Heart Disease: Invasive Treatment is Not Necessarily Better

Saturday, November 30, 2019 // Uncategorized

There have been some studies showing that in patients with stable heart disease caused by narrowing of the coronary arteries, stents and bypass surgery don’t necessarily improve mortality.  The following is the last salvo in that debate.  This is a summary from Physician’s First Watch


ISCHEMIA: Invasive Treatment Not Better Than Meds in Patients with Stable Ischemic Heart Disease

By Amy Orciari Herman

In patients with stable ischemic heart disease, invasive treatment appears no better than optimal medical therapy for preventing cardiovascular (CV) events, according to the international ISCHEMIA trial. The findings were presented on Saturday at the American Heart Association’s annual meeting in Philadelphia.

Nearly 5200 adults with stable ischemic heart disease and moderate-to-severe ischemia (usually diagnosed by stress imaging) were randomized to invasive or conservative management. In the invasive group, patients underwent cardiac catheterization followed by percutaneous coronary intervention (PCI) or coronary artery bypass grafting, when feasible; they also received optimal medical therapy. The conservative group received optimal medical therapy alone. Of note, patients with left main disease were excluded.

At 4 years, incidence of the primary endpoint — a composite of CV death, myocardial infarction (MI), resuscitated cardiac arrest, hospitalization for unstable angina, or heart failure — did not differ significantly between the invasive and conservative groups (13.3% and 15.5%, respectively). A major secondary endpoint comprising CV death or MI also did not differ significantly (11.7% and 13.9%).

Dr. Harlan Krumholz, editor-in-chief of NEJM Journal Watch Cardiology, offered his take: “The ISCHEMIA study is a lot to digest — and the results haven’t yet been published in a peer-reviewed journal. Yet, what seems clear is that patients with stable ischemic disease are safe with medical therapy, which is consistent with many other studies. A side question is whether stress myocardial perfusion studies are providing much value for these patients.”

Why We Chose This as Our Top Story

André Sofair, MD, MPH: Similar results have been described in other studies. I think that this is another case where less may be more for our patients. I think Dr. Krumholz’s comment is an important one — whether we should be performing stress tests on these patients is still an unanswered question.

William E. Chavey, MD, MS: As we digest the results of this trial, the take-home message for primary care may not be about who deserves PCI — but may be about the importance of ensuring that our patients get appropriate guideline-directed therapy.


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There Is Something Going Around

Monday, November 18, 2019 // Uncategorized

According to flu surveillance, there is an increase in Influenza Like Illness or ILI (formerly known as FLI) around the state.  Most of it isn’t the flu.  It’s a respiratory virus with flu-like symptoms.  We treat the symptoms with rest and acetaminophen or ibuprofen.  Anti viral medication like Tamiflu are ineffective against this virus.  The following is the summary from  the Center for Disease Control.


Texas Influenza Surveillance Report

2019-2020 Season/2019 MMWR Week 45

(November 3, 2019 – November 9, 2019)

Report produced on 11/15/2019


Influenza activity is increasing and has exceeded the Texas-specific ILI baseline for the first time this season. The percentage of patient visits due to influenza-like illness (ILI) has increased. One influenza-associated pediatric death was reported. One influenza-associated institutional outbreak was reported.

x Due to technical issues with the National Respiratory and Enteric Virus Surveillance System (NREVSS) reporting platform, clinical laboratory data are not available for week 45. This affects data for Table 1, Table 2, Table 4, and Figure 1. An update to previous weeks is included in Table 2. Reporting of this data will resume once the technical issues have been resolved.

