Top POEMs of 2018: Screening and Prevention

Top 20 POEMs of 2018

FIT More Acceptable with Better Detection Rate Than gFOBT for Colorectal Cancer Screening

Clinical question
Are the uptake and detection rates better for the fecal immunochemical test than for older guaiac-based screening tests for colorectal cancer?

Bottom line
The fecal immunochemical test (FIT) is more sensitive and specific than the older guaiac-based fecal occult blood tests (gFOBTs) when screening for colorectal cancer. We now know that it is also more acceptable to patients and increases uptake in a centrally administered screening program. Physicians should offer patients the option of FIT or colonoscopy, and should replace their stocks of gFOBTs with FITs in their office practice. (LOE = 1b)

Reference
Moss S, Mathews C, Day TJ, et al. Increased uptake and improved outcomes of bowel cancer screening with a faecal immunochemical test: results from a pilot study within the national screening programme in England. Gut 2017;66(9):1631-1644.

Study design: Non-randomized controlled trial

Funding source: Government

Allocation: Concealed

Setting: Population-based

Synopsis
Previous randomized trials have shown that screening for colorectal cancer, even using the older gFOBTs, reduces disease-specific mortality. The most recent modeling estimates put this benefit at 220 to 270 life-years saved per 1000 persons screened over their lifetime (https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/colorectal-cancer-screening2). The FIT is a newer test for occult blood in the stool that is specific to human blood, and only requires a single sample with no food restrictions prior to testing. But do these advantages translate into greater uptake by patients? In England, the standard of care has been to mail 3 gFOBT cards to all persons aged 60 years to 74 years every 2 years, and ask them to obtain 2 samples from each of 3 separate bowel movements. The current study gave every 28th person (in a region with 1.2 million screening candidates) the newer FIT; the other 27 people got the standard gFOBT. Although not randomized, the authors assure us that the order of persons on the screening list is not influenced by age, sex, socioeconomic status, or other demographic factors. They found that the uptake was significantly higher for the FIT than for gFOBTs (66.4% vs 59.3%; P < .001). Uptake increased for both men and women in all age groups and in all levels of socioeconomic status. The increase in uptake was somewhat greater in men than in women. And among previous nonresponders, the response rate approximately doubled. At lower cutoffs for hemoglobin, the number of colonoscopies required increased three- to fourfold, but the detection rate for cancers and advanced adenomas was also significantly higher. For example, using a cutoff of 40 mcg/g feces, 5.2% of persons had a positive FIT result compared with 1.7% using gFOBTs; the rates of cancer and advanced adenoma detection were 0.24% and 1.29% with the FIT, and only 0.12% and 0.35% with gFOBTs.

Mark H. Ebell, MD, MS
Professor
University of Georgia
Athens, GA

Statins Ineffective for Primary Prevention in Patients 75 Years or Older Without Diabetes

Clinical question
In older people without a history of cardiovascular disease, is statin treatment associated with better outcomes

Bottom line
In this retrospective study, statin treatment in patients 75 years or older without pre-existing cardiovascular disease (CVD) did not change the likelihood of developing CVD or reduce any-cause mortality. However, patients aged 75 to 84 years with diabetes benefitted from treatment. (LOE = 2b)

Reference
Ramos R, Comas-Cufi M, Marti-Lluch R, et al. Statins for primary prevention of cardiovascular events and mortality in old and very old adults with and without type 2 diabetes: retrospective cohort study. BMJ 2018;362:k3359.

Study design: Cohort (retrospective)

Funding source: Government

Setting: Population-based

Synopsis
This study enrolled 46,864 patients 75 years or older with no cardiovascular disease from a population database in Spain. The patients had an average age of 76 years (63% were women) and were followed up for an average of 5.6 years. Of these, 6550 patients began statin treatment in the 18 months before the start of the study. In participants without diabetes there was no difference in the onset of CVD (hazard ratio [HR] 0.94; 95% CI 0.86 - 1.04) or the rate of mortality due to any reason (HR 0.98; 0.91 - 1.05). In patients 85 years or older, there also was no reduction in the likelihood of CVD (HR 0.93; 0.82 - 1.06) or all-cause mortality (HR 0.97; 0.90 - 1.05), However, in patients with diabetes who were between the ages of 75 and 84 years, the likelihood of developing CVD was reduced (HR 0.76; 0.65 - 0.89). All-cause mortality was decreased over an average 5.6 years, with one additional person alive for every 16 persons treated with a statin (number needed to treat [NNT] = 15.63; 9.5 - 49.6). The difference was not significant for any patients 85 years or older.

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

Aspirin's Benefits and Harms Are Less Clear for Primary Prevention in Moderate-Risk Patients (ARRIVE)

Clinical question
Is low-dose aspirin effective for the primary prevention of cardiovascular disease in moderate-risk patients?

