Tuesday, May 31, 2016

Realistic expectations for prostate cancer treatment

- Kenny Lin, MD, MPH

For patients to make informed decisions about treatment for localized prostate cancer, they must receive accurate information about the effects of various therapies and guidance from clinicians who understand their preferences and values. Unfortunately, a study in the May/June issue of Annals of Family Medicine suggested that one or both of these is lacking for many men. Dr. Jinping Xu and colleagues surveyed a population-based sample of 260 men in the metropolitan Detroit area who were newly diagnosed with localized prostate cancer between 2009 and 2010. The survey asked them to estimate how many years they would live without any treatment and with their chosen treatment.

Men greatly underestimated their life expectancy without treatment and overestimated the gain in life expectancy with surgery or radiation. Although 98% of patients with localized prostate cancer who choose active surveillance will not have died from prostate cancer 10 years after diagnosis, only 25% of study participants thought that they would live at least 10 years without treatment. And although the only U.S. study to compare radical prostatectomy to watchful waiting for localized prostate cancer showed no overall or prostate cancer-specific mortality benefit, men in this study who underwent surgery expected to live an average of 12 years longer than if they did not choose surgery. The authors suggested that the typically short time frame for urologists or radiation oncologists to establish patient relationships between diagnosis and treatment discussions may contribute to misconceptions about treatment prognoses. In contrast, they argue that

Primary care physicians, who care for patients over long periods, have the advantage of intimate knowledge of their patients’ approach to clinical decision making and disease management in the course of their prior illnesses. If primary care physicians are included in the decision process following diagnosis, they could begin to focus on helping patients with localized prostate cancer develop realistic expectations and make choices that support their treatment goals.

Whether or not more of these "primary care consultations" have occurred in recent years is unclear, but last week a New York Times story highlighted the increasing number of men with low-risk prostate cancer choosing active surveillance rather than surgery or radiation, from 10-15 percent five years ago to nearly half of men today. Delaying or avoiding the adverse effects of traditional therapies should ultimately reduce the burden of urinary incontinence and sexual dysfunction in many prostate cancer survivors. An article in the May 1st issue of AFP reviewed key American Cancer Society recommendations for primary care of the prostate cancer survivor, including monitoring for common physical and psychosocial issues and encouraging healthy lifestyle choices.

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 overdiagnosis...by 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.