Table 1: Summary of Texas Influenza (Flu) and Influenza-like Illness (ILI) Activity for the Current Week Texas Surveillance Component Change from Previous Week Current Week Previous Week Page of Report
Statewide influenza activity level reported to CDC (geographic spread of influenza) Increase Regional Local
Statewide ILINet Activity Indicator assigned by CDC (intensity of influenza-like illness) Increase Moderate Low
Percentage of specimens positive for influenza by hospital laboratories x 5.32% 1
Percentage of visits due to ILI (ILINet) ▲1.17% 4.91% 3.74% 4
Number of regions reporting increased flu/ILI activity ▲2 7 5 5
Number of regions reporting decreased flu/ILI activity No change 1 1 5
Number of variant/novel influenza infections No cases reported 0 0 5
Number of ILI/influenza outbreaks No change 1 1 5
Number of pediatric influenza deaths ▲1 1 0 6
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At Home Genetic Testing

Monday, October 22, 2018 // Uncategorized

What is At-Home Genetic Testing?

Understanding what an at-home test will – and will not – tell you

For a price (typically several hundred to a thousand dollars) you can order a genetic testing kit online or by phone. You’ll swab your cheek or spit into a test tube. Then you will mail it to a lab where it may be tested for a wide variety of things — from whether you inherited your intolerance to the lactose in dairy products to your risk of certain types of cancer to if you carry a gene for a serious illness such as Cystic Fibrosis and could pass it on to your children.

There are at-home tests for:

  • Traits ( e.g., male hair loss to dimples)
  • Wellness (e.g.,  risk of certain types of cancer to restless leg syndrome)
  • Ancestry reports (i.e., ethnicity and lineage)
  • Carrier status (e.g., Tay-Sachs Disease to Sickle Cell Anemia)
  • Paternity testing (i.e., determining a child’s biological father)

There are three general ways to get genetic testing:

  • Through your physician or a genetic counselor – These are the most detailed and comprehensive tests available. They include cancer testing and testing for genetic disorders.  They include large “panels,” meaning they test for the most genes.
  • Physician-ordered online testing – While you can order some of the more comprehensive tests online, you will still need a physician’s approval. In some cases, your physician can order the test. In some cases, the testing company employs a physician who can order the test for you.
  • Direct-to-consumer testingThese are the at-home tests you most often hear about. They do not require a physician’s order. However, they don’t fall under the same guidelines as the other two types of testing, and they may provide incomplete information. For example, they may not test for the genes you’re most interested in. Or they provide you raw data, but don’t provide guidance regarding the results and what they may mean for you or your family.

Before you order at-home genetic testing, it’s important to consider your goals for testing. It’s also a good idea to understand what a test may or may not tell you, how reliable the testing is, and whether you will receive any guidance to help you understand what the test restuls mean for you and your family. If you’re thinking about at-home genetic testing, consider the following.

Is the company trustworthy?

If you decide to order an online test, research the company providing the service. Verify that:

  • The lab that conducts the tests has received one of the following certifications: Clinical Laboratory Improvement Amendments (CLIA), College of American Pathologists (CAP) or AABB. The Food and Drug Administration (FDA) is still exploring how it will address genetic testing and has approved some but not all such tests.
  • The company’s staff members have received extensive education in the subject, such as being certified genetic counselors, medical geneticists, pathologists, Ph.D. geneticists, biologists or molecular pathologists.

What will the test tell you, exactly?

It’s important to fully understand the test results. You should determine:

  • Exactly what is being tested (health conditions, ancestry, traits, carrier status)
  • How the results will be provided
  • What you will do with your results, and if they will help you make health decisions
  • If you might find out information you might not be expecting
  • If you plan to share your results with your family
  • If the company will contact you if there are new scientific findings that may change your results

Will your personal information be protected?

Carefully review the testing company’s privacy and security policy. Be sure to find out:

  • What does the company plan to do with your genetic information, now and in the future?
  • Will the company share your genetic information with pharmaceutical or biotechnology companies, researchers, not-for-profit groups or public or private DNA databases?
  • Will the company let you know if its policies change, or if your information is shared?

What professional help will the company provide?

No matter the results of your test, you likely will have questions. You should find out how the company plans to answer your questions.

