Preventing cervical cancer with HPV vaccine

Human papillomaviruses (HPV) are the subject of the cover article of AFP's November 15th issue, authored by Drs. Gregory Juckett and Holly Hartman-Adams from the West Virginia University Robert C. Byrd Health Sciences Center School of Medicine. While "low risk" HPV types 6 and 11 cause up to 95 percent of genital warts, "high risk" HPV types 16 and 18 cause the majority of cervical cancers. In recognition of these risks, the American College of Obstetricians and Gynecologists recently recommended that women older than 30 years receive high-risk HPV DNA testing in addition to cytology for cervical cancer screening.

Previous issues of AFP reviewed the efficacy of the quadrivalent HPV recombinant vaccine and recommendations for its administration by the American Cancer Society and the CDC's Advisory Committee on Immunization Practices. HPV vaccine is only the second cancer-preventing vaccine, after hepatitis B vaccine (which prevents liver cancer). However, Drs. Juckett and Hartman-Adams observe in their article that implementing HPV vaccine recommendations has been challenging:

Controversy about HPV vaccination involves its high cost (approximately $150 per injection), uncertain duration of protection, and concerns that it provides tacit approval of sexual activity and a false sense of security. In addition, the necessity of vaccinating girls as young as nine to 11 years, before they become sexually active, unsettles many parents. There has been criticism for aggressive marketing of HPV vaccine to older women already exposed to HPV, while less attention has been given to the subpopulations at highest risk.

AAFP News Now recently reported that HPV vaccination rates in 2009 varied widely from state to state, with 44.3 percent of teenage girls nationally having received at least one dose and 26.7 percent having completed the 3-dose series. Just last week, a U.S. Food and Drug Administration advisory committee meeting reviewed the evidence that HPV vaccination prevents anal cancer in men who have sex with men. How the committee's reported decision to approve HPV vaccine for this indication will affect future national recommendations for vaccination in males remains to be seen.

How has the availability of HPV vaccine affected your practice? What approach do you take in discussions with adolescents and parents? We would love to hear about your experiences.

Asthma management: a stepwise approach

The November 15th issue of AFP features an updated clinical review of medical therapies for asthma, based on the 2007 Expert Panel Report of the National Asthma Education and Prevention Program (NAEPP). This review recommends a "stepwise approach" for asthma management in patients 12 years and older, depending on the severity of asthma and response to first-line medications. Persons with intermittent symptoms may use an inhaled short-acting beta-agonist as needed; older children and adults with persistent asthma generally require daily inhaled corticosteroids, and possibly additional medications.

Another component of effective management is the use of written asthma action plans for patients to monitor asthma control outside of planned office visits and to take physician-approved steps to address worsening symptoms. The article includes examples of asthma action plans for children and adults, as well as a link to a short video about asthma action plans on Familydoctor.org.

For information about related clinical issues such as the role of allergens in asthma, treatment of asthma in young children, managing acute exacerbations, and practice-level approaches to planned asthma care, you can consult our AFP By Topic collection.

Telephone triage for suspected influenza

Although the Centers for Disease Control and Prevention's weekly flu tracking report showed "low" influenza activity in the U.S. as of the publication date of AFP's November 1, 2010 issue, we know that it is only a matter of time before family physicians' offices are filled with patients either seeking the vaccine or presenting with symptoms of an acute infection. Accordingly, this issue contains several key resources for managing influenza, including a focused clinical review of testing and treatment; a Tip on the effectiveness and limitations of oseltamivir (Tamiflu) for reducing flu duration in children; and an updated influenza management guide from the University of California at San Francisco's Department of Family and Community Medicine. The guide suggests using "telephone triage" to reduce office visits that can potentially transmit influenza to other patients and staff:

Telephone triage can assess severity of symptoms and identify patients at risk of complications who would benefit from expedited access to antiviral medications, which can then be prescribed by telephone or fax. This approach provides timely access to treatment while reducing waiting room exposures. Conversely, if telephone triage identifies concerning symptoms that would require outpatient or emergency department evaluation, this can be arranged and expedited.

For additional information about best practices and a sample protocol for telephone triage, you can refer to a previous editorial by Jonathan L. Temte, MD, PhD. This editorial and other up-to-date resources, including the CDC's 2010-11 vaccination guidelines, are all included in AFP's Influenza Topic Collection. Finally, you can also click on the CDC's Flu.Gov widget, located on the lower right border of this blog, for updates and alerts throughout the influenza season.

