Beneficios y "maleficios" del cribado. El sobrediagnóstico y la medicina anticipativa / Benefits and damages of Screening. Overdiagnosis and anticipatory medicine

Mucho han cambiado los resultados en el tratamiento del cáncer de mama desde la publicación de trabajos que recomendaban la realización de cribados para diagnosticar precozmente los tumores de mama. Los posteriores re-análisis, que mostraron errores en las evaluaciones, los avances en la terapia oncológica y la concienciación de profesionales y público, han demostrado la dudosa efectividad de esta medida y como contrapartida los riesgos dependientes por sobrediagnóstico y sobretratamiento. Por otra parte la falta de información e incluso la desinformación existente sobre el tema, han ocasionado una desorientación entre los posibles beneficiarios del procedimiento. Se les ha recomendado, por parte de organizaciones, plataformas, sociedades privadas y servicios de salud pública, un procedimiento ocultando daños importantes: físicos, psicológicos y económicos. Es fácil promover el examen de mamografía si la mayoría de las mujeres cree que previene o reduce el riesgo de contraer cáncer de seno y salva muchas vidas mediante la detección temprana de tumores agresivos. Desgraciadamente eso no es así. A la vista de ello, existen muchos detractores del cribado que vienen recomendando la información fiable y correcta y la indicación personal no tanto del cribado como de la exploración como procedimiento diagnóstico. Las mujeres deben discutir con sus médicos su propio perfil de riesgo, los posibles beneficios, daños y complejidades de la mamografía de detección, y tomar decisiones informadas sobre la realización del cribado. Definir qué mujeres se beneficiarían de un seguimiento debido a factores de riesgo definidos y aquellas que por el contrario corren más riesgos que beneficios. Un programa de salud pública que claramente no produce más beneficios que daños es difícil de justificar. Proporcionar información clara e imparcial, promover la atención adecuada y prevenir el sobrediagnóstico y el sobretratamiento sería la mejor opción

Treatment of breast cancer has changed markedly since the publication of papers recommending screening programs for early diagnosis. Posterior reevaluations demonstrated mistakes; advances in oncological therapy and better knowledge of the problem have demonstrated the doubtful efficacy of these procedures which, on the other hand have also side effects with risk of overdiagnosis and overtreatment. Misinformation confuses patients. This procedure has been recommended by many institutions without explaining possible important risks. It is very easy to promote mammograms if the majority feel that it reduces risk of breast cancer and saves many lives. Unfortunately this is not the case. At present there are many people against screening who are recommending explicit and precise explanations of the procedure as well as of the importance of physical examination. Women must discuss with their physicians their own risk, possible benefits and eventual risks and damages of mammograms and they must take informed decision about screening. Women should be classified in those with potential benefits of mammograms and those with more risks than benefits. A program which does not offer clearly more benefits than risks cannot be implemented by Public Heath institutions. Complete and impartial information, adequate attention and prevention of overdiagnosis and overtreatment would be the best option

The World Heart Federation criteria raise the threshold of diagnosis for mild rheumatic heart disease: Three reviewers are better than one.

BACKGROUND: The World Heart Federation (WHF) criteria, published in 2012, provided an evidence-based guideline for the minimal diagnosis of echocardiographically-detected RHD. Primary aim of the study was to determine whether use of the WHF criteria altered the threshold for the diagnosis of echocardiographically-detected RHD compared with the previous WHO/NIH criteria. A secondary aim was to explore the utility of a three reviewer reporting system compared to a single or two reviewer reporting structure. METHODS: 144 de-identified echocardiograms (RHD, congenital valvar abnormality, physiological valvar regurgitation) were independently reported using the WHF criteria by two reviewers blinded to the previous WHO/NIH diagnosis. If there was discordance between the two reviewers, a third cardiologist independently performed a tie-breaker review. RESULTS: There was a 21% reduction of cases classified as RHD using the WHF criteria compared to the modified WHO/NIH criteria (68 cases compared to 86, p = 0.04). There was a 60% consensus across the different diagnostic categories with 2 reviewers, 89% majority agreement with 3 reviewers. 11% required an open label discussion. There was moderate agreement between 2 reviewers for any RHD, kappa 0.57 (CI 0.44-0.70), with no significant difference in agreement between the different categories. CONCLUSION: The WHF criteria have raised the threshold for the diagnosis of RHD compared to the WHO/NIH criteria. However, inter-reporter variability of the WHF criteria is high. A three reviewer system is likely more accurate than a single or two reporter system for the diagnosis of mild RHD. This has resource implications for echocardiographic screening programmes.