  • Is a genetic counselor or other trained professional available before or after testing to provide guidance and help?
  • If so, is this service included in the cost of testing, or is there an extra charge?
  • Is the professional employed by the company, or is the service separate?
  • If the company does not have trained genetic professionals on staff, can it refer you to someone?

Receiving the results may produce a variety of emotions. You may be surprised, relieved, disappointed or confused. Whether you choose at-home testing or seek out testing through a medical professional, seeing a genetic counselor can provide helpful guidance.

Wishing you good health!

Mark L. Thornton, M.D.

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High Blood Pressure

Monday, October 22, 2018 // Blood Pressure

New Multisociety Hypertension Guideline Is Released

Allan S. Brett, MD and Karol E. Watson, MD, PhD, FACC reviewing Whelton PK et al. J Am Coll Cardiol 2017 Nov 13.

The guideline lowers thresholds for categorizing people as having hypertension and for prescribing drug therapy.

Sponsoring Organizations: American College of Cardiology (ACC), American Heart Association (AHA), and nine other organizations

Target Audience: All clinicians


In 2003, the National Institutes of Health (NIH) issued its last guideline on hypertension (Seventh Joint National Committee [JNC7]; NEJM JW Gen Med Jun 15 2003 and JAMA 2003; 289:2560). In 2014, the JNC8 guideline — written by an expert panel no longer affiliated with NIH — was published (NEJM JW Gen Med Jan 15 2014 and JAMA 2014; 311:507). Now, the ACC and AHA have issued a new guideline, intended to be the U.S. standard of care.

Key Recommendations

  • Newly defined categories are “elevated blood pressure (BP)” (systolic BP, 120–129 mm Hg and diastolic BP, <80 mm Hg); stage 1 hypertension (systolic BP, 130–139 mm Hg or diastolic BP, 80–89 mm Hg), and stage 2 hypertension (systolic BP, ≥140 mm Hg or diastolic BP, ≥90 mm Hg).
  • For people with elevated BP (but not hypertension), lifestyle modification is recommended.
  • For people with stage 1 hypertension who have known atherosclerotic cardiovascular disease (CVD) or 10-year cardiovascular risk ≥10% (according to the ACC/AHA calculator, which also is used for cholesterol management), both lifestyle modification and drug therapy are recommended. Stage 1 patients with <10% 10-year risk should pursue lifestyle modification only.
  • All people with stage 2 hypertension should receive medication (in addition to lifestyle modification).
  • The treatment goal for everyone is <130/80 mm Hg.

I’m not going to change my practice until I weigh responses to this guideline from a broad range of experts. In the end, initiating drug therapy in patients with BPs near treatment thresholds should reflect shared decision-making between clinicians and patients. One of the problems with these guidelines is that they don’t age into account.  Older, stiffer arteries may be less forgiving to attempts to lower blood pressure.  The risk’s of treatments have to be weighed against the risk of side effects.

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The New Shingles Vaccine

Monday, October 22, 2018 // Uncategorized


The short version: As many of you know, a new shingles vaccine (“SHINGRIX”) was introduced in the past year, and is recommended for all adults over 50 years of age. The new vaccine is much more effective than the old vaccine (“Zostavax”). The new vaccine is associated with a higher incidence of side effects (such as pain and swelling at the injection site, or flu-like symptoms—achiness, fatigue—typically lasting a day or two after the vaccine), but because of its improved effectiveness, SHINGRIX has essentially replaced the old shingles vaccine.  More detailed information from The Medical Letter follows: 

The long version:

The FDA has approved an adjuvanted, recombinant varicella zoster virus (VZV) vaccine (Shingrix – GSK) for prevention of herpes zoster (shingles) in adults ≥50 years old. Shingrix is the second herpes zoster vaccine to be approved in the US; Zostavax, a live-attenuated VZV vaccine approved for the same indication, has been available since 2006.1,2

