Press releases Monday 27 July to Friday 31 July 2009
Please remember to credit the BMJ
as source when publicising an article and to tell your readers that they can
read its full text on the journal's website (http://www.bmj.com).
(1) Smear tests for under 25s have little impact on cancer rates
(2) Questions over treatment policies for women with abnormal smear test results
(3) Simple urine test could help cut chlamydia in men
(4) The authoritative swine flu guide from BMJ Group
(5) Legalised euthanasia is not detrimental to palliative care
(1) Smear tests for under 25s have little impact on cancer rates
(Research: Effectiveness of cervical screening with age: population based case-control study of prospectively recorded data)
http://www.bmj.com/cgi/doi/10.1136/bmj.b2968
(Research: Short term persistence of human papillomavirus and risk of cervical precancer and cancer: population based cohort study)
http://www.bmj.com/cgi/doi/10.1136/bmj.b2569
(Editorial: Cervical screening according to age and HPV status)
http://www.bmj.com/cgi/doi/10.1136/bmj.b3005
Cervical screening in women aged 20-24 has little or no impact on rates of invasive cervical cancer up to age 30, concludes a study published on bmj.com today.
A second study shows that the risk of developing pre-cancerous lesions on the surface of the cervix (known as cervical intraepithelial neoplasia or CIN) is much higher in women with persistent human papillomavirus (HPV) infection, especially the high-risk HPV types 16 and 18.
Together, these findings highlight the challenges faced by policy makers in balancing the benefits and harms of screening women at different ages and at different levels of risk.
In 2003, cervical screening in England was moved to start at age 25 as it was felt it did more harm than good in younger women. But recent public controversy has led the government to review whether women aged 20-24 should be offered smear tests, as they are in Scotland, Wales and Northern Ireland.
So researchers at Queen Mary, University of London set out to study the impact of screening on risk of cervical cancer at different ages. They identified 4,012 women aged 20-69 diagnosed with cervical cancer between 1990 and 2008 and a matched group of 7,889 healthy controls of the same age and living in the same area.
They found no evidence that screening women aged 22-24 reduced the incidence of cervical cancer over the next five years (at ages 25-29).
Screening was associated with a 60% reduction of cancers in women aged 40, increasing to 80% at age 64. Screening was particularly effective in preventing advanced stage cancers. However, in younger women, the effect of screening was substantially and significantly less.
For example, screening between the ages of 30 and 37 was associated with a reduction in the risk of cervical cancer over the next five years of between 43 and 60%, while screening at ages 20-24 had no detectable impact on cervical cancer rates under the age of 30.
In fact, a careful review of the screening histories of women aged 20-24 with a diagnosis of cancer suggests that few, if any, of the cancers occurred through a lack of screening, say the authors. Indeed, only five of 73 women had not been screened in the previous six years.
Finally, they point out that the risk of cancer under age 25 in women vaccinated against HPV will be low enough to make screening at such an age unjustifiable. Policy decisions should be based on balancing the benefits and harms of screening and the need to take into account the underlying risk of cervical cancer at different ages, write the authors. "We have provided more accurate estimates of the benefits of cervical screening in different age groups, which should aid policy makers in making their decisions," they conclude.
In an accompanying editorial, three cancer specialists suggest that in many developed countries the low incidence of invasive cervical cancer and the lack of effectiveness of screening in young women indicate that screening should not start before the age of 25. At younger ages, the main challenge is to find the progressive lesions and to avoid treating the remaining lesions, given that treatment may be harmful to future reproductive health, they conclude.
Contacts:
Research: Peter Sasieni, Professor of Biostatistics and Cancer Epidemiology, Cancer Research UK Centre for Epidemiology, Mathematics and Statistics, Wolfson Institute of Preventive Medicine, Bart's and The London School of Medicine, Queen Mary University of London, UK
Email: k.noble@qmul.ac.uk
Philip Castle, Investigator, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
Email: ncipressofficers@mail.nih.gov
Editorial: Guglielmo Ronco, Unit for Cancer Epidemiology, Centre for Cancer Prevention, Turin, Italy
Email: guglielmo.ronco@cpo.it
Three studies published on bmj.com today examine the merits of conservative versus aggressive treatment policies of women with low-grade abnormal results detected by cervical screening.
Together they form the Trial of Management of Borderline and Other Low-grade Abnormal Smears (TOMBOLA).
The first finds no benefit in referring these women for colposcopy (a detailed inspection of the cervix to detect pre-cancerous cells) compared to regular surveillance.
