Active surveillance is a solution to the widely acknowledged problem of overdiagnosis and overtreatment of clinically insignificant disease which accompanies early detection of prostate cancer using prostate-specific antigen (PSA) and biopsy. It is an approach to the management of favorable-risk prostate cancer which uses the opportunity provided by the long natural history of the disease to incorporate a period of initial observation into patient management. The basic concept is that most men diagnosed with low-grade, small-volume disease are not destined to have any clinical manifestations of the condition during their lifetime. However, a subset of patients with favorable-risk prostate cancer is at risk, due to either the presence of higher-risk disease not apparent at diagnosis or progression to a more aggressive phenotype over time. These patients can be identified with reasonable accuracy by close follow-up, including serial PSAs and biopsies, and treated effectively in most cases. The rationale, patient selection, method of follow-up, triggers for intervention, and recent results of this approach will be reviewed.
Patients with ulcerative colitis (UC) are at high risk of colonic dysplasia. Therefore, surveillance colonoscopy to detect early dysplasia has been endorsed by many professional organizations.
To determine whether gastroenterologists at Hamilton Health Sciences (Hamilton, Ontario) adhere to recommendations for UC surveillance issued by the Canadian Association of Gastroenterology and to retrospectively assess the incidence and type of dysplasia found and the subsequent outcome of patients with dysplasia (ie, colorectal cancer [CRC], colectomy, dysplasia recurrence).