HERPES ZOSTER – Following primary infection, VZV persists in a latent form in sensory ganglia; VZV-specific cell-mediated immunity (CMI) prevents reactivation and multiplication of latent virus. When CMI falls below a critical threshold, as it can in older and immunocompromised persons, VZV can reactivate, causing shingles and, occasionally, postherpetic neuralgia (PHN) and other complications. About 1 million cases of shingles occur in the US each year.3,4  

ZOSTAVAX  In clinical trials, the live-attenuated vaccine significantly reduced the incidence and severity of herpes zoster and PHN in adults ≥50 years old, but its effectiveness declines sharply with age (see Table 1), and its protection against shingles wanes to 4% within 8 years after inoculation in persons vaccinated at ≥60 years old.5-9 Zostavax is contraindicated for use in immunocompromised patients and it must be frozen during storage and transport. The Advisory Committee on Immunization Practices (ACIP) recommends Zostavax only for adults ≥60 years old, even though it was approved by the FDA for use in those ≥50 years old.10

SHINGRIX  The new recombinant vaccine contains a surface VZV glycoprotein E (gE) antigen obtained from cultured, genetically engineered Chinese hamster ovary cells that triggers a targeted immune response to VZV. It also contains a liposomal adjuvant (AS01B) to enhance the immune response. Unlike ZostavaxShingrix is not contraindicated for use in immunocompromised patients and does not need to be frozen during storage and transport.

CLINICAL STUDIES – FDA approval of Shingrix was based on the results of two observer-blind trials, one in adults ≥50 years old and the other in adults ≥70 years old, in which a total of 27,922 persons were randomized to receive two doses of vaccine or placebo two months apart.11,12 The vaccine was effective in preventing herpes zoster and PHN in all age groups. Pooled results of the trials are summarized in Table 1.

The duration of protective immunity against shingles with Shingrix is unknown. In persons ≥70 years old, vaccine efficacy was 85.1% in the fourth year after vaccination.12 Immunogenicity data suggest that the protective effect of Shingrix will persist for at least 9 years after vaccination.13 The efficacy of Shingrix in persons who receive only one dose is not known. Shingrix and Zostavax have not been compared in head-to-head trials.

ADVERSE EFFECTS — Although not directly compared to one another in clinical trials, adverse reactions appear to occur more often with Shingrix than with Zostavax. Common adverse effects of the new vaccine include myalgia (45%), fatigue (45%), headache (38%), shivering (27%), fever (21%), GI symptoms (17%), and injection-site pain (78%), redness (38%), and swelling (26%). Severe local reactions preventing normal daily activities occurred in 17% of persons who received Shingrix and persisted for a mean of 2 days. Serious adverse events, including new-onset immune-mediated disease and death, occurred at similar rates in the vaccine and placebo groups. Long-term data on the safety of Shingrix are lacking.

DRUG INTERACTIONS – The efficacy of Shingrix may be reduced in patients who are receiving immunosuppressive therapy.

DOSAGE AND ADMINISTRATION – Shingrix should be given as two 0.5-mL doses administered intramuscularly 2-6 months apart. It can be given at the same time as influenza vaccine, but a different injection site should be used.

The vaccine is supplied in two single-dose vials, one containing the lyophilized antigen component and the other containing the adjuvant suspension component. Both vials should be refrigerated during storage; the vaccine should be discarded if frozen. Before administration, the antigen component must be reconstituted with the adjuvant component to form an opalescent, colorless to pale-brown liquid. The reconstituted vaccine should either be administered immediately or refrigerated and given within 6 hours. It should be discarded if it appears discolored or contains visible particulates.

NEW RECOMMENDATIONS – The ACIP now recommends that healthy adults ≥50 years old, including those who have already received Zostavax, be vaccinated with two doses of Shingrix (2-6 months apart).10 The committee voted that Shingrix is preferred over Zostavax for herpes zoster prevention. The optimal time between administration of Zostavax and vaccination with Shingrix has not been established.

