547 - Blood Test for Colon Cancer, DICE Model in Dementia, I See You

From the Medical News

1) Blood Testing for Colorectal Cancer (CRC)

The benefits of colorectal cancer screening are well known. The US Preventive Services Task Force (USPSTF) gives it an A rating for ages 50-74, a B rating for ages 45-49, and a C rating from ages 75-85. The USPSTF recommends any of the approved testing technologies to achieve this screening – high-sensitivity guaiac-based stool testing, fecal immunochemical testing (FIT), FIT + DNA testing, CT colonography, flexible sigmoidoscopy and colonoscopy. Each of these is statistically modeled to predict, in a population, the number of colon cancers detected, the number of life years gained, and the number of colonoscopies required (with their attendant harms) to achieve those gains. Perhaps not surprisingly, FIT and colonoscopy have the most acceptable benefit risk ratios according to that modeling.

Enter, now, Guardant Health’s Shield test, a blood test “…intended to detect colorectal

cancer derived alterations in cell-free DNA from blood,” which achieved Food and Drug Administration approval in May. This test provides a result of “signal detected” or “not detected”, and if “detected,” the patient is advised to have a colonoscopy to look for colorectal cancer. This test was studied in a single study (whose results are not published) and was found (according to the FDA report) to have a sensitivity of 83.1% for colorectal cancer, a sensitivity of 13.2% for advanced adenoma, and a specificity of 89.6% for advanced neoplasia.

Quotations from a Medscape article about this approval include: “it’s a good test for late-stage colon cancer, but not for early stages or advanced adenomas,” and “is not designed as a preventative strategy.” The FDA report states that the committee discussed whether repeat testing may overcome the low sensitivity for advanced adenomas but could not reach a conclusion in the absence of evidence.

John’s Comments:

Readers that follow preventive services recommendations may recognize some of the quotations as similar to criticisms of stool-based colon cancer screening. Proponents of a primary colonoscopy-based screening program often tout the ability of colonoscopy not only to find colorectal cancer but also to find and remove advanced adenomas – a “double-whammy” of prevention that stool tests cannot match, since they only detect lesions that bleed, i.e., mostly cancers. Stool tests, and now blood tests, have low sensitivities for advanced adenomas. Stool tests make up for this defect through close-interval re-testing, thereby increasing their sensitivity over time. It is not yet known whether this strategy can work for blood testing. The FDA committee discussed that this blood test might be able to recruit patients to screening who have refused other screening tests due to discomfort or other barriers. We have a few years until the USPSTF updates its recommendation, and we have not yet seen the company’s study used for approval. So, if insurances decide to cover it, I would try to restrict its use to those that refuse other screening methods and only as long as they would consent to a colonoscopy if the test is positive.

References:

· Blood Test for Colon Cancer Screening Secures FDA Panel’s Blessing. Published May 24, 2024. Accessed May 25, 2024. Link

· Molecular and Clinical Genetics Panel of the Medical Devices Advisory Committee. Brief Summary of the Molecular and Clinical Genetics Panel of the Medical Devices Advisory Committee. US Food and Drug Administration; 2024. Accessed June 3, 2024. Link

From the Literature and “Nudge” From a Colleague

2) Using the DICE Model in Dementia to Help Support Caregivers

Currently, there are more than 6 million persons living with dementia (PLWD) in the US and 11 million family caregivers providing unpaid care for those individuals. Most persons living with dementia will exhibit at least one behavioral or psychological symptom of dementia (BPSD), such as wandering, aggression, and hallucinations, over the course of their illness. Adverse consequences of BPSD include unplanned hospitalizations and nursing home placement. When this occurs, caregivers are more likely to experience caregiver burden, including stress and depression.

A patient-centered approach is required to address specific behavioral concerns and underlying factors. While non-pharmacological approaches are the recommended first-line treatment for managing BPSD, psychotropic medications are commonly used, despite minimal evidence of benefit and substantial risks. It is postulated that a major reason for this is the absence of training for front-line clinicians, resulting in discomfort addressing BPSD themselves, and in turn, being ill-equipped to educate caregivers.

The DICE model is a structured approach designed to evaluate and manage BPSD. Developed by a team of dementia care experts, DICE stands for Describe, Investigate, Create, and Evaluate. This model provides a systematic method for clinicians and caregivers to understand and address the complex and often distressing behaviors exhibited by individuals with dementia. It emphasizes a person-centered approach, aiming to improve the quality of life for both patients and caregivers by identifying and addressing the underlying causes of BPSD.