Is the Montreal Cognitive Assessment (MoCA) screening superior to the Mini-Mental State Examination (MMSE) in the detection of mild cognitive impairment (MCI) and Alzheimer's Disease (AD) in the elderly?

ABSTRACTObjective:To compare the accuracy of Mini-Mental State Examination (MMSE) and of the Montreal Cognitive Assessment (MoCA) in tracking mild cognitive impairment (MCI) and Alzheimer's Disease (AD). METHOD: A Systematic review of the PubMed, Bireme, Science Direct, Cochrane Library, and PsycInfo databases was conducted. Using inclusion and exclusion criteria and staring with 1,629 articles, 34 articles were selected. The quality of the selected research was evaluated through the Quality Assessment of Diagnostic Accuracy Studies 2 tool (QUADAS-2). RESULT: More than 80% of the articles showed MoCA to be superior to MMSE in discriminating between individuals with mild cognitive impairment and no cognitive impairment. The area under the curve varied from 0.71 to 0.99 for MoCA, and 0.43 to 0.94 for MMSE, when evaluating the ability to discriminate MCI in the cognitively healthy elderly individuals, and 0.87 to 0.99 and 0.67 to 0.99, respectively, when evaluating the detection of AD. The AUC mean value for MoCA was significantly larger compared to the MMSE in discriminating MCI from control [0.883 (CI 95% 0.855-0.912) vs MMSE 0.780 (CI 95% 0.740-0.820) p < 0.001]. CONCLUSION: The screening tool MoCA is superior to MMSE in the identification of MCI, and both tests were found to be accurate in the detection of AD.

Búsqueda de cáncer oculto en pacientes con tromboembolismo venoso: un dilema por resolver / Search for occult cancer in patients with venous thromboembolism: A dilemma to resolve

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Estudio comparativo de la supervivencia del cáncer de mama según diagnóstico asistencial versus programa de detección precoz / Comparison of breast cancer survival by diagnosis in the clinical setting versus screening

Objetivo. Comparar la supervivencia del cáncer de mama en mujeres que han sido cribadas en el programa de Detección Precoz del Cáncer de Mama (DPCM) y en las que no han participado en él. Pacientes y métodos. Es un estudio descriptivo y longitudinal en el que se han estudiado todos los cánceres de mama registrados en el servicio de Anatomía Patológica del Hospital de Tortosa Verge de la Cinta (Tarragona) de mujeres de 50-65 años, que se habían detectado la enfermedad ellas mismas o que la había detectado el programa DPCM, desde junio de 1999 hasta junio de 2003. Se registraron 101 pacientes con cáncer de mama, de las que en 84 se pudieron recoger todos los datos relativos al tumor, la cirugía y el tratamiento. En el 2014, tras un seguimiento de 11,6 ± 1,8 años, se anotó el estado actual. Resultados. No hay diferencia estadísticamente significativa en la supervivencia de los 2 grupos. Pacientes con carcinoma in situ y sin ganglios metastásicos se encuentran entre las fallecidas, mientras que ninguna paciente con carcinoma bien diferenciado falleció. Conclusiones. En nuestro estudio, el cribado del cáncer de mama no mejora la supervivencia y determinados factores en los que se apoyan los programas de cribado, como la detección de carcinomas no infiltrantes y/o de ganglios no metastásicos, no aseguran la curación (AU)