Update 1/26/18: Since publication, the ACIP has recommended that Shingrix not be given <2 months after vaccination with Zostavax.14

CONCLUSION – The adjuvanted, recombinant varicella zoster virus (VZV) vaccine (Shingrix) appears to be considerably more effective than the live-attenuated VZV vaccine (Zostavax) for prevention of herpes zoster (shingles), especially in older patients. Two doses of Shingrix administered 2-6 months apart are now recommended for healthy adults ≥50 years old, including those who have previously received Zostavax. Ensuring completion of the two-dose series may be challenging, particularly in patients who experience severe adverse effects with the first dose.

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The Flu

Monday, October 22, 2018 // Flu

As most of you know the recent flu season was the worst flu season since 2009. It is now flu shot season.  When you see pumpkins, think flu shots. Patients with fall appointments will get the vaccination during their office visit.  We schedule brief appointments for individuals who want to get the vaccine to avoid waiting. We prefer not to do walk INS ins to minimize wait times. We will be giving the quadrivalent vaccine against 4 flu strains. For those over 65, a high dose vaccine is available which is a little more effective.  Let’s hope for a good match this year!

The flu takes a formidable toll each year. Researchers and health workers save lives by routinely rolling out seasonal vaccines and deploying drugs to fight the virus and its secondary infections. But in the U.S. alone the flu still kills tens of thousands of people and hospitalizes hundreds of thousands more.

A big part of the problem has been correctly predicting what strains of the influenza virus health officials should try to combat in a given season. A team of scientists from the U.S. and China now say they have designed a vaccine that could take the guesswork out of seasonal flu protection by boosting the immune system’s capacity to combat many viral strains.

The University of California, Los Angeles–led group reported in a recent Science that they may have created the “Goldilocks” of flu vaccines—one that manages to trigger a very strong immune response without making infected animals sick. And unlike current flu vaccines, the new version also fuels a strong reaction from disease-fighting white blood cells called T cells. That development is important because a T cell response will likely confer longer-term protection than current inoculations do and defend against a variety of flu strains (because T cells would be on the lookout for several different features of the flu virus whereas antibodies would be primarily focused on the shape of a specific strain). “This is really exciting,” says Kathleen Sullivan, chief of the Division of Allergy and Immunology at The Children’s Hospital of Philadelphia, who was not involved in the work.


The overall effectiveness of last season’s influenza vaccine has been estimated at 36%, according to an analysis in MMWR.

Researchers examined data on nearly 4600 patients who sought outpatient care for acute respiratory illness with cough within 7 days of symptom onset between November 2017 and February 2018. Some 38% tested positive for influenza on reverse-transcription polymerase chain reaction.

Roughly 43% of those with influenza had been vaccinated. Vaccine effectiveness was estimated for each virus type as follows:

  • Influenza A(H3N2): 25%
  • Influenza A(H1N1)pdm09: 67%
  • Influenza B: 42%

When examined by age group, statistically significant protection against influenza was observed only among children aged 6 months through 8 years (59% effective) and adults aged 18 through 49 (33% effective).

The report’s authors write, “Even with current vaccine effectiveness estimates, vaccination will still prevent influenza illness, including thousands of hospitalizations and deaths. Persons aged ≥6 months who have not yet been vaccinated this season should be vaccinated.”

Dr. Anne Schuchat noted that three out of four children who’ve died from flu this season were not vaccinated.

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15th Anniversary

Monday, October 22, 2018 // News

Happy Fall! It is hard to believe it has been 15 years since the practice opened as the first concierge/personalized care physician practice in San Antonio. At the time a patient-centered practice was controversial. A practice that restricted its size so that there was more time to spend on preventive care and access was newsworthy then, but now is more in demand than ever. It’s been incredibly rewarding to practice medicine the way that I thought I would be able to in medical school. We’ve grown, Dr. Jennifer Wallace joined the practice and we continue to treat patients with the time and expertise an Internal Medicine specialty practice offers. We look forward to practicing this way for many years to come!

