Letters to the Editor
Clarification of Prostate Cancer Screening Recommendations
to the editor: As a family physician who is very interested in partaking in shared decisions with my patients, I always look forward to the patient education handouts from the American Academy of Family Physicians printed in American Family Physician. I find that these handouts empower patients to take an active role in their own health care.
However, in the February 1, 2004, issue, the patient education handout1 about prostate cancer misquoted the recommendations of the American Cancer Society. The handout1 stated, "The American Cancer Society recommends [prostate-specific antigen test] for all men older than 50 years." In fact, this was the original recommendation before more was known about the risks and benefits of the prostate-specific antigen (PSA) test. The current American Cancer Society2 guideline, which is quite similar to the American Academy of Family Physician's guideline, recommends that: "the PSA test and the [digital rectal examination] should be offered annually beginning at age 50 to men who have a life expectancy of at least 10 years. Men at high risk should begin testing at age 45. Information should be provided to patients about benefits and limitations of testing. Specifically, prior to testing, men should have an opportunity to learn about the benefits and limitations of testing, for early prostate cancer detection and treatment."2
The American Cancer Society Web site (http://www.cancer.org) has further information on the uncertainty of PSA testing. The Web site states: "Health care professionals should give men the opportunity to openly discuss the benefits and risks of testing at annual checkups. Men should actively participate in the decision by learning about prostate cancer and the pros and cons of early detection and treatment of prostate cancer."3 It adds that, "Studies are underway to try to prove that early detection tests for prostate cancer in large groups of men will lower the prostate cancer death rate. Until that information is available, whether you have the test is something for you and your doctor to decide."3
It is important for physicians to realize that we do not always have the answers and, because of that, we need to actively involve our patients in making decisions, especially in areas of uncertainty. As a 35-year-old man, I would no more believe to know what is best for a 53-year-old woman regarding hormone therapy than I would for a 53-year-old man regarding prostate cancer screening. Instead, family physicians need to follow the evidence, the national guidelines, and common sense, and relay to our patients the risks and benefits to help them make decisions that are in their best interest.
References
1. Prostate cancer [patient education]. Am Fam Physician 2004;69:619-20.
2. Smith RA, von Eschenbach AC, Wender R, Levin B, Byers T, Rothenberger D, et al. American Cancer Society guidelines for the early detection of cancer: update of early detection guidelines for prostate, colorectal, and endometrial cancers. CA Cancer J Clin 2001;51:38-75.
3. Accessed online June 4, 2004 at: http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_Can_prostate_cancer_be_found_early_36.asp?sitearea=.
editor's note: We appreciate Dr. Merenstein's bringing our attention to this important distinction. We would like to emphasize that the American Cancer Society now only recommends offering the prostate-specific antigen test annually to men over age 50 who are expected to live another 10 years, after informing the patient of the limitations and benefits of the test. The American Cancer Society, the National Cancer Institute, the U.S. Preventive Services Task Force, and the American Academy of Family Physicians now share a similar position on prostate cancer screening and the importance of a discussion between a patient and his physician before screening routinely. The wording in the patient education handout has been clarified on the American Family Physician Web site (http://www.aafp.org/afp/20040201/619ph.html).
 Figure. Serum sample from a 60-year-old woman with diabetes. Lactescent (milk-like) appearance suggests markedly elevated triglyceride level. |
Case Report
Milk-Like Serum Suggests Markedly Elevated Triglycerides
to the editor: Occasionally, clinicians encounter a finding that is rarely seen, and thus is worth sharing. The accompanying figure is a serum sample from a 60-year-old woman with diabetes who presented for evaluation of severe abdominal pain, nausea, and vomiting that had been worsening over a 24-hour period. She denied any chest pain, shortness of breath, fever, or chills. A nonfasting lipid panel revealed a triglyceride level of 8,535 mg per dL (96.3 mmol per L; normal range: 40 to 150 mg per dL [0.45 to 1.69 mmol per L]). Her lipase level was elevated at 1,476 U per L (normal range: 23 to 300 U per L).
Approximately 1.3 to 3.8 percent of cases of acute pancreatitis may be secondary to hypertriglyceridemia.1 Serum triglyceride levels of about 1,000 mg per dL (11.29 mmol per L) can precipitate such attacks, although the exact mechanism is unknown. When the triglyceride level is above 4,500 mg per dL (50.81 mmol per L), as in this patient, the serum is described as lactescent (milk-like). Such appearance should prompt the physician to get an immediate lipid level.1
Reference
1. Fortson MR, Freedman SN, Webster PD 3d. Clinical assessment of hyperlipidemic pancreatitis. Am J Gastroenterol 1995;90:2134-9.
The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Navy Medical Department or the U.S. Navy Service at large.
Appearance of Pityriasis Rosea in Patients with Dark Skin
to the editor: I would like to comment on the article, "Pityriasis Rosea,"1 by Drs. Stulberg and Wolfrey in the January 1, 2004, issue of American Family Physician. Pityriasis rosea can have a distinctly different appearance on patients with brown skin or dark skin. The herald patch, as well as the diffuse rash that follows, may have a gray, dark brown, or even black appearance. There may be either hypopigmented or hyperpigmented areas visible after the lesions resolve.
Reference
1. Stulberg DL, Wolfrey J. Pityriasis rosea. Am Fam Physician 2004;69:87-92.
Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org.
Please include your complete address, telephone number, fax number, and e-mail address. Letters should be submitted on disk, double-spaced, fewer than 500 words, and limited to one table or figure and six references. Please submit a word count.
Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.
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