Monday, May 23, 2016

Preventing cancer with lifestyle counseling

- Jennifer Middleton, MD, MPH

You may have heard about a study examining the correlation among lifestyle habits and cancer that has been making headlines in both the medical and lay press this past week; the researchers found that individuals who met their criteria of a "healthy lifestyle pattern" had significantly lower risk of developing multiple types of cancers. This finding should further bolster our efforts to provide lifestyle counseling to our patients.

The study researchers examined data from the Nurses' Health Study (NHS) and the Health Professionals Follow-up Study (HPFS), both large U.S. population cohorts. The NHS has been following female nurses since 1976, and the HPFS has been following male health professionals since 1986. Both cohorts are composed of entirely white individuals. The researchers divided each cohort into two groups: those enrollees who met 4 criteria for a "healthy lifestyle pattern" (never smoked or less than 5 pack-years of smoking, no or moderate alcohol intake, BMI between 18 and 27.5, and at least 75 minutes of vigorous aerobic activity a week and/or 150 minutes of moderate physical activity a week) and everyone else, that is, those who did not meet all 4 criteria and therefore fell into the "high risk group." Since they assumed that even the high risk group might still follow healthier behaviors compared to the general population, given that the cohort enrollees all worked in the health professions, they also compared their findings against the U.S. white population as a whole.

The researchers included most cancers in their analyses but excluded skin, brain, lymphatic, and hematopoietic cancers ("because these cancers likely have other strong environmental causes"), along with non-fatal prostate cancers ("given the concern for prostate-specific antigen screening"). 18.5% of the women fell into the healthy lifestyle group, compared to 25.3% for men. 4.6% of the women in the healthy lifestyle group developed cancer compared to 6.2% of women in the high risk group and 7.9% of women in the general US white population; 2.8% of the men in the healthy lifestyle group developed cancer compared to 4.3% in the high risk group and 7.6% in the general US white population. The risk of mortality from cancer follows a similar trend for both genders. The numbers that have been widely quoted in the media in the last week, the population attributable risk, suggests a 20-40% lower cancer incidence and an approximately 50% lower cancer mortality rate among the healthy lifestyle groups compared to the high risk groups. It's not necessarily unreasonable to extrapolate these results to non-white populations, but hopefully future studies will include a more diverse population.

It's important to remember that cohort studies can demonstrate an association or correlation between risk factors and disease, but they cannot definitively prove causation in and of themselves. Regardless of this caveat, the media coverage of this study (which rarely seems to include this point) may still spur more patients to discuss lifestyle counseling with us. The current issue of AFP reviews the recent United States Preventive Services Task Force (USPSTF) recommendations regarding tobacco smoking cessation, which serves as a good reminder that even brief behavioral interventions can help our patients quit smoking. Physicians and their staff can maximize the efficacy of behavioral interventions by providing them repeatedly, since the intensity of counseling does correlate with quit rates. Providing nicotine replacement therapy is also an effective option for helping patients quit.

Many patients may already connect tobacco use with an increased risk for cancers, but I suspect few relate excessive alcohol use, obesity, and/or lack of exercise to an increased cancer risk. Discussing this study's findings with patients may help encourage lifestyle changes, since fear of developing cancer generally ranks quite high among our patients' health concerns. Here are some recent AFP articles that provide additional information regarding counseling for excessive alcohol use, obesity, and exercise. For more in-depth reading, check out the AFP By Topics on Alcohol Abuse and DependenceObesity, and Health Maintenance and Counseling.