Objective. To compare survival in breast cancer between women diagnosed in an early breast cancer detection programme and those not attending this programme. Patients and methods. We conducted a descriptive and longitudinal study that analysed all types of breast cancer registered in the Pathology Service of the Hospital de Tortosa Verge de la Cinta (Tarragona, Spain). Tumour samples were obtained from 50-65-year-old women who had detected alterations on self-examination and from those attending the early breast cancer detection programme from June 1999 to June 2003. All the information relating to the tumour, surgery or treatment was registered. In 2014, after a follow-up of 11.6 ± 1.8 years, the current status of each patient was recorded. Results. There was no significant statistical difference in survival between the two groups of patients. Non-survivors included patients with in situ carcinoma and without lymph node metastases. Survival was 100% in patients with well differentiated carcinoma. Conclusions. Breast cancer screening did not improve survival in our study. The elements on which screening programs are based, such as non-invasive carcinoma detection and/or non- metastatic lymph nodes, do not ensure recovery (AU)

¿La mitad de la población con diagnóstico de depresión? / Half of the population diagnosed with depression?

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Rebajar la edad de diagnóstico del autismo: la neurociencia del desarrollo social afronta un importante problema de salud pública / Reducing age of autism diagnosis: developmental social neuroscience meets public health challenge

El trastorno del espectro autista (autismo) es una familia de trastornos del neurodesarrollo de origen genético y de elevada prevalencia y heterogeneidad que puede tener efectos devastadores para el niño, la familia, y los sistemas sanitario y educativo. A pesar de los avances en la detección sistemática a través de escalas y cuestionarios y en la armonización de los métodos de diagnósticos, la edad de diagnóstico del autismo en Estados Unidos ronda todavía los 4 o 5 años, y aún más en los colectivos desfavorecidos, lo que supone varios años después del segundo o tercer año de vida en que un especialista puede diagnosticarlo con fiabilidad. Dado que la detección y el tratamiento precoz son dos factores primordiales para optimizar el desenlace del trastorno, y dado que el diagnóstico es casi siempre una condición necesaria para que las familias puedan acceder al tratamiento precoz, la rebaja de la edad de diagnóstico se ha convertido en una de las mayores prioridades de la disciplina. Los últimos avances en la neurociencia del desarrollo social anuncian la aparición de métodos basados en el rendimiento, rentables y viables en el ámbito extrahospitalario, y sugieren un método complementario para fomentar el cribado universal y ampliar el acceso al diagnóstico. Estudios pequeños, pero cruciales, ya han descrito experimentos que diferencian grupos de niños en riesgo de sufrir autismo de los grupos de control y, hasta ahora, por lo menos un estudio ha podido predecir la clasificación diagnóstica y el grado de incapacidad por medio de un experimento breve. A pesar de que el camino para convertir esos métodos en eficaces herramientas de cribado diagnóstico será largo y de que conviene evitar conclusiones precipitadas, tal esfuerzo podría ser crítico para abordar este problema de salud pública de alcance mundial (AU)

Autism spectrum disorder (autism) is a highly prevalent and heterogeneous family of neurodevelopmental disorders of genetic origins with potentially devastating implications for child, family, health and educational systems. Despite advances in paper-and-pencil screening and in standardization of diagnostic procedures, diagnosis of autism in the US still hovers around the ages of four or five years, later still in disadvantaged communities, and several years after the age of two to three years when the condition can be reliably diagnosed by expert clinicians. As early detection and treatment are two of the most important factors optimizing outcome, and given that diagnosis is typically a necessary condition for families to have access to early treatment, reducing age of diagnosis has become one of the greatest priorities of the field. Recent advances in developmental social neuroscience promise the advent of cost-effective and community-viable, performance-based procedures, and suggest a complementary method for promoting universal screening and much greater access to the diagnosis process. Small but critical studies have already reported on experiments that differentiate groups of children at risk for autism from controls, and at least one study so far could predict diagnostic classification and level of disability on the basis of a brief experiment. Although the road to translating such procedures into effective devices for screening and diagnosis is still a long one, and premature claims should be avoided, this effort could be critical in addressing this worldwide public health challenge (AU)