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New Employee

Monday, October 2, 2017 // Blog, News

We are pleased to have hired a new nurse Amber Allen. Amber was born in Oakland, California and raised in the Bay area. She moved to Texas in 1990.

Amber graduated from St. Philips Nursing School in 2010. Prior to joining us, she worked as a nurse at Haven for Hope.

She has a 9-year-old son named Caleb who plays baseball and football. Amber loves the water, floating the river and taking her son to concerts. They are also big football fans especially the Dallas Cowboys.

– – – – – –

Words written in italic are directly from Mark L. Thornton, M.D., F.A.C.P.

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Lifestyle Modification Reduces Heart Disease Risk

Monday, October 2, 2017 // Blog, Blood Pressure, News, Prevention

Nature versus Nurture: Even though people may have inherited genes that confer an increased risk of cardiovascular disease that doesn’t mean that there isn’t something that they can do about it. Not smoking, maintaining a normal weight, exercise and healthy eating will reduce that risk. Below is a summary of a study published in the New England of Journal Medicine in December.

Cardiovascular Disease: Genetics versus Lifestyle NEJM

December 15, 2016, Original Article:

Genetic Risk, Adherence to a Healthy Lifestyle, and Coronary Disease

Amit V. Khera, M.D., Connor A. Emdin, D.Phil., Isabel Drake, Ph.D., Pradeep Natarajan, M.D., Alexander G. Bick, M.D., Ph.D., Nancy R. Cook, Ph.D., Daniel I. Chasman, Ph.D., Usman Baber, M.D., Roxana Mehran, M.D., Daniel J. Rader, M.D., Valentin Fuster, M.D., Ph.D., Eric Boerwinkle, Ph.D., Olle Melander, M.D., Ph.D., Marju Orho-Melander, Ph.D., Paul M Ridker, M.D., and Sekar Kathiresan, M.D.

N Engl J Med 2016; 375:2349-2358December 15, 2016DOI: 10.1056/NEJMoa1605086


Both genetic and lifestyle factors contribute to an individual-level risk of coronary artery disease. The extent to which increased genetic risk can be offset by a healthy lifestyle is unknown.


Using a polygenic score of DNA sequence polymorphisms, we quantified genetic risk for coronary artery disease in three prospective cohorts — 7814 participants in the Atherosclerosis Risk in Communities (ARIC) study, 21,222 in the Women’s Genome Health Study (WGHS), and 22,389 in the Malmö Diet and Cancer Study (MDCS) — and in 4260 participants in the cross-sectional BioImage Study for whom genotype and covariate data were available. We also determined adherence to a healthy lifestyle among the participants using a scoring system consisting of four factors: no current smoking, no obesity, regular physical activity, and a healthy diet.


The relative risk of incident coronary events was 91% higher among participants at high genetic risk (top quintile of polygenic scores) than among those at low genetic risk (bottom quintile of polygenic scores) (hazard ratio, 1.91; 95% confidence interval [CI], 1.75 to 2.09). A favorable lifestyle (defined as at least three of the four healthy lifestyle factors) was associated with a substantially lower risk of coronary events than an unfavorable lifestyle (defined as no or only one healthy lifestyle factor), regardless of the genetic risk category. Among participants at high genetic risk, a favorable lifestyle was associated with a 46% lower relative risk of coronary events than an unfavorable lifestyle (hazard ratio, 0.54; 95% CI, 0.47 to 0.63). This finding corresponded to a reduction in the standardized 10-year incidence of coronary events from 10.7% for an unfavorable lifestyle to 5.1% for a favorable lifestyle in ARIC, from 4.6% to 2.0% in WGHS, and from 8.2% to 5.3% in MDCS. In the BioImage Study, a favorable lifestyle was associated with significantly less coronary-artery calcification within each genetic risk category.


Across four studies involving 55,685 participants, genetic and lifestyle factors were independently associated with susceptibility to coronary artery disease. Among participants at high genetic risk, a favorable lifestyle was associated with a nearly 50% lower relative risk of coronary artery disease than was an unfavorable lifestyle. (Funded by the National Institutes of Health and others.