Monday, May 16, 2016

Countdown to World Family Doctor Day

- Kenny Lin, MD, MPH

On Thursday, May 19th, the World Organization of Family Doctors (WONCA) will celebrate World Family Doctor Day, a day that since 2010 has highlighted the roles and contributions of family physicians in health and health care systems worldwide. The term "global health" has evolved from being used primarily to describe volunteer medical work in developing countries to a broader concept that recognizes the easy transmission of infectious diseases across continents and international boundaries (e.g., outbreaks of Ebola and Zika virus) and the presence of international refugee and immigrant populations with specific medical needs in the "backyards" of the United States. In a 2015 AFP editorial, Drs. Ranit Mishori and Jessica Evert explained why incorporating global health experiences into Family Medicine training and practice "matters now more than ever":

Global health exposure internationally and locally helps develop a broader health system perspective, greater attention to the social determinants of health, and an understanding of population health concepts. Engaging in global health can bolster cross-cultural competencies, along with the desire to work in resource-poor settings. Additionally, it can strengthen skills and passion to care for underserved populations domestically. A few studies have even suggested an association between global health experiences and an increased interest in primary care.

Dr. Kyle Hoedebecke, the American Academy of Family Physicians' New Physician representative to WONCA Polaris, wrote a blog post last year about why new physicians should care about global health and hosted an episode of "Family Medicine On Air" directed at family medicine interest groups (FMIGs) in the U.S. This year, Dr. John Parks, whose health policy fellowship research into the global landscape of family medicine training informed the AAFP's World Health Mapper online tool, will host a live Google Hangout at 11 AM Eastern on World Family Doctor Day. Medical students can submit questions for Dr. Parks, who is now a faculty lecturer in the Department of Family Medicine at the University of Malawi College of Medicine, by e-mailing their FMIG Network Regional Coordinator by Wednesday, May 18th.

Monday, May 9, 2016

Prescribing exercise to help back pain and decrease injurious falls

- Jennifer Middleton, MD, MPH

The current issue of AFP features the Top 20 Research Studies of 2015 for Primary Care Physicians, and two of the included studies discuss exercise's benefits: one for chronic low back pain and the other for decreasing the rate of injurious falls in older women. These studies provide specific recommendations to offer patients that can improve their quality of life.

The first study randomized patients with chronic low back pain to one of three treatments: an individual walking program, an exercise class, and physical therapy. Patients ranged in age from 18 to 65 years (mean around 45 years) and had at least 12 weeks of pain. As Drs. Ebell and Grad discuss in the AFP article, the walking program group cost the least, had the highest level of adherence, and resulted in the best improvements in pain and disability scores. Walkers received a pedometer and an exercise prescription to start with 10 minutes of walking 4 days a week, eventually working their way up to 30 minutes 5 days a week.

The second study examined the efficacy of exercise and vitamin D in home-dwelling women aged 70-80 years. Participants were randomized into four groups: exercise only, vitamin D supplementation only, exercise and vitamin D supplementation, and control (neither exercise or vitamin D supplementation). The two study groups that included exercise participated in group exercise classes twice a week for a year and then once a week after; on rest days, they had a home training program to follow. The researchers found no difference in the rate of falls per group but did find that participants in both of the exercise groups were much less likely to sustain an injury from their falls; the researchers defined an injurious fall as one where participants sought medical attention for anything from bruises to fractures. As an aside, they found no benefit for vitamin D, reinforcing what Dr. Lin recently wrote about vitamin D supplementation on this blog.

These two studies provide additional reasons to recommend exercise to two groups of patients: those with chronic low back pain and community-dwelling women aged 70-80 years. Providing an exercise prescription to patients that details your recommendations about aerobic, resistance, and flexibility training can increase adherence; you can see an example in Table 4 of this AFP article on Exercise and Older Patients. This article on Physical Activity Counseling includes an exercise calendar template (online Figure C) that may be useful for patients in the context of an exercise prescription, and this article on Promoting and Prescribing Exercise for the Elderly includes helpful strategies for counseling older adults.

To be effective, however, the United States Preventive Services Task Force (USPSTF) found that a minimum of 31 minutes of counseling was necessary to effect behavior change related to exercise habits. In the studies the USPSTF examined, physicians were usually not the providers of the counseling, and in-person and telephone counseling were both effective. This finding may feel discouraging, but family physicians can employ a team-based approach to helping patients increase their physical activity; physicians can initiate the conversation and explore readiness to change using motivational interviewing techniques before referring patients to a nurse or medical assistant educator to provide additional support.

