508 - Breast CA Screening, Chronic Coronary Dz, End of Life Conversation
From the US Preventive Services Task Force
1) Draft Breast Cancer Screening Recommendation
Breast cancer is the second leading cause of cancer and cancer death in women, causing the deaths of over 42,000 women in 2022. The US Preventive Services Task Force (USPSTF) recommendations for screening have changed multiple times over the years, and the current recommendations seem to continue that pattern.
The USPSTF draft recommendations are:
· Screen for breast cancer with mammography (including digital breast tomosynthesis (DBT)) every 2 years between the ages of 40 and 74. (B recommendation)
· There is insufficient evidence to recommend testing in women aged 75 or older. (I statement).
· There is insufficient evidence to recommend additional testing for women with dense breasts. (I statement)
After years of inadequate evidence to recommend DBT (“3D mammography”), there is finally enough to incorporate it into the standard screening recommendations – largely from the angle of increased detection of cancers compared to digital mammography. In the decision analysis, DBT screening was preferred because it limited false positives.
To arrive at the new age ranges and confirm the biennial interval of screening the USPSTF used both an evidence report and a microsimulation-based decision analysis.
Since there have been no new randomized trials in breast cancer screening that had mortality as an outcome, the evidence report reviewed non-randomized studies that looked at intervals and age ranges, and other trials that used detection rates as outcomes. A non-randomized “trial emulation” study using Centers for Medicare and Medicaid Services data that showed a benefit from screening mammography through age 74, but not beyond. Another set of non-randomized studies that suggested 1- and 3-year screening intervals produced similar outcomes. The decision analysis revealed several efficient strategies for screening, most beginning screening at age 40 or 45. Efficiency, in this case, refers to an acceptable balance of reduced mortality and life-years gained vs. harms (additional screenings, biopsies, false positive results). The USPSTF also looked specifically at efficient screening strategies for Black women and found that initiating screening at 40 or 45 and continuing biennially showed the most promise.
The USPSTF determined that screening biennially from age 40 to 74 would result in 1.3 additional breast cancer deaths averted per 1000 women (compared with screening from 50-74), and, for Black women, an additional 1.8 breast cancer deaths averted per 1000. Given that the rate of invasive breast cancer among women 40-49 years has risen more quickly in the last few years, these additional gains were felt to be important. Biennial screening was determined to confer the best balance between detection of cancer and false positives and other harms.
Remember that these are, as yet, DRAFT recommendations. Given that no new randomized controlled trials of breast cancer screening with mortality outcomes are likely to be done, we must use analysis of non-randomized studies, epidemiologic data, and microsimulation modeling and decision analysis to further fine tune screening decisions. The USPSTF has made reasonable arguments for these recommendations. We will discuss more on breast cancer screening in Take 3 next week.
A special note is made of the rate of breast cancer mortality in Black women despite higher self-reported rates of screening. The USPSTF suggests particular attention to ensuring that women with positive screening “receive equitable and appropriate follow up evaluation and additional testing, inclusive of indicated biopsies, and that all persons diagnosed with breast cancer receive effective treatment.”
· Draft Recommendation: Breast Cancer: Screening | United States Preventive Services Taskforce. Accessed August 14, 2023. Link
From the American College of Cardiology/American Heart Association
2) Management of Chronic Coronary Disease (CCD) – Part 1
Chronic coronary disease (CCD) is a heterogeneous group of conditions that includes obstructive and nonobstructive CAD with or without previous myocardial infarction (MI) or revascularization, ischemic heart disease diagnosed only by noninvasive testing,
and chronic angina syndromes with varying underlying causes. Approximately 20.1 million persons in the United States live with CCD. Despite an approximate 25% overall
relative decline in death from coronary heart disease (CHD) over the past decade, it remains the leading cause of death in the US.
Developed by the American Heart Association (AHA), the American College of Cardiology (ACC), and other specialty societies, the 2023 guideline both updates and consolidates ACC/AHA guidelines previously published in 2012 and 2014 for the management of patients with stable ischemic heart disease. This current document provides an evidence-based and patient-centered approach to management of chronic coronary disease (CCD) incorporating the principles of shared decision-making, social determinants of health (SDOH), and team-based care. Where applicable and based on availability of cost-effectiveness data, value recommendations are also provided for clinicians.
Among the key recommendations:
· Emphasis is on team-based, patient-centered care that considers social determinants/drivers of health along with associated costs while incorporating shared decision-making in risk assessment, testing, and treatment.
· Nonpharmacologic therapies, including healthy dietary habits and exercise, are recommended for all patients with chronic coronary disease (CCD).
· Patients with CCD who are free from contraindications are encouraged to participate in habitual physical activity, including activities to reduce sitting time and to increase aerobic and resistance exercise. Cardiac rehabilitation for eligible patients provides significant CV benefits, including decreased morbidity and mortality outcomes.
