What's new in the other journals?
These snippets are extracts from a monthly service called the Journal Article Summary Service. It is a service that summarises all that is new in obstetrics and gynaecology over the preceding month. If you would like to know the details of how to subscribe, please email the editor Athol Kent at email@example.com or visit the website www.jassonline.com.
Screening mammography in low-risk populations
Screening mammography's role as a means of saving women's lives and as ‘the right thing to do’ has come under close scrutiny in recent years. Breast cancer remains a common and feared disease impacting on women's femininity, image and, for some, their life expectancy. The major factor in favour of mass population screening programmes is the increase in the detection of small lesions (possibly early disease) that have a better prognosis than pathology presenting at a later stage.
Mammography does not diagnose breast cancer. It does detect lesions in the breast that require further elucidation, which may or may not need biopsy and histology. The histology itself is by no means perfect in predicting which lesions are slow-growing or indolent or even benign and which are likely to be rapidly growing aggressive and potentially lethal. Hopefully additional biomarkers, like genetic polymorphisms, will allow clinicians to differentiate between tumours’ prognoses and recommend appropriate action or inaction.
Another issue is that if mammography does indeed detect disease sooner than it would otherwise have been detected, then more breast cancers will be found and the incidence will increase but mortality rates will drop. This is true for populations undergoing screening programmes, which seems to vindicate their introduction but closer inspection of the data shows that mortality rates started dropping before screening was popularised and continues to do so in populations where screening has not been introduced. This raises the possibility that the association of screening and declining death rates may be serendipitous rather than causal.
Medical science has no plausible explanation as to why the prevalence of breast cancers rose dramatically three or four decades ago and has now plateaued and may be decreasing. Certainly more logical surgery, radiotherapy and adjuvant treatments have led to considerably improved prognoses in developed countries. The clarion call that ‘screening can save your life’ is being questioned and its applicability to an individual needs to be weighed up against the potential harms of screening.
The harms of overscreening, false positives and overdiagnosis have been underplayed by those supporting screening whereas those unconvinced by mammography screening have made known their disquiet about biased information. This has come to a head in the UK where blatantly biased promotional material in favour of screening has been reviewed and replaced by more balanced literature. The latest approach is now to ‘consider an offer’ rather than using coercive language that fails to acknowledge the downside of screening (Mayor BMJ 2012;345:e5322). The crucial point is that not accepting an offer of screening is now regarded as a ‘reasonable choice’.
Finally, there are publications that find in favour of screening programmes, and the Journal of Medical Screening has brought out a supplement on the findings of the Euroscreen Working Group (J Med Screen Sept 2012;19:Suppl). This European review of national screening programmes—and not of randomised controlled trials—states that there are more ‘lives saved’ than overdiagnoses in low-risk women who accept offers of regular mammography. However, one of the problems is that as cures become more commonplace the term ‘lives saved’ becomes more difficult to interpret. As normal life expectancy for early disease is well over 90% at present, are claims for ‘saved lives’ still justifiable?
The Euroscreen survey is based on 2-yearly screening starting at age 50 years for the next 20 years—in other words, ten mammograms. They estimate that over a woman's life expectancy (which is 80 years) she will have a 3% chance of dying of breast cancer that can be reduced to 2.2% by screening mammography. Against these data must be weighed the short-term harms of false positives, which are between 1 in 6 and 1 in 2, plus the long-term harms of overdiagnosis and overtreatment, which is about 0.4%. All of these estimates assume free, quality-controlled, state-run consultations and facilities at no cost to the individual in terms of money or time.
The decision to join such a programme or not to join, are both reasonable choices. It is up to the individual and her doctor to decide on personal factors such as fears, desires, resources, the willingness to become involved in the process or not, costs, peer pressure or individual liberty considerations. These are not evidence-based criteria but valid for each person.
What is wrong is to pressurise a woman one way or the other without presenting the available information. This will change with time and it is our clear obligation to remain informed.
