatic children and adolescents 20 years or younger cannot be determined. (I Recommendation). 

Mark’s Comments:

An important reminder that an “I” statement does not say “don’t do it,” but rather acknowledges there are substantial gaps in our knowledge in terms of the benefits (or risks) of screening.  The low uptake of the AAP guideline after a decade indicates that clinicians (both Pediatricians and Family Physicians) are not yet sold on the benefits of screening.  This recent USPSTF recommendation is unlikely to change that sentiment. 

In my own clinical practice, I continue to inquire about a family history of premature ASCVD, and for those with a positive FH, will recommend a one-time screen.  I will also recommend a lipid profile as part of the clinical work-up for metabolic syndrome in patients who are showing signs/symptoms of this, including those with BMIs above the 99^th percentile for age/gender.  We’ll tackle the “BMI controversy” in a future Take 3.    

References:

·         Barru MJ et al.  Screening for Lipid Disorders in Children and Adolescents:  US Preventive Services Task Force Recommendation Statement.  JAMA. 2023 Jul 18;330(3):253-260.  Link

·         Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128 Suppl 5:S213–56. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  “The Great Recalibration” (Part 1):  The Importance of Living the Questions

“Be patient toward all that is unresolved in your heart and try to love the questions themselves …” ― Rainer Maria Rilke, Letters to a Young Poet

Over the past 2 years, I’ve written about the many changes occurring for those of us who work in healthcare that were catalyzed by the COVID pandemic, including “The Great Resignation” (from work), as well as my self-named “Great” reprioritization (of focus/time), reduction (of work time), and relocation (of work place).   The common denominator for all these is an underlying sense that if there’s going to be so much external change, then perhaps it’s time for each of us to seize the opportunity and look at what might also need to change on the “inside.” 

Now, as we continue to heal from the past 3-years, many find themselves tempted by the sentiment to “move on” or “pick up where we left off”, both individually and organizationally.  Neither of these temptations acknowledge lingering post-pandemic wounds and in no way address the questions, “pick up from where or move on to what?”  If your view is anything like mine, the healthcare landscape (as well as the social and political ones) appears forever changed, and there is no “going back” and certainly no clear sense of what lies ahead.

It is during such times that I find a personal “pause” is in order – taking intentional time to reflect, reground, and recalibrate as I seek a sense of direction amidst the surrounding swirl.  Yet “pausing” for many of us is challenging, threatening, and even counter intuitive.  Afterall, we’re barely getting through the day now, so facing the prospect of having to “catch up” even more in the future seems ominous and therefore unattractive.  For me, there is also a “fear of what I’ll hear” if I really pause long enough to listen.  Perhaps I’ll find that I don’t like what I’m doing or who I’ve become or where I’m headed.  What then!?

Such questions are the exact reason why we need to take such a pause.  For some, this pause may involve taking extended time away from work.   Though attractive, this option may not be a feasible one for many.  That is the case for me, so my pause, for now, is a longitudinal one.  I’m calling it my “Great Recalibration”.  It started this spring with a “paddle the lake adventure” done in the midst of my work schedule, and consisted of me paddle boarding the entire distance of a local lake in sections, spending more than 30 hours and 100 miles alone with my paddleboard, the water, the natural landscape, and many questions, and it will continue with a one-week upcoming “staycation” spent at the same lake, processing what I “heard” during those many hours alone.   Not surprisingly, my initial very simple question, “What now?”, has now multiplied to more questions and presently, few “answers.” 

Next week, I’ll share more of what some of those questions have been and continue to be for me, and the surprising source from where they came.  Until then, I would encourage you to spend some time reflecting on this question:  “What question or questions would be important for you to answer about your life were you to create some time, space, and focus to ponder?”   You could start with “What now?”  If you’re unsure or uneasy about your answer to that question, perhaps a longer version of Rilke’s quote above will be reassuring for you.  This quote sits on my desks at both work and home, serving as a reminder of the importance of “living” into my questions rather than too often trying to immediately find “the answer” – and giving myself “grace” in the midst of the process.

“Be patient toward all that is unsolved in your heart and try to love the questions themselves, like locked rooms and like books that are now written in a very foreign tongue. Do not now seek the answers, which cannot be given you because you would not be able to live them. And the point is, to live everything. Live the questions now. Perhaps you will then gradually, without noticing it, live along some distant day into the answer.”  Rainer Maria Rilke

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Mark and John

Carilion Clinic Department of Family and Community Medicine

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Email: mhgreenawald@carilionclinic.org