De la detección precoz a la atención temprana: estrategias de intervención a partir del cribado prospectivo / From early detection to early care: intervention strategies based on prospective screening

Introducción. El reto de la detección precoz puede realizarse desde una perspectiva evolutiva. Los tratamientos de intervención emprana han demostrado su eficacia siempre y cuando se apliquen sistemáticamente en el marco de una planificación estratégica del tratamiento. Objetivos. Proporcionar una revisión actualizada para responder a las críticas a la detección precoz y aportar una reflexión sobre la estrategia de intervención, basada en la revisión de las técnicas de atención temprana usuales en el campo del autismo, reflejando los aspectos más relevantes que se deducen de las experiencias y estudios llevados a cabo hasta el momento. Conclusiones. Tras la revisión realizada se concluye que la detección precoz puede ser más eficiente si se lleva a cabo en el marco de la vigilancia del desarrollo, que además ofrece la oportunidad de proporcionar orientación sobre el desarrollo del menor. La atención temprana constituye un recurso eficaz para atender las necesidades del menor con autismo. Los profesionales tienen la responsabilidad de evaluar el trabajo que hacen con una actitud reflexiva y crítica sobre los tratamientos disponibles tomando en consideración los valores y las preferencias de las familias. Los programas deben centrarse en los síntomas nucleares aplicando ingredientes activos del tratamiento (AU)

Introduction. The challenge of early detection can be tackled from an evolutionary perspective. Early intervention treatments have shown themselves to be effective provided that they are applied systematically as part of the strategic planning of the treatment. Aims. The aim of this study is to provide an updated review in response to the criticism targeted towards early detection and to offer some considerations on the intervention strategy. Our research is based on a review of the early care techniques that are commonly used within the field of autism and it intends to reflect the most significant aspects that can be deduced from the experiments and studies carried out to date. Conclusions. From the findings of the review it can be concluded that early detection may be more efficient if carried out within the framework of developmental surveillance, which also offers the opportunity to provide guidance on the child’s development. Early care is an effective resource for attending to the needs of children with autism. Professionals have the duty to assess the work they do on available treatments with a reflexive, judicious attitude, taking into account the values and preferences of the families. Programmes must focus on the core symptoms and apply the active ingredients of the treatment (AU)

[Clinical and ethical differences between diagnosing and screening].

Screening is often defined as systematic examinations of healthy citizens to identify those with asymptomatic disease. In our modern society many persons have chronic conditions and it is not so easy to draw the line between healthy and unhealthy citizens. Today, many health-care activities aim at detecting conditions at an early non-symptomatic stage of the disease process in order to be able to avoid possible progression to the next stage. On this basis, we suggest to broaden the definition of screening to reflect the realities of modern health care.

Effective classification of the prevalence of Schistosoma mansoni.

OBJECTIVE: To present an effective classification method based on the prevalence of Schistosoma mansoni in the community. METHODS: We created decision rules (defined by cut-offs for number of positive slides), which account for imperfect sensitivity, both with a simple adjustment of fixed sensitivity and with a more complex adjustment of changing sensitivity with prevalence. To reduce screening costs while maintaining accuracy, we propose a pooled classification method. To estimate sensitivity, we use the De Vlas model for worm and egg distributions. We compare the proposed method with the standard method to investigate differences in efficiency, measured by number of slides read, and accuracy, measured by probability of correct classification. RESULTS: Modelling varying sensitivity lowers the lower cut-off more significantly than the upper cut-off, correctly classifying regions as moderate rather than lower, thus receiving life-saving treatment. The classification method goes directly to classification on the basis of positive pools, avoiding having to know sensitivity to estimate prevalence. For model parameter values describing worm and egg distributions among children, the pooled method with 25 slides achieves an expected 89.9% probability of correct classification, whereas the standard method with 50 slides achieves 88.7%. CONCLUSIONS: Among children, it is more efficient and more accurate to use the pooled method for classification of S. mansoni prevalence than the current standard method.

The reporting of anal cytology and histology samples: establishing terminology and criteria.