Will these two "Top 20" studies change how you - and your office team - counsel patients about exercise?

Monday, May 2, 2016

Don't delay palliative care in heart failure

- Kenny Lin, MD, MPH

For me, the words "palliative care" bring to mind a picture of a patient suffering from incurable cancer, perhaps one that has spread to the bone or brain. Avoiding death from cancer, even via screening tests or therapies that increase the risk of death from other causes (thus providing no overall health benefit) is a reason that physicians sometimes cite for continuing cancer screening long beyond what guidelines recommend. Clinicians may be less likely to view patients with non-cancer diagnoses, such as end-stage heart disease, as potentially eligible for palliative or hospice care, Dr. Marc Kaprow wrote in a 2010 editorial in American Family Physician. In a 2013 editorial, Drs. Rebecca McAteer and Caroline Wellbery encouraged readers to take a broader view of this underutilized service:

Palliative care improves the quality of life for patients with a life-threatening illness and for their families. It aims to relieve suffering by identifying, assessing, and treating pain and other physical, psychosocial, and spiritual problems. Palliative care can be provided whether an illness is potentially curable, chronic, or life-threatening; is appropriate for patients with noncancer diagnoses; and can be administered in conjunction with curative-aimed therapies at any stage of the illness.

Heart failure provides a good example of a condition that benefits from palliative care, especially in its advanced stages. Although increasing resources have been devoted to preventing heart failure readmissions, palliative care interventions remain poorly integrated despite the downward disease trajectory that nearly all patients experience. A 2009 review in Circulation concluded that palliative care improved patient and family satisfaction; facilitated communication between patients and health professionals; increased access to community support services; and was associated with a greater likelihood of patients dying at home. It also produced significant cost savings from fewer invasive end-of-life interventions and hospitalizations.

A more recent review in BMJ summarized the past 5 years of medical literature on palliative care in heart failure. Common symptoms that palliative care can address effectively include pain, breathlessness, fatigue, and depression. Older adults with heart failure have 4-5 comorbidities on average and are more likely to experience frailty than the general population. As rising numbers of these patients receive implanted cardioverter defibrillators and left ventricular assist devices, device deactivation is rarely discussed even when patients become critically ill. The American Heart Association encourages scheduling an "annual heart failure review" to provide time for shared decision-making around these topics and to assure that treatment intensity and future plans are aligned with patients' goals and preferences.

Monday, April 25, 2016

Hyaluronic acid injections don't help knee DJD

- Jennifer Middleton, MD, MPH

Options for helping patients with knee degenerative joint disease (DJD) seem to be getting more limited. A POEM in the April 15 AFP reviews a meta-analysis showing that hyaluronic acid injection is no better than sham injection for treating pain from knee DJD. This meta-analysis confirms what other recent studies have found; hyaluronic acid injections don't meaningfully help patients with knee DJD.

The meta-analysis included 19 randomized controlled trials comparing hyaluronic acid injections to sham injections (14 trials), usual care (2 trials), or combined with some other treatment (3 trials). The non-blinded trials did show modest improvement in pain scores, but the double-blinded trials showed negligible improvements, if any. Although early studies of hyaluronic acid suggested it was effective, these studies tended to be small and were frequently unblinded or inadequately blinded. Higher quality double-blinded studies, especially when considered in aggregate in this meta-analysis, did not confirm this benefit.

The placebo effect can be powerful, as evidenced by participants' perceived improvements in the non-blinded trials compared to the double-blind trials. And, perhaps, that is not always a negative; I suspect those participants who did feel better in the non-blinded trials were pleased with the improvements they noted in their pain. Unfortunately, the placebo effect with hyaluronic acid comes with cost and risk; injections can cost hundreds of dollars for one dose, and typical therapeutic regimens involve a series of 3-5 injections over several weeks. Injecting into a joint is also not a zero-risk procedure; although rare, serious complications like joint infection can occur.

