Practice Guidelines
American Cancer Society Releases Annual Guidelines for the Early Detection of Cancer
The American Cancer Society (ACS) has released its annual recommendations for the early detection of cancer. The report was published in the January/February 2005 issue of CA: A Cancer Journal for Clinicians and is available online at: http://caonline.amcancersoc.org/cgi/content/full/55/1/31.
Recommendations
breast cancer screening
Breast cancer screening should begin when women are 20 years of age and should consist of clinical breast examinations, counseling to raise awareness of symptoms, and regular mammography after the age of 39. Clinical breast examinations should take place every three years in women 20 through 39 years of age and annually in women 40 years and older. Women at average risk should begin annual mammography at the age of 40 and should continue the practice as long as they are in good health and would be candidates for breast cancer treatment. The ACS no longer recommends monthly breast self-examinations, but instead recommends that women be informed of the potential limitations, risks, and benefits associated with self-examination. The new guidelines emphasize the physician's role in raising and reinforcing awareness of breast cancer, early detection, and the importance of timely reporting of any symptoms.
cervical cancer screening
Cervical cancer screening should begin three years after the onset of vaginal intercourse but no later than 21 years of age. Screening should be performed annually until the age of 30 with conventional cervical cytology smears, or every two years until the age of 30 with liquid-based cytology. Women older than 30 years who have had three consecutive normal or negative cytology results may reduce the frequency of screening to every two to three years. Women 70 years and older with an intact cervix may cease cervical cancer screening if they have had three or more consecutive normal or negative cytology results within the 10-year period before the age of 70.
Women with a history of cervical cancer or in utero exposure to diethylstilbestrol should continue annual screening after age 30. Women who are immunocompromised (i.e., organ transplant patients, those receiving chemotherapy, those with human immunodeficiency virus infection) should be tested twice in the first year after diagnosis and annually thereafter as long as they are in good health and would benefit from early detection and treatment.
Cervical cancer screening is not indicated for women who have had a total hysterectomy for benign gynecologic disease. Women with subtotal hysterectomy should follow the recommendations for women at average risk.
colorectal cancer screening
Adults at average risk of developing colorectal cancer should begin screening at 50 years of age using one of five options: (1) annual fecal occult blood test or fecal immunochemical test, (2) flexible sigmoidoscopy every five years, (3) annual fecal occult blood test or fecal immunochemical test plus flexible sigmoidoscopy every five years, (4) colonoscopy every 10 years, or (5) double-contrast barium enema every five years.
More intensive surveillance is recommended for patients with a history of adenomatous polyps, a history of curative-intent resection of colorectal cancer, a family history of colorectal cancer or colorectal adenomas diagnosed in a first-degree relative before the age of 60, a history of inflammatory bowel disease of significant duration, or family history of genetic testing indicating one of two hereditary syndromes.
endometrial cancer screening
Endometrial cancer screening is not recommended for women at average or somewhat increased risk. However, the ACS recommends that women in these categories be informed of the risks and symptoms of endometrial cancer at the onset of menopause. Women at very high risk of endometrial cancer (i.e., those with known hereditary nonpolyposis colon cancer-associated genetic mutation carrier status, substantial likelihood of being a mutation carrier, or absence of genetic testing results in families with suspected autosomal dominant predisposition to colon cancer) should consider annual screening beginning at 35 years of age.
prostate cancer screening
There is insufficient evidence to recommend that men at average risk undergo regular prostate cancer screening. However, the ACS stresses that it is inappropriate not to offer testing or to discourage testing in men who request early prostate cancer detection tests. Prostate-specific antigen test and digital rectal examination should be offered annually beginning at 50 years of age to men who have a life expectancy of at least 10 more years.
Men at high risk (i.e., men of African decent, men with a first-degree relative diagnosed before the age of 65) should begin testing for prostate cancer at the age of 45. Men with more than one first-degree relative diagnosed with prostate cancer before 65 years of age could begin testing at the age of 40.
lung cancer screening
Testing for early lung cancer detection is not recommended for asymptomatic persons who are at risk. The ACS maintains that patients at risk for lung cancer because of significant exposure to tobacco smoke or occupational exposures may discuss with their physicians the benefits and risks of testing and may decide to undergo testing on an individual basis. Ideally, testing should be done only in experienced centers that are linked to multidisciplinary subspecialty groups. Patients who currently smoke should be informed that the immediate preventive health priority is the elimination of tobacco use.