Slings to prevent incontinence
About 20% of all women in developed countries will have surgery for prolapse in their lifetime. As populations age and quality-of-life issues gain more significance the number of women having restorative procedures will increase. Fads change but at present vaginal repairs are in favour so research is focusing on what operation and which additional procedures should be carried out.
A proportion of women without urinary incontinence before a vaginal repair will develop stress leakage postoperatively so it would seem logical to place a midurethral sling in situ to prevent the anticipated incontinence at the time of the original operation. To test this hypothesis, Wei et al. from the USA randomised women having a vaginal repair to the insertion of a sling or a sham incision and followed them up for a year (NEJM 2012;366:2358–67).
The addition of the midurethral sling prophylactically did result in lower rates of incontinence at 3 and 12 months with the number needed to treat to prevent one case of incontinence being 6. There were higher rates of adverse events with the extra procedure group but the need for further surgery for incontinence was avoided so the option of a preventive sling should be discussed with women preoperatively.
Human papillomavirus vaccines in the USA
In the USA the Centers for Disease Control and Prevention (CDC) keeps a vigilant eye on the prevalence of many diseases. Among these are cancers caused by human papillomavirus (HPV) at the following sites: cervix, vulva, vagina, penis, anus and oropharynx. The causative role of HPV in these malignancies is most clearly established in cervical cancer but it is suspected that many of the others are preventable through the use of HPV vaccines (Report CDC JAMA 2012;308:445–7).
The CDC Report echoes the Advisory Committee on Immunization Practices recommendation that three doses of vaccine are given to females 11–12 years old and the quadrivalent vaccine be given to males of the same age with catch-up vaccination to ages 26 and 21 years, respectively. They report that about one-third of all girls received the vaccine in the USA in 2010. The recommendation for vaccine use in males was only mandated late in 2011.
They estimate that tens of thousands of cancers can be prevented by broader uptake of primary prevention by vaccines and secondary prevention using cytological and HPV DNA screening. The confounding factor is, as always, that those most vulnerable to the disease are those least likely to be vaccinated or screened. This conundrum is the next frontier to be crossed and will take social and political as well as medical science for progress to be made.
A different way of looking at fractures
Those looking after older women are concerned about fractures—especially hip fractures. It is probable that most of these breakages occur as a result of falls so public health workers have given attention to hip-padding, protectors and the environment in which the elderly live.
But what about eyesight? Do cataracts hinder older people's vision, causing them to fall and would cataract surgery reduce the risk? It seems that it would according to Tseng et al. (JAMA 2012;308:493–501) who calculated the risk of hip fractures in people over the age of 65 years who underwent cataract surgery and those who did not. They measured the odds of hip fracture in people 1 year after surgery compared with those not having surgery. There was a 16% reduction in risk of fracture in women having the operation so when thinking about fracture risk overall, a person's vision is part of the bigger picture.
Do you know about sexting? It is sending a nude image of yourself to someone else by smart phone or email.
Does it sound bizarre or extremely unlikely behaviour—even in the free-wheeling world of today's teenagers with their seemingly unfettered access to the electronic media? It would appear less unusual than many adults would suspect, at least according to a survey in Texas of nearly 1000 teenagers (Temple et al. Arch Ped Adol Med 2012;166:828–33). The researchers found that one-quarter of those canvassed had sent nude pictures of themselves to friends. A similar number had been offered a sext. More than half of those in the study had been asked to send a sext but most were bothered by such approaches or concerned about becoming involved.
Clearly sexting is widespread but does it reflect a moral decline among the youth of America? The lead author thinks not, believing that it is an outlet for teenage boundary-pushing behaviour that technology makes accessible. On the other hand, there was an association between sexting and sexual activity and there was a correlation between sexting and risky behaviour.
Those dealing with adolescent sexual exploration have a new handle to open the door to discussions so sexting is certainly something that people need to know about.