A second paper also questions the benefit of immediate treatment to remove abnormal tissue from the cervix (a procedure known as large loop excision) over the more conservative strategy of taking small tissue samples (biopsies) and recalling women for treatment only if pre-cancerous lesions are confirmed.
Finally, a cost effectiveness study shows that immediate colposcopy is no more, or no less, cost effective than regular surveillance.
The findings are based on data from about 4,500 women aged 20-59 from two regions of Scotland (Grampian and Tayside) and one of England (Nottingham) with borderline or low-grade abnormal smears detected after NHS cervical screening examinations.
In the first study, women were randomised to either repeat smears or to immediate referral for colposcopy. All women were tracked for three years and underwent a colposcopic examination at the end of the study.
The results showed that, although colposcopy detects more high-grade pre-cancerous lesions (known as cervical intraepithelial neoplasia or CIN) than surveillance, it causes more side effects and can lead to over-treatment, complications and later problems in pregnancy. The authors conclude that "a policy of referral for colposcopy after low-grade cervical abnormalities confers no clear benefit compared to cytological surveillance, and causes more side effects."
In the second study, women were randomised to either immediate large loop excision or up to four biopsies with recall for treatment if necessary. Again, women were tracked for three years and underwent a colposcopic examination at the end of the study.
There was no difference between the policies with regard to detection of high-grade cervical intraepithelial neoplasia over three years. However, immediate large loop excision resulted in substantial over-treatment and more after effects than biopsy and recall. The authors conclude that a policy of immediate large loop excision confers no clear advantage over a policy of punch biopsies with recall for treatment, and the latter provides the best balance between benefits and harms.
A cost effectiveness study shows that, taking into account costs, outcomes, and quality of life, follow-up by immediate colposcopy is no more and no less cost effective than follow-up by regular surveillance. The authors conclude that "there is no compelling economic reason to favour any one follow-up method over either of the others."
The dilemma of choosing between conservative and aggressive policies remains, adds Professor Eduardo Franco of McGill University in an accompanying editorial. Further analyses and secondary economic evaluations of the TOMBOLA data may help policy makers fully appreciate the evidence from this landmark study, he says.
Contacts:
Research: Professor Julian Little, Canada Research Chair in Human Genome Epidemiology, Department of Epidemiology and Community Medicine, University of Ottawa, Ontario, Canada
Email: jlittle@uottawa.ca
Or
Linda Sharp, Epidemiologist, National Cancer Registry Ireland, Cork, Republic of Ireland
Email: linda.sharp@ncri.ie
Cost effectiveness study: David Whynes, Professor of Health Economics, School of Economics, University of Nottingham, UK
Email: david.whynes@nottingham.ac.uk
Editorial: Eduardo Franco, Professor of Epidemiology, Departments of Oncology and Epidemiology, McGill University, Montreal, QC, Canada
Email: eduardo.franco@mcgill.ca
A simple urine test for diagnosing chlamydia in men could help reduce the risks of persistent infection and transmission to sexual partners, finds a study published on bmj.com today.
Chlamydia trachomatis infection is the most common sexually transmitted bacterial infection in the United States and United Kingdom, but often has no symptoms and remains undiagnosed. If left untreated it can lead to serious complications in women such as pelvic inflammatory disease, infertility and ectopic pregnancy. Recent evidence also suggests it may cause infertility in men.
Nucleic acid amplification based tests such as the Polymerase Chain Reaction are currently used to diagnosis infection, but they are costly, technically complex and can take several days to obtain the results.
A previous study found that the Chlamydia Rapid Test for women was sensitive and quicker when compared to the polymerase chain reaction test, so researchers assessed the performance of the same test in men.
Just over 1,200 men aged 16 to 73 years attending two clinics in the UK were included in the study. Each participant received an information sheet about the study and provided two urine samples. The first was collected using Firstburst - a device designed to collect the first 4-5 ml of urine that contains higher levels of bacteria. The second was collected using a standard urine cup.
The Chlamydia Rapid Test achieved a high level of sensitivity (82.6%) and specificity (98.5%) compared with the Polymerase Chain Reaction test when using the Firstburst device. It also provided results within one hour, thus allowing positive individuals to be offered treatment while still at the clinic.
This "test and treat" strategy, say the authors, could help reduce the risks of persistent infection and onward transmission. This approach would also be valuable in developing countries, given the high prevalence of chlamydial infection among sex workers in these settings.