The first step, "Describe," involves a detailed characterization of the behaviors, including their frequency, duration, and context. Caregivers and healthcare providers gather comprehensive information about the behavior, noting any patterns or triggers. This descriptive phase is crucial as it sets the foundation for understanding the behaviors in the context of the individual's life and environment. It encourages a thorough observation and documentation process, which is essential for next steps.

In the "Investigate" phase, attention is directed to identifying possible causes of the behaviors. This involves examining medical, psychological, and environmental factors that could be contributing to the BPSD. Clinicians review the patient's medical history, current medications, and overall physical health, as well as psychosocial factors such as recent changes in routine or environment. The goal is to uncover any reversible factors or unmet needs that could be addressed to mitigate the problematic behaviors.

The "Create" step focuses on developing and implementing a comprehensive care plan tailored to the individual's needs. This plan may include non-pharmacological interventions, such as environmental modifications, behavioral strategies, and support for caregivers. When necessary, pharmacological treatments might also be considered, but the emphasis is on personalized, non-drug approaches first.

Finally, the "Evaluate" phase involves monitoring the effectiveness of interventions and making adjustments as needed. This ongoing assessment ensures that the care plan remains effective and responsive to the changing needs of the individual with dementia.

Mark’s Comments:

With appreciation to Brian Unwin, MD, who is the Section Chief of Geriatrics at Carilion Clinic, for his “nudge” to share this model more broadly. Brian shares, “The DICE model for BPSD isn’t new, but it is very helpful in trying to understand why an individual with dementia is having behavioral/emotional change. It helps us do better than "let's just check a urine. I find that we often fall short in the investigation piece, especially the environmental and caregiver issues.”

There is now a free training in the DICE model that provides case-based skills building and resources for both clinicians and family caregivers and is intended to improve family and formal caregivers’ confidence and knowledge of individualized dementia care. Additionally this Worksheet provides a nice summary of the model and the process for evaluation as well as an extensive list of helpful non-pharmacological interventions to consider.

References:

· Kales H, et al. Moving Evidence-Informed Assessment and Management of Behavioral and Psychological Symptoms of Dementia into the Real World: Training Family and Staff Caregivers in the DICE Approach. Am J Psych 28(12):December 2020: 1248-1255. Link

· DICE Approach – Free Training. Link

From PeerRxMed ( www.PeerRxMed.org )

3) Being Admitted by a Colleague to the “I See You …”

“The ultimate touchstone of friendship … is witness.” David Whyte; poet, author, philosopher

Recently I have become aware of more than a handful of colleagues who are facing significant personal health concerns. Some have been very forthcoming regarding these challenges, and others have remained quite private, often for very extended periods of time.

As I spoke with some of them about their journey and then reflected on some of my own past and present health challenges, I noted a common thread for those times when they (and I) felt most supported. It was when a friend created a safe space for them to feel seen and heard – when that friend was actively and unconditionally present. It is that space that I have come to understand as the place of “witness.”

In his essay on “Friendship” from the book “Consolations: The Solace, Nourishment, and Underlying Meaning of Everyday Words,” David Whyte writes the following about this type of friendship: “A friend knows our difficulties and shadows and remains in sight, a companion to our vulnerabilities more than our triumphs, when we are under the strange illusion we do not need them.”

But need them we do, and after providing caution regarding how overwork and too much emphasis on a professional identity can cause us to lose perspective on the importance of these relationships, he concludes by highlighting the healing power of witness in friendship: “ … the ultimate touchstone of friendship … is witness, the privilege of having been seen by someone and the equal privilege of being granted the sight of the essence of another, to have walked with them and to have believed in them, and sometimes just to have accompanied them for however brief a span, on a journey impossible to accomplish alone”

Yet, despite our “knowing better,” we are too often tempted to try and travel portions of this professional journey alone, and these are often the times that we need witness the most. So as you connect with your PeerRx partner in the coming weeks for your weekly check-ins, take advantage of this time to reciprocally serve not only as an encourager, but also as a supportive witness to each other’s healing – a mutual practice of allowing yourselves to be admitted to the “I See You.” There is no more powerful of a gift that you could give to each other.

NOTE: Here is a recording of David Whyte reading and reflecting upon the entire “Friendship” essay (5 minutes): Friendship - David Whyte

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

Mark and John