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Top POEMs of 2017: Screening

Top 20 POEMs of 2017

Two Questions Effective in Identifying Patients Who are Not Depressed

Clinical question
Can two questions screen for depression in older adults?

Bottom line
The Two-Question Screen for depression is recommended by the United Kingdom's National Institute for Health and Care Excellence and consists of 2 written questions: (1) In the past month, have you been troubled by feeling down, depressed or hopeless? and (2) In the past month, have you experienced little interest or pleasure in doing things? If both answers are "no," these questions are good at quickly ruling out depression (sensitivity 92%), but if either answer is "yes," more patient questioning is needed to confirm the diagnosis (specificity 68%). (LOE = 1a)(www.essentialevidenceplus.com)

Reference
Tsoi KK, Chan JY, Hirai HW, Wong SY. Comparison of diagnostic performance of Two-Question Screen and 15 depression screening instruments for older adults: systematic review and meta-analysis. Br J Psychiatry 2017;210(4):255-260.

Study design: Meta-analysis (other)

Funding source: Other

Setting: Various (meta-analysis)

Synopsis
These investigators used several databases to identify a total of 133 studies that evaluated 16 screening instruments for depression in older adults. The study was conducted according to PRISMA standards. Most (80%) of the studies were deemed to be at low risk of bias. Six studies evaluated the Two-Question Screen in 1670 patients (prevalence of depression = 14.3%). The combined sensitivity of Two-Question Screen was 91.8% (95% CI 85.2 - 95.6) and the specificity was 67.6% (58.1 - 76.0). There was moderate heterogeneity among the sensitivity results and substantial heterogeneity among specificity results. In other words, the 2 questions are good at ruling out depression in older patients but further questioning is needed to confirm depression. The performance of the Two-Question Screen is similar to other screening tests, though no studies have directly compared them.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

Prostate Cancer Screening: No Mortality Benefit After 15 Years of Follow-Up (PLCO)

Clinical question
Does screening of asymptomatic men for prostate cancer improve mortality?

Bottom line
After nearly 2 decades of follow-up from the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, there appears to be no mortality benefit to screening asymptomatic men for prostate cancer. (LOE = 1b)(www.essentialevidenceplus.com)

Reference
Pinsky PF, Prorok PC, Yu K, et al. Extended mortality results for prostate cancer screening in the PLCO trial with median follow-up of 15 years. Cancer 2017;123(4):592-599.

Study design: Randomized controlled trial (single-blinded)

Funding source: Government

Setting: Population-based

Synopsis
We have previously reported data from the original PLCO study (http://www.essentialevidenceplus.com/content/poem/110501) and its 13-year follow-up (http://www.essentialevidenceplus.com/content/poem/140343). In the original trial, more than 76,000 men between the ages of 55 years and 74 years at 10 centers were randomized to receive prostate cancer screening (annual prostate-specific antigen for 6 years plus digital rectal examination for 4 years) or no scheduled screening. This study reports additional follow-up (up to 19 years; median 15 years). The cumulative prostate cancer mortality rates were virtually identical (4.8 and 4.6 per 10,000 person-years, respectively). Additionally, there was no difference in all-cause mortality between the groups (173 and 177 per 10,000 person-years).

Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI

Older Patients Do Not Like Discussions Involving Choices Based on "Limited Life Expectancy"

Clinical question
How do older patients react to the idea of stopping cancer screening toward the end of life?

Bottom line
It seems that we don't want to be reminded that we are approaching what Harlan Ellison calls "the downhill side" of life. When bringing up the idea that cancer screening may no longer be beneficial given a patient's limited life expectancy, using direct language such as "You may not live long enough to benefit from this test" is perceived by many patients as overly harsh. Instead, statements such as "This test will not help you live longer" may be better received. Although not studied, this same approach may be helpful for de-prescribing efforts. (LOE = 4)(www.essentialevidenceplus.com)

Reference
Schoenborn NL, Lee K Pollack CE, et al. Older adults' views and communication preferences about cancer screening cessation. JAMA Intern Med 2017;177(8):1121-1128.

Study design: Cohort (prospective)

Funding source: Government

Setting: Outpatient (any)

Synopsis
Many guidelines, such as those from the Choosing Wisely campaign, suggest stopping screening for cancer at an age when early identification is not likely to produce a net benefit. This study enrolled 40 patients, with an average age of 75.7 years, to collect their thoughts about how the topic of stopping screening should be broached. Individuals were interviewed after they were given a brief overview of the benefits and harms of cancer screening, using common cancers as examples. They were also told that someone who will not live for 10 more years might not benefit and might be harmed by screening. Patients were then asked what factors they would consider to stop getting regular screening, and what their reactions would be if a clinician suggested stopping screening. Patients were interviewed by an investigator not known to them and the interviews were recorded, transcribed, and open-coded to identify themes. Transcripts were coded independently by 2 investigators. Three themes emerged: (1) participants were amenable to stopping cancer screening, especially if suggested by a trusted clinician; (2) they objected to the concept that a clinician could accurately predict life expectancy; and (3) they preferred that a clinician explain a recommendation to stop screening by incorporating individual health status, but were divided as to whether life expectancy should be brought into the discussion.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

POEMs are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com(www.essentialevidenceplus.com).

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