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Words written in italic are directly from Mark L. Thornton, M.D., F.A.C.P.

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Prostate Cancer Screening Revisited

Monday, October 2, 2017 // Blog, News, Prostate

Opinions in medicine change over time. “Every dogma shall have its day,” I tell my medical students. Two years ago the United services Preventive Task Force (USPSTF) recommended against screening for prostate cancer because the risk and expense of screening were felt to outweigh the benefits. Now they have revised that recommendation as follows:

The USPSTF recommends that clinicians inform men ages 55 to 69 years about the potential benefits and harms of prostate-specific antigen (PSA)–based screening for prostate cancer.

The decision about whether to be screened for prostate cancer should be an individual one. Screening offers a small potential benefit of reducing the chance of dying of prostate cancer. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and impotence. The USPSTF recommends individualized decision making about screening for prostate cancer after discussion with a clinician so that each man has an opportunity to understand the potential benefits and harms of screening and to incorporate his values and preferences into his decision.

We will ask men age 45-69 if they wish to be screened for prostate cancer. For those interested in additional information here is a related article for National Public Radio.

Federal Task Force Softens Opposition To Routine Prostate Cancer Screening

April 11, 2017 – Rob Stein

A common blood test checks for elevated levels of prostate-specific antigens (PSA) in a man’s blood, as an indicator that he may have prostate cancer.

An influential federal task force is relaxing its controversial opposition to routine screening for prostate cancer.

In the proposed revised guidelines released Tuesday, the U.S. Preventive Services Task Force says men ages 55 to 69 should decide individually with their doctors whether and when to undergo prostate-specific antigen (PSA) testing.

The task force would continue to recommend against PSA testing for men age 70 and older, saying the potential harms continue to outweigh benefits of routine screening in this age group.

The proposal, which isn’t yet final, pending input from the public, comes five years after the task force surprised many men and their doctors by recommending against the routine use of the commonly used blood test. That 2012 guidance prompted a significant drop in PSA testing.

Almost 180,000 American men are diagnosed with prostate cancer each year, and at least 26,000 die from the disease, making it one of the most common and deadly cancers among men.

The task force decided to adjust its screening recommendations based on new research.

“The new evidence allowed us to say that, on balance, we think now the benefits do outweigh the harms,” says Dr. Kirsten Bibbins-Domingo, a professor of medicine at the University of California, San Francisco, who chairs the task force. The latest research also suggests a small net benefit from screening, she says.

“Therefore,” Bibbins-Domingo says, “what we are recommending is that doctors and patients talk together about whether screening is right for them.”

While PSA tests can detect prostate tumors at their smallest, most treatable stage, the testing has some risks, she says.

The harms include stressful false alarms that often lead to painful and sometimes dangerous biopsies. And even if the test detects an actual malignancy, many prostate cancers grow so slowly that they never become life-threatening. Nonetheless, many men undergo surgery and radiation, which can leave them incontinent or impotent.

Why Prostate Cancer Screening Is So Tricky

“The PSA test is not a great test,” Bibbins-Domingo says. “It doesn’t help us distinguish the types of cancers that are going to kill you from those cancers that are going to not progress over time and will not cause a man health problems.”

So when the task force last issued guidelines in 2012, the panel decided the potential harms of screening outweighed the benefits.

But the results of research from the last five years have changed that equation, the task force says.

Specifically, the European Randomized Study of Screening for Prostate Cancer (ERSPC) found PSA testing cuts the chances of developing advanced prostate cancer by about 30 percent and the risk of dying from the disease by about 20 percent.

At the same time, an increasing number of men confronted with a diagnosis of prostate cancer are skipping treatment, according to recent research. Instead, they and their doctors are opting for “watchful waiting” or active surveillance of the malignancy. That less aggressive approach to treatment minimizes the harms of screening, the task force says.