A survey of participants also showed that 97.6% found the instructions easy to understand and 97.4% found collection of their urine easy. With regard to waiting time, 95.6% of respondents indicated that they were willing to wait one hour or more, while 4.4% indicated they would not wait more than one hour.
These results indicate that the Chlamydia Rapid Test is suitable as a primary diagnostic tool, especially in settings where patients need to be tested and treated in one visit, say the authors.
More studies are warranted to verify whether the Chlamydia Rapid Test would reassure young men that testing can be quick, simple and non-invasive, and this might increase uptake, they conclude.
Contact:
Helen Lee, Reader in Medical Biotechnology, Department of Haematology, Diagnostics Development Unit, University of Cambridge, UK
Email: hl207@cam.ac.uk
(4) The authoritative swine flu guide from BMJ Group
BMJ Group has developed a Pandemic Flu site (http://pandemicflu.bmj.com/) to bring doctors and healthcare professionals the latest updates on swine flu. The site includes articles, podcasts, learning modules, and other resources, including information for patients, on a range of pandemic flu issues.
Useful links are included to news on numbers of deaths, travel advice, and maps of countries with the highest rates of infection.
Find out more about the start of the outbreak in Mexico and the arrival of a vaccine, plus the reaction of governments, the Health Protection Agency, and Centers for Disease Control and Prevention (CDC) to the pandemic.
Assisted dying laws do not mean that fewer people use palliative care, according to a study published on bmj.com today.
The research also shows that receiving spiritual care in the final three months of life was associated with higher frequencies of euthanasia or physician assisted suicide than receiving little or no spiritual care.
Dr Lieve Van den Block and colleagues from the End-of-Life Care Research Group in Brussels, found that far from opposing each other, life shortening and palliative care complemented one another and often worked in unison.
Previous studies have already revealed that death is often preceded by medical end of life decisions that had a life shortening effect, for example, the use of lethal drugs, continuous sedation or intensifying drugs to alleviate symptoms that also had the effect of hastening death. However, this is the first large scale study exploring the relationship between end of life decisions and end of life care.
Van den Block investigated almost 2,000 non-sudden deaths that took place in Belgium from 2005 to 2006. Belgium is particularly suited to this study because it has well developed integrated palliative care provision as well as legalised euthanasia.
In the study, 32% of patients were 85 or older, 50% were male and cancer was the cause of death for 43% of cases. Assisted dying, intensified prescribing and continuous deep sedation without food/fluid administration were more commonly decided on for patients with cancer.
The authors found that the use of specialist multidisciplinary palliative care in Belgium was often associated with medical decisions to shorten life and that end of life decisions and palliative care do not contradict but worked together.
The concern that euthanasia or physician assisted suicide might be disproportionately chosen by or for patients who do not access palliative care services is not supported in Belgium.
Whether these results would be mirrored in other countries needs to be studied, say the authors, but results will depend on individual legal situations, palliative care systems and medical practice. However, Van den Block argues that studies from Oregon (where physician assisted suicide is permitted) "showed that most patients receiving physician assisted suicide were enrolled in hospice care and that the legalisation of physician assisted suicide has resulted in more hospice referrals and training of physicians in palliative care."
In the accompanying editorial, Dr Ira Byock, a Director of Palliative Medicine in the USA, says that while Van den Block’s research provides "a valuable contribution to understanding the context of dying in Belgium," he is concerned about some of the conclusions being extrapolated from the study.
Byock says the data show that assisted dying is rarely performed in Belgium and "it would be a mistake to suggest that these findings dispel concerns about euthanasia or that they support including euthanasia within palliative care."
Contacts:
Research: Lieve Van den Block, Professor of Communication and Education in General Practice, and Postdoctoral Researcher, End-of-Life Care Research Group, and Department of General Practice, University of Brussels, Belgium
Email: lvdblock@vub.ac.be
Editorial: Professor Ira Byock, Director, Palliative Medicine, Dartmouth-Hitchcock Medical Center, USA
Email: ibyock@aol.com
FOR ACCREDITED JOURNALISTS
For more information please contact:
Emma Dickinson
Tel: +44 (0)20 7383 6529
Email: edickinson@bmj.com
Press Office telephone : 020 7383 6254 (Weekdays : 0900hrs - 1800hrs)
British Medical Association
BMA House, Tavistock Square, London WC1H 9JP
and from:
the EurekAlert website, run by the
American Association for the Advancement of Science (http://www.eurekalert.org)
[[$FOOTER]]