Changes to cervical screening announced
CHANGES to the National Cervical Screening Program (NCSP) have been announced in a special issue of NPS RADAR, the publication from NPS Medicinewise Rational Assessment of Drugs and Research. The changes will come into effect in May 2017. The key changes will be replacing Pap smears with human papillomavirus (HPV) testing of cervical samples with partial HPV genotyping, and reflex liquid-based cytology (LBC) on samples testing positive for HPV; increasing entry age from 18 to 25 years; and extending the screening interval from 2 to 5 years. Women will exit the program if they have a negative HPV test between 70 and 74 years of age. Negotiations are also underway for a national register for cervical screening to replace the current state- and territory-based registries. Although the new tests are not currently available on the Medicare Benefits Schedule, they will be subsidised from May 2017. The RADAR special issue said that HPV testing with partial genotyping combined with LBC triage for HPV-positive women was an effective strategy for early detection of cervical abnormalities, with equivalent or better sensitivity, specificity and positive predictive value compared with the Pap smear. It said while it was possible that cervical cancer may go undetected in women who test negative for high-risk HPV genotypes until symptoms appear, no screening test was 100% accurate. “Despite this possibility the renewed NCSP is predicted to reduce incidence and mortality from cervical cancer by at least 15%, which is a major improvement.”
Reassurance for pregnant women with cancer
RESEARCH published in the New England Journal of Medicine suggests the diagnosis of cancer during pregnancy is not necessarily an indication to terminate. The US multicentre case–control study compared 129 children whose mothers received a diagnosis of cancer during pregnancy with 129 children of women without a cancer diagnosis. Health questionnaires and medical files were used to collect data on neonatal and general health, and all children were prospectively assessed at 18 months, 36 months, or both, with a cardiac assessment performed at 36 months. During pregnancy, 96 children (74.4%) in the exposure to cancer group were exposed to chemotherapy (alone or in combination with other treatments), 11 (8.5%) to radiotherapy (alone or in combination), 13 (10.1%) to surgery alone, two (1.6%) to other drug treatments and 14 (10.9%) to no treatment. The research showed children who had prenatal exposure to cancer and the associated stress, imaging studies and treatments had normal development during testing at 18 months, 36 months, or both. “In particular, chemotherapy had no clear adverse effects on postnatal growth or on cognitive or cardiac function”, the authors wrote. They said the reassuring outcome might be explained by the timing of chemotherapy administration as all chemotherapy cycles were administered after the first trimester of pregnancy. The likelihood of prematurity was higher in the exposure to cancer group than in the general population. However, the authors wrote that preterm babies were “unlikely to have unique problems more serious than those of preterm babies born of women without cancer during pregnancy”. An accompanying editorial said the data “should be reassuring to women who are facing a new diagnosis of cancer during pregnancy and to their families”.
Heart impacts of psychological distress
A LONG-TERM study that followed 6714 people born in 1958 has found those who had psychological distress at any period in their lifetime were at increased risk for cardiometabolic diseases at age 45 years. The study, published in the Journal of the American College of Cardiology, was based on members of the 1958 British Birth Cohort Study who had completed repeated measures of psychological distress and a biomedical survey at age 45 years. Psychological distress profiles over the life course (no distress, childhood only, adulthood only, or persistent distress) were identified from six assessments between age 7 years and 42 years. Cardiometabolic risk was based on nine biomarkers of immune, cardiovascular, and metabolic system function. Almost half (49.3%) of the sample reported no significant psychological distress at any point in childhood or adulthood, 10.7% had persistent distress (both childhood and adulthood), 25.1% had distress only in childhood and 15.0% had distress only in adulthood. A larger proportion of female (13%) than male (9%) participants had persistent distress. Compared with the no distress reference group, people with childhood only, adulthood only and persistent distress had significantly higher cardiometabolic risk scores in sex-adjusted models. Even though adjusting for other childhood covariates in addition to sex somewhat attenuated the estimates, all associations remained significant. The authors wrote that the estimated effect on cardiometabolic risk was greater than that of being overweight in childhood and comparable to having lower childhood socioeconomic position. They said the study provided support “for the importance of attending to early emotional development as a primordial prevention strategy”. An accompanying editorial said that given the prospective link between childhood distress and subsequent cardiovascular disease (CVD) risk, “this study reminds us that we must seriously address our patients’ psychological needs if we want to prevent CVD-related pathology”.