So, in its proposed revision, the task force drops its “D” recommendation against PSA testing for men ages 55 to 69 and replaces it with a “C” recommendation that each man in that age group make the decision about whether to get screened individually — in consultation with his doctor.

Bibbins-Domingo stresses that the task force has stopped short of urging screening for all young men.

“There are some men who might say, ‘You know, I really want to avoid dying of prostate cancer. That’s the most important thing to me. So even if there’s a small likelihood this will work I want to do it,’” Bibbins-Domingo says. Screening saves an estimated one or two lives out of every 1,000 men who get screened.

And with treatment’s risk of impotence or incontinence, it’s also a reasonable choice for some men to decide, “ ‘I’m not willing to risk the things that may happen along the way,’ “ Bibbins-Domingo notes.

Doctors who have long advocated aggressive PSA testing are praising the new guidelines.

“I’m very pleased. I view this as a victory for PSA screening for prostate cancer,” says Dr. William Catalona, a professor of urology at the Northwestern University Feinberg School of Medicine.

“PSA screening saves lives,” he says. “And having the U.S. Preventive Services Task Force discourage PSA screening has sort of created a whole generation of family practitioners and internists who feel that PSA screening is a bad thing to do for patients. If this were to continue, we would lose all these gains in reducing the prostate cancer death rate.” He says he wishes the group had gone further and recommended that doctors actively encourage PSA screening beginning at age 40 and continuing past age 70.

Dr. David Penson, a urologist at Vanderbilt-Ingram Cancer Center, agrees with the task force’s decision. “The idea of letting men make their own decision, I think, is a really terrific thing,” he says, noting that the new draft guidelines are in line with those of other medical groups.

But other doctors fear the task force’s recommendation will be oversimplified into a recommendation for screening.

Dr. Dan Merenstein, a family medicine physician at Georgetown University, doesn’t think the new evidence warrants a change. And he worries the new guidelines are confusing.

“What I’m afraid of is that rather than having this discussion — because it’s a difficult and long discussion — physicians will just order this test like they do… a cholesterol panel,” Merenstein says. “And that will cause much more harm than good.”

Meanwhile, Dr. Otis Brawley, the chief medical officer for the American Cancer Society, believes the guidelines strike the right balance.

“I really do think that there is a pendulum in a lot of things that we do in medicine,” Brawley says. “And the pendulum here may be getting to the right place where we realize there are harms and there are benefits and individuals need to weigh these harms and benefits and tailor a decision that’s right for them.”

And the latest word from The Annals of Internal Medicine:

More Support for Prostate Cancer Screening?

By Amy Orciari Herman

A reanalysis of U.S. and European data seems to offer more support for prostate-specific antigen (PSA)-based screening for prostate cancer. The findings appear in the Annals of Internal Medicine.

Researchers re-examined data from the European Randomized Study of Screening for Prostate Cancer, which originally showed a reduction in prostate cancer mortality with screening, and the U.S. Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, which showed no reduction. In the new analysis, the researchers attempted to account for the high rate of PSA screening that contaminated the control group of the U.S. trial. Ultimately, they concluded that the results of both screening trials could be consistent with roughly a 25%–30% reduction in prostate cancer mortality over 11 years’ follow-up.

Dr. Allan S. Brett, editor-in-chief of NEJM Journal Watch General Medicine, weighed in: “I’d like to see a critical analysis of this report by other groups with sophisticated statistical expertise. But in the end, it doesn’t really matter whether the U.S. data legitimately can be interpreted as supporting the European data. We already know (from the European trial) that screening likely confers a small absolute reduction in prostate cancer mortality, but that many men must be treated (or subjected to repeated testing and biopsy) to benefit one person. So this latest analysis doesn’t change anything: We’re still left with the same debate about benefit vs. harm in PSA screening.”

We will screen men 45-69 years of age if they want. We won’t screen older men unless there extenuating circumstances.

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Words written in italic are directly from Mark L. Thornton, M.D., F.A.C.P.

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