Bottom line
In this study, after 5 years of treatment, patients at moderate risk of heart disease who took low-dose aspirin did not show a decrease in coronary events and all-cause mortality, and had slightly more, albeit minor, gastrointestinal bleeding. If you are confused by all the aspirin-related folderol of late, join the club. Using aspirin for primary prevention of cardiovascular disease is not a one-size-fits-all proposition. We need to risk-stratify patients according to benefits and harms and engage in shared decision-making with each patient. (LOE = 1b)

Reference
Gaziano JM, Brotons C, Coppolecchia R, et al, for the ARRIVE Executive Committee. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Lancet 2018;392(10152):1036-1046.

Study design: Randomized controlled trial (double-blinded)

Funding source: Industry

Allocation:Concealed

Setting: Outpatient (any)

Synopsis
Low-dose aspirin for secondary prevention and in the face of acute coronary events is pretty much a slam dunk. But despite of years of research, several meta-analyses, and numerous guidelines, its use for primary prevention still seems to rile people up. These researchers point out that most of the recommendations are largely for patients whose 10-year risk of a coronary event exceeds 20% and the role of aspirin in patients of intermediate risk is less clear. So, they conducted a double-blind randomized trial of 100 mg aspirin daily (n = 6270) or placebo (n = 6276) in patients at moderate risk of coronary artery disease. The study participants were men at least 55 years of age or women at least 60 years of age with a 10% to 20% 10-year risk based on age, sex, smoking status, blood pressure, lipid concentrations, and family history. They excluded patients with diabetes and those at high risk for bleeding complications. Using intention-to-treat analysis, after 5 years the rate of events (a composite of myocardial infarction, stroke, cardiovascular death, unstable angina, or transient ischemic attack) was similar between the treatment groups (4.3% vs 4.5%, respectively). The overall death rate was the same (2.6%) in each group. The aspirin-treated patients had more bleeding events (1% vs 0.5%), although very few had moderate or severe gastrointestinal bleeding. The graphs in the paper demonstrate nearly a linear relationship in outcomes over time, so the projected 10-year outcomes indicate that 9% of the placebo-treated patients would have had a coronary event. Recall last month another study that suggested aspirin's effect was potentially influenced by weight and sex (Rothwell et al. Lancet 2018;392(10145):387-399).

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

Exercise Alone and Various Combinations of Interventions Reduces the Risk of Injurious Falls in Older Adults

Clinical question
Are there specific interventions that are effective in reducing the risk of injurious falls in older adults?

Bottom line
Exercise alone; exercise combined with vision assessment/treatment; exercise combined with vision assessment/treatment and environmental assessment/modification; and clinic-level quality improvement strategies combined with multifactorial assessment/treatment and calcium and vitamin D supplementation are all effective interventions for reducing the risk of injurious falls in older adults. (LOE = 1a)

Reference
Tricco AC, Thomas SM, Veroniki AA, et al. Comparisons of interventions for preventing falls in older adults. A systematic review and meta-analysis. JAMA 2017;318(17):1687-1699.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Foundation

Setting: Various (meta-analysis)

Synopsis
These investigators thoroughly searched multiple databases including MEDLINE, EMBASE, the Cochrane Register, Ageline, and reference lists of relevant trials and reviews for randomized controlled trials that examined fall-prevention interventions for adults 65 years or older. Study authors were also contacted for unpublished studies or additional data. Two investigators independently reviewed all potential studies for inclusion criteria and methodologic quality using standard risk-of-bias scoring tools. Conflicts were resolved by consensus agreement with a third reviewer. The primary outcome of interest was the number of injurious falls and fall-related hospitalizations. A total of 283 randomized trials and 20 companion reports (N = 159,910 participants) met inclusion criteria. The overall risk of bias among the studies was moderate, with an unclear risk of bias for allocation concealment, contamination, and selective outcome reporting. A funnel plot analysis found no evidence of publication bias. Four interventions were significantly associated with a reduced risk of injurious falls compared with usual care: exercise alone; combined exercise and vision assessment and treatment; combined exercise, vision assessment and treatment, and environmental assessment and modification; and combined clinic-level quality improvement strategies, multifactorial assessment and treatment, calcium supplementation and vitamin D supplementation. Combined exercise and vision assessment and treatment was the most effective intervention. In a subgroup analysis, the best intervention for reducing the risk of hip fracture was combined osteoporosis treatment, calcium supplementation, and vitamin D supplementation.ealth status, but were divided as to whether life expectancy should be brought into the discussion.

David C. Slawson, MD
Professor and Vice Chair of Family Medicine for Education and Scholarship
Atrium Health
Professor of Family Medicine, UNC Chapel Hill
Charlotte, NC

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).