Practice Guideline Briefs
FDA Warns Against Off-Label Use of Antipsychotic Drugs
The U.S. Food and Drug Administration (FDA) has released a warning to physicians and patients that off-label use of certain drugs called "atypical antipsychotics” could be dangerous to older patients with dementia. Included in the advisory are antipsychotics such as aripiprazole (Abilify), olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), clozapine (Clozaril), and ziprasidone (Geodon). Currently, these drugs are approved to treat schizophrenia and mania. However, clinical studies have found that older patients with dementia who received an antipsychotic regimen had a mortality rate 1.6 to 1.7 times higher than patients who received placebo. In these studies, most deaths were heart related or from infection.
The FDA has requested that manufacturers include a warning on the labels of antipsychotic medications describing the risk of off-label use to older patients with dementia. Patients who are taking an antipsychotic to treat a behavioral disorder associated with dementia should consult their physician about continued use.
Additional information regarding this advisory or the specific medications included in the warning is available on the FDA Web site at: http://www.fda.gov/cder/drug/infopage/antipsychotics/default.htm.
Other FDA Advisories:
Recall of urine processing kit. The U.S. Food and Drug Administration (FDA) has issued a Class I recall of the ProbeTec ET Urine Processing Kit, which screens for Chlamydia and gonorrhea. Because the kit may cause false-negative results, the FDA is concerned that some patients might not receive treatment. If left untreated, these infections can worsen or cause further disease transmission and complications in pregnant patients.
Combination therapy may cause hepatitis. Studies have found that healthy volunteers could contract drug-induced hepatitis with marked transaminase elevations after taking simultaneous regimens of rifampin (Rifadin) and ritonavir (Norvir)-boosted saquinavir (Fortovase). The drug's manufacturer recommends that physicians not prescribe rifampin for patients taking ritonavir-boosted saquinavir. The combination regimen is used as an antiretroviral therapy for human immunodeficiency virus infection.
Warning labels ordered for two eczema medications. The FDA has announced that it will require warning labels for pimecrolimus (Elidel) and tacrolimus (Protopic), topical creams used to manage eczema. Recent studies on animals and limited case studies on humans have found an increased cancer risk associated with the two medications. Although more studies are needed, the FDA recommends that physicians prescribe these medications only as a second-line, short-term therapy for patients unresponsive to other treatments. The FDA also advises physicians to avoid prescribing them to children younger than two years and to persons with weakened immune systems.
AAP Recommends Caring for Children with Special Needs at Home
The Committee on Children with Disabilities of the American Academy of Pediatrics (AAP) has released a clinical report recommending that children with special needs receive care at home-not in a group home or institutional setting. The full report, "Helping Families Raise Children with Special Health Care Needs at Home,” is available on the AAP Web site (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;115/2/507).
The report facilitates permanency planning (i.e., securing a permanent family environment and long-term relationships with caring adults) for persons with special needs. It is geared toward meeting the U.S. Department of Health and Human Services' goal of having no person 21 years or younger with special needs living in a group home or institution by 2010. Because some families are unable to care for their children at home, the AAP suggests acceptable alternative living situations, such as families who already have children with special needs or parents who work in the health care industry. The Committee also gives suggestions for parents and physicians on how to provide an optimal living situation, home modifications, and transportation to fit each child's needs; how to find faith- and community-based support; and how to help these children transition into adulthood.
Physician-specific recommendations developed by the AAP Committee include the following:
- Address each child's need for and the availability of appropriate education, including later transition services. Physician advocacy may be necessary to ensure that the patient receives adequate service from the school and to decrease the parents' burden.
- Identify which support services would most suit each child's needs, and help families gain access to these services through referral to social service agencies.
- Lobby for increased funding for family support by working with legislators.
- Assist in training caregivers for children with special needs.
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| Copyright © 2005 by the American
Academy of Family Physicians. |