Do you use AFP to teach evidence-based medicine?

For the past few days, I participated in the annual Northeast Region meeting of the Family Medicine Education Consortium in Hershey, Pennsylvania. In addition to presenting a well-received session on social media tools in family medicine (including the AFP Community Blog), I attended a thought-provoking seminar on "Reinventing Journal Club: Innovations in the Internet Age" led by faculty and residents from the University of Rochester. This seminar demonstrated their program's successful experience with increasing residents' use of AAFP-recommended evidence-based medicine resources such as reports from the Agency for Healthcare Research and Quality, the Cochrane Database of Systematic Reviews, and Essential Evidence Plus to answer clinical questions.

At the end of the seminar, I asked the presenters if they encouraged their residents to read American Family Physician, and what role the journal plays in their evidence-based medicine curriculum, if any. (After all, we require AFP's clinical review authors to consult the same types of EBM resources as part of their literature searches and to label key clinical recommendations using the rigorous Strength-of-Recommendation Taxonomy.) Their response was that everyone reads AFP, so they didn't necessarily see a need to promote the journal as a resource.

In a previous editorial, AFP Deputy Editor Mark Ebell, MD, MS argued that rather than focusing on the skills needed to analyze original research studies, the typical family physician should instead aim to be an "informed consumer of the secondary literature" and "an expert at assessing the quality of an information source." Since medical school and residency are the best times for family physicians to develop skills in answering clinical questions, we would like to know how teachers of family medicine are using the journal for this purpose. Are there any particular AFP features that you find especially useful for teaching EBM, or areas where you feel we could improve? We welcome your feedback and suggestions.

Complementary and alternative medicine: what should FPs and patients know?

Since 2003, AFP has published an occasional series of articles evaluating the evidence for complementary and alternative medicine (CAM) therapies, ranging from ecinachea to probiotics to yoga and meditation for anxiety and depression. In an editorial introducing the series, associate medical editor Sumi Sexton, MD wrote:

The intent of this new AFP series is to summarize and label the evidence behind various alternative therapies, starting with the most frequently prescribed and well-researched herbal remedies and supplements. ... Currently, an abundance of information on CAM exists in textbooks, journals, newsletters, and Web sites. The purpose of the series is not to replace the existing information or to encourage physicians to prescribe CAM therapies, but rather to extract the most important data in the literature and present it as concisely as possible.

However, as an exchange of letters in the October 15th issue of AFP about an article on acupuncture for pain demonstrates, drawing conclusions about the effectiveness of CAM therapies can be challenging. Dr. Paul Delaney asserts that "in a desire to present information regarding treatments designated as complementary and alternative medicine (CAM), the editors of American Family Physician seem willing to suspend the usual criteria for evidence-based medicine." In rebuttal, Dr. Robert Kelly cites a Cochrane review that supports the effectiveness of acupuncture in relieving chronic low back pain, and Dr. Sexton notes that the article's supporting references "included several RCTs, systematic reviews, and a meta-analysis, which would warrant an evidence level A for any review article."

A recent report from the National Center for Health Statistics found that U.S. adults spent nearly $34 billion in out-of-pocket costs for CAM practitioners and purchases of CAM therapies, classes, and educational materials in 2007. What do you think family physicians and patients should know about CAM, and how would you rate AFP's CAM series at meeting these needs?

Putting depression guidelines into practice

It's difficult to find time to ask about depressive symptoms in practice, and family physicians who want to make screening a priority must also ensure access to follow-up resources that improve patient outcomes. Recently, the U.S. Preventive Services Task Force and the AAFP both updated their clinical recommendations on screening adults for depression. Both organizations now recommend screening only "when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up." The October 15th issue of AFP contains several valuable depression care resources, including a clinical review of postpartum major depression, an abridged version of the USPSTF statement, a case study and quiz questions on applying the USPSTF and AAFP recommendations in practice, and an editorial about the experience of the integrated delivery system MaineHealth in improving depression screening and care for its members.

Readers seeking to remodel their care management processes to be consistent with the latest depression guidelines will find the editorial to be a good start. In addition, AFP and its sister publication, Family Practice Management, offer helpful online content on proven staff-assisted depression care supports, including validated screening tools, patient registries, and communication strategies to encourage self-management. Finally, you can find links to these resources and more in the AFP By Topic collection on depression and bipolar disorder.