Antidepressant decision aid improves quality of care
A DECISION aid designed to help patients and primary care doctors consider available antidepressant treatments for moderate-to-severe depression has improved the quality of care for patients but not depression outcomes, according to research published in JAMA Internal Medicine. The aid was assessed in a cluster randomised trial of 297 adults with depression considering treatment with an antidepressant who attended 117 doctors in 10 rural, suburban and urban primary care practices in the US. Patients were randomly allocated to treatment of depression with or without use of the depression medication choice (DMC) decision aid, which included a series of cards highlighting the effect of the available antidepressant options during face-to-face consultations. Patients in the decision aid group reported significantly higher comfort with treatment decisions and were more knowledgeable and satisfied compared with patients in the control arm. Doctors using the aid also reported more comfort with the treatment decision. However, there was no observed difference between the two patient groups in control of depression symptoms, remission rate or responsiveness at 3 and 6 months, or in medication use or adherence. The authors wrote that several practice guidelines called for shared decision making in the management of depression “under the premise that for treatment to be effective, patients need to actively participate and adhere to these treatments despite their side effects, cost, and burden”. They said the DMC could “provide a means to meet this recommendation”. An accompanying commentary said that decision aids to inform patient choices about depression treatment could be useful across systems that had variable available resources.
Benefits of diabetes behavioural programs limited
TWO meta-analyses published in the Annals of Internal Medicine to evaluate the effectiveness of behavioural programs for patients with type 1 and type 2 diabetes have both found the programs offer some benefits for glycaemic control, but limited improvements in other outcomes. The type 1 diabetes meta-analysis included 35 prospective controlled studies involving participants of any age group that compared behavioural programs with usual care, active controls or other programs. The researchers found that, overall, behavioural programs had some benefit for reducing HbA1c when follow up extended beyond the immediate post-intervention period. There was wide variation in the duration of programs, ranging from 1.5 months to 25 months. They wrote that “current evidence does not support encouraging patients with [type 1 diabetes] to participate in behavioral programs to improve outcomes apart from HbA1c”. The type 2 diabetes meta-analysis included 132 randomised, controlled trials evaluating behavioural programs compared with usual care, active controls or other behavioural programs. It found that most lifestyle and diabetes self-management education (DSME) and support programs (usually offering ≥11 contact hours) led to clinically important improvements in glycaemic control (≥0.4% reduction in HbA1c), but that DSME programs without added support (particularly those offering ≤10 contact hours) provided little benefit. The researchers wrote that the effectiveness of behavioural programs on glycaemic control was moderated to the greatest extent by program intensity and to a lesser extent by delivery personnel or format (eg, individual v group). “It seems that programs require a substantial amount of contact time or, for DSME-based programs, a support component to best train people in their self-care”, they wrote.
Rising health costs not inevitable with ageing
THE WHO’s latest World report on ageing and health says that as more people reach advanced old age, enabling people to lead long and healthy lives may actually ease inflation pressures on health care costs. In an introduction to the report, Dr Margaret Chan, the director-general of the WHO, said that the report emphasised that healthy ageing was more than just the absence of disease. Dr Chan said that for most older people, maintenance of their functional ability was their highest priority. “The greatest costs to society are not the expenditures made to foster this functional ability, but the benefits that might be missed if we fail to make the appropriate adaptations and investments”, Dr Chan wrote. “The recommended societal approach to population ageing, which includes the goal of building an age-friendly world, requires a transformation of health systems away from disease-based curative models and towards the provision of integrated care that is centred on the needs of older people.” The report said that in some high-income countries health care expenditure per person fell significantly after the age of around 75 years, while expenditure on long-term care increased. It said that although the greatest health care costs were associated with the last year or two of life, this relationship varied significantly among countries. “For example, around 10% of all health-care expenditures in Australia and the Netherlands, and around 22% in the United States of America, are incurred in caring for people during their last year of life”, the report said.