Our understanding of the human papillomavirus (HPV) related cytomorphology and histopathology of the anal canal is underpinned by our knowledge of HPV infection in the cervix. In this review, we utilise cervical reporting of cytological and histological specimens as a foundation for the development of standardised and evidence-based terminology and criteria for reporting of anal specimens. We advocate use of the Australian Modified Bethesda System 2004 for reporting anal cytology. We propose the use of a two-tiered histological reporting system for noninvasive disease - low-grade and high-grade anal intraepithelial neoplasia. These classification systems reflect current understanding of the biology of HPV and enhance diagnostic reproducibility. Biomarkers such as p16(INK4A) may prove useful in further improving diagnostic accuracy. Standardisation is important because it will increase the value of the data collected as Australian centres develop programs for screening for anal neoplasia.

Cervical cancer screening in Australia: modelled evaluation of the impact of changing the recommended interval from two to three years.

BACKGROUND: The National Cervical Screening Program in Australia currently recommends that sexually active women between the ages of 18-70 years attend routine screening every 2 years. The publically funded National HPV Vaccination Program commenced in 2007, with catch-up in females aged 12-26 years conducted until 2009; and this may prompt consideration of whether the screening interval and other aspects of the organized screening program could be reviewed. The aim of the current evaluation was to assess the epidemiologic outcomes and cost implications of changing the recommended screening interval in Australia to 3 years. METHODS: We used a modelling approach to evaluate the effects of moving to a 3-yearly recommended screening interval. We used data from the Victorian Cervical Cytology Registry over the period 1997-2007 to model compliance with routine screening under current practice, and registry data from other countries with 3-yearly recommendations to inform assumptions about future screening behaviour under two alternative systems for screening organisation--retention of a reminder-based system (as in New Zealand), or a move to a call-and-recall system (as in England). RESULTS: A 3-yearly recommendation is predicted to be of similar effectiveness to the current 2-yearly recommendation, resulting in no substantial change to the total number of incident cervical cancer cases or cancer deaths, or to the estimated 0.68% average cumulative lifetime risk of cervical cancer in unvaccinated Australian women. However, a 3-yearly screening policy would be associated with decreases in the annual number of colposcopy and biopsy procedures performed (by 4-10%) and decreases in the number of treatments for pre-invasive lesions (by 2-4%). The magnitude of the decrease in the number of diagnostic procedures and treatments would depend on the method of screening organization, with call-and-recall screening associated with the highest reductions. The cost savings are predicted to be of the order of A$10-18 M annually, equivalent to 6-11% of the total cost of the current program (excluding overheads), with call-and-recall being associated with the greatest savings. CONCLUSIONS: Lengthening the recommended screening interval to 3 years in Australia is not predicted to result in increases in rates of cervical cancer and is predicted to decrease the number of women undergoing diagnostic and treatment procedures. These findings are consistent with a large body of international evidence showing that screening more frequently than every three years with cervical cytology does not result in substantial gains in screening effectiveness.

TRICARE: changes included in the National Defense Authorization Act for Fiscal Year 2007; improvements to descriptions of cancer screening for women. Final rule.

The Department is publishing this final rule to implement section 703 of the National Defense Authorization Act (NDAA) for Fiscal Year 2007 (FY07), Public Law 109-364. Specifically, that legislation authorizes breast cancer screening and cervical cancer screening for female beneficiaries of the Military Health System, instead of constraining such testing to mammograms and Papanicolaou smears. The rule allows coverage for "breast cancer screening" and "cervical cancer screening" for female beneficiaries of the Military Health System, instead of constraining such testing to mammograms and Papanicolaou tests. This rule ensures new breast and cervical cancer screening procedures can be added to the TRICARE benefit as such procedures are proven to be a safe, effective, and nationally accepted medical practice. This amends the cancer specific recommendations for breast and cervical cancer screenings to be brought in line with the processes for updating other cancer screening recommendations. In response to public comment on the proposed rule, this final rule includes a clarification that the benefit encompasses screening based on Health and Human Services guidelines.