· Use of sodium glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists are recommended for select groups of patients with CCD, including groups without DM and in particular those with HFrEF.
· New recommendations for beta-blocker use in patients with CCD: (a) Long-term beta-blocker therapy is not recommended to improve outcomes in patients with CCD in the absence of myocardial infarction in the past year, LV ejection fraction ≤50%, or another primary indication for beta-blocker therapy; and (b) Either a calcium channel blocker or beta blocker is recommended as first-line antianginal therapy.
· Statins remain first line therapy for lipid lowering in patients with CCD. Several adjunctive therapies (eg, ezetimibe, PCSK9 [proprotein convertase subtilisin/
kexin type 9] inhibitors, inclisiran, bempedoic acid) may be used in select populations, although clinical outcomes data are unavailable for novel agents such as inclisiran and bempedoic acid.
· Shorter durations of dual antiplatelet therapy are safe and effective in many circumstances, particularly when risk of bleeding is high and ischemic risk is low to moderate. This should be managed in collaboration with patient’s Cardiologist.
· The use of nonprescription or dietary supplements, including fish oil and omega-3 fatty acids or vitamins, is not recommended in patients with CCD given the lack of benefit in reducing CV events.
· Routine periodic anatomic or ischemic testing without a change in clinical or functional status is not recommended for risk stratification or to guide therapeutic decision-making in patients with CCD.
· Although e-cigarettes increase the likelihood of successful smoking cessation compared with nicotine replacement therapy, because of the lack of long-term safety data and risks of sustained use, e-cigarettes are not recommended as first-line therapy for smoking cessation.
It should be noted that in the context of this guideline, the definition of CCD includes patients who may or may not have classic signs and symptoms of CAD, including those with known but asymptomatic CVD. Given the gap of a decade since the previous guidelines and the rapid changes occurring in this area of medicine, the authors not that these guidelines will need to be a 'living document' to ensure the most up to date care is being provided to all patients. It was heartening to see “value” included as a criterion in this guideline, acknowledging the high cost of some of the newly approved pharmaceuticals. There was also a much greater emphasis of the impact of social drivers/determinants of health and how these should be considered as part of our care of patients with CCD.
There are more specifics regarding lipid therapy that are very relevant to we who provide primary medical care, and I will cover these in next week’s Take 3.
· Virani S, et al. 2023 AHA/ACC Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. Published ahead of print 20 July 2023. Link
From PeerRxMed – “The Great Recalibration” (Part 2)
3) Is it Time for an “End of Life” (as you know it) Conversation?
“Look closely at the present you are constructing. It should look like the future you are dreaming.” - Alice Walker, Pulitzer Prize winning author
In last week’s blog, I explored the opportunity that our current circumstances in healthcare have provided for each of us to ask some important questions regarding the present and future direction of our professional lives. In order to do this, it will be necessary to take a “pause” and carve out time and attention to consider what those questions are for us. I have called this opportunity “The Great Recalibration.”
For me, perhaps unexpectedly, the questions that have emerged were those posed many years ago by Atul Gawande, MD in his book Being Mortal. When I reflected that these questions were intended to be ask as part of a conversation for those who had a finite time to live (“end of life”), that sometimes annoying and persistent little voice inside me responded, “That’s all of us, including you ….”
So here are some of the questions (modified for context) that I have been posing to myself during my ongoing “longitudinal pause”. In the spirit of the “Great Recalibration” opportunity we’ve all been afforded, I’m hoping you will join me by carving out some time and asking yourself these same questions. Perhaps you could consider them your “End of Life as I Knew It” conversation.
· What is your understanding of your present condition and any “distress” you are feeling?
· What are your fears (or worries) about the future?
· What are your goals for the time you have remaining and therefore, your priorities right now?
· What outcomes are unacceptable to you and therefore, what trade-offs are you willing to make?
· What would a good day look like for you (both at work and beyond work)?
Tragically some people go an entire lifetime without answering most of these even once. If the questions (or your own version of them) resonate with you, consider carving out some protected “me times” for reflection and then doing some journaling or even sharing with someone (your PeerRxMed partner?) regarding what you are hearing. You could even frame such times as part of your “longitudinal sabbatical.”
I greatly admire colleagues who have the insight and courage to realize the importance of carving out time to take a “pause” and regain perspective – to recalibrate. Doing so certainly deviates from our professional programming and therefore is not easy. But then again, neither is feeling demoralized and exhausted. In answering these questions, I suspect I (and you) will experience some “endings” and possibly new beginnings. I’ll let you know, and hope you’ll take time to let me know as well. After all, we’re in this together. No one should care alone ….
Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.
Mark and John