Hyaluronic acid injections' limitations should not come as a surprise; a web search of "hyaluronic acid knee injections" reveals many critical lay press articles over the last couple of years, and the American Association of Orthopedic Surgeons (AAOS) even states "We cannot recommend using hyaluronic acid for symptomatic arthritis of the knee" in their Summary of Recommendations for Treatment of Osteoarthritis of the Knee (which was cited in this 2014 AFP article). I suspect, though, that I am not alone in seeing this intervention still commonly offered for patients, both by family physician colleagues and local orthopedists. 

With glucosamine and chondroitin also now out of favor for treating knee DJD, non-surgical options for helping patients are currently limited to oral analgesics and, possibly, intra-articular corticosteroid injections - though the AAOS cites a lack of data regarding corticosteroid injections' efficacy in their summary statement as well. Given the prevalence of knee DJD, we can only hope that researchers are investigating novel treatment methods to help those patients who are not yet (or will never be) candidates for knee joint replacement.

You can read more at the AFP By Topic on Arthritis and Joint Pain, and you might also want to check out the Choosing Wisely recommendations from the AAOS (though Dr. Lin critiqued the limitations of these recommendations in this post from last year). The AFP Choosing Wisely search tool is a handy way to review other interventions shown to be of little utility for orthopedic conditions as well as other specialties; you can access it from the AFP home page or bookmark it on your personalized AFP Favorites page.

How are you treating knee DJD in your office?

Tuesday, April 19, 2016

Obstacles to stopping cancer screening in older adults

- Kenny Lin, MD, MPH

I recognized a glitch in my electronic medical record's decision support software when it prompted me to consider prostate and colorectal cancer screening in a 93 year-old man, who, though remarkably vigorous for his age, was unlikely to live for the additional 10 years needed to benefit from either test. Although deciding not to screen this patient was easy, determining when to stop cancer screening in older patients is often more challenging. In the April 15th issue of American Family Physician, Drs. Brooke Salzman, Kathryn Beldowski, and Amanda de la Paz present a helpful framework for decision making in these clinical situations, where population-level guidance derived from studies of screening younger patients "generally do not address individual variations in life expectancy, comorbid conditions, functional status, or personal preference."

The authors recommend that clinicians take into account not only average life expectancy at a given age, but also significant variations in life expectancy linked to functional impairment and comorbid conditions, using one or more validated prognostic tools. Although the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence about screening mammography in women 75 years or older, modeling studies suggest that women with projected life expectancies of greater than 10 years may still benefit from this test - with these important caveats:

Although the sensitivity and specificity of mammography increase with age, overdiagnosis also increases because of reduced life expectancy and an increased proportion of slower-growing cancers. In other words, women with breast cancer diagnosed at an older age are more likely to die of something else, compared with younger women. In addition, treatment of breast cancer in advanced age is associated with greater morbidity, including an increased risk of postoperative complications and toxicity from chemotherapy.

Similar considerations apply to screening for colorectal cancer, which the USPSTF made a "C" grade recommendation (small population-level benefit, use individual decision making) for adults 76 to 85 years of age and recommended against screening adults older than 85 years, when the harms clearly exceed the potential benefits. Nonetheless, surveys have found that 31% of adults age 85 years and older, and 41% of adults with a life expectancy of less than 10 years, received screening colonoscopies. To discourage overuse of cancer screening without alienating patients, the authors advise: "It is important to convey that a decision to stop cancer screening does not translate into decreased health care. Rather, discussions can focus on health promotion strategies that are most likely to benefit patients in the more immediate future, such as exercise and immunizations."

A recent qualitative study in JAMA Internal Medicine explored the reluctance of primary care clinicians to explicitly incorporate long-term prognosis in the care of older adults. Most study participants relied on their own clinical experience, rather than validated tools, to estimate a patient's life expectancy, and were reluctant to stop screening in relatively younger patients even with limited life expectancies. Barriers mentioned by participants included inadequate training, time constraints, concern about negative patient reactions, competing practice incentives, and fear of lawsuits. Do you share these concerns? What strategies do you use to communicate with an older adult whose age or life expectancy suggests stopping cancer screenings?