Los efectos negativos de las intervenciones preventivas basadas en el individuo. Informe SESPAS 2008 / Negative effects of individual-based preventive interventions. 2008 SESPAS Report

Como se suele suponer que las intervenciones preventivas tienenpocos riesgos, la investigación sobre sus efectos negativoses escasa, tal como pone de manifiesto una revisión de la literaturamédica española. Esos estudios analizan efectos a cortoplazo (como falsos positivos de los cribados), pero no tratan efectosa largo plazo de las medidas poscribado (p. ej., fármacos preventivos)ni efectos negativos más intangibles (como la medicalización).Se produce una expansión acrítica de la medicinapreventiva: continuas propuestas de nuevos cribados (incluidaslas preenfermedades y los factores de riesgo) y vacunas. El balanceentre beneficios y riesgos de esta expansión es, como mínimo,dudoso.En este proceso la industria farmacéutica desempeña un papelclave, pero también hay que revisar cómo actúan otros agentes:profesionales y autoridades sanitarias, medios de comunicacióny sociedad en general. Resaltamos sobre todo el papel de la profesiónmédica, pues sin ella no sería posible definir nuevas enfermedadesy preenfermedades ni recomendar el uso de nuevasintervenciones preventivas.La profesión médica tiene el prestigio suficiente ante el restode los agentes para liderar cualquier cambio. Previamente lassociedades científicas deberían tener un debate interno sobresu papel actual en la adopción de nuevas intervenciones preventivas,sus relaciones con la industria y sus conflictos deinterés. Algunas asociaciones médicas ya están adoptando unenfoque más crítico y analizando el impacto de sus propias recomendacionespreventivas sobre la medicalización de la vida(AU)

Es necesario analizar de forma continuada los efectos adversosde las medidas preventivas implantadas en la práctica y establecermecanismos para la evaluación crítica del balance beneficios-riesgos-costes de las nuevas intervenciones preventivasantes de incluirlas en la cartera de servicios. En la práctica clínicacotidiana habría que fomentar la participación de las personasen las decisiones y que los profesionales adopten el enfoquede la prevención cuaternaria(AU)

Because preventive interventions are usually assumed to carryfew risks, research on their negative effects is scarce, as revealedby a review of the Spanish literature. The studies retrievedanalyze short-term effects (such as false-positive results of screeningtests), but do not evaluate the long-term effects of postscreeninginterventions (for example: preventive drugs) or evenless tangible negative effects (such as medicalization). Uncriticalspread of preventive medicine is occurring, with continual proposalsfor new screening tests (for pre-diseases and risk factors)and new vaccines. The risk-benefit ratio of this spread is, at thevery least, doubtful.The pharmaceutical industry plays a key role in this process butthe role of other stakeholders (health professionals and healthauthorities, mass media and society) should also be reviewed.The present article highlights the role of the medical profession,since, without it, definition of new diseases and pre-diseases andthe creation of guidelines on the use of new preventive interventionswould not be possible.The medical profession has sufficient prestige to lead any change.Before any change occurs, however, scientific societies shouldconduct an internal debate on their current role in the adoptionof new preventive interventions, their relationships with the pharmaceuticalindustry and their conflicts of interest. Some medicalassociations are already adopting a more critical approach to theevaluation of the benefit-risk trade-off of new interventions andare analyzing the impact of their own preventive recommendationson the medicalization of life(AU)

The adverse effects of the preventive measures implementedin health services should be continually assessed and proceduresfor the critical evaluation of the benefit-risk-cost trade-offs ofnew preventive interventions should be established before makingdecisions on their incorporation in the health services’ portfolio.Finally, in daily clinical practice, enhancing citizen participationin decisions and adopting the approach of quaternary preventionwould be desirable(AU)

Prevención secundaria: estrategias de cribado y situación en España / Secondary prevention: screening strategies and situation in Spain

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Estrategia global de prevención frente al VPH: papel de la Atención Primaria / Global prevention strategy against HPV: role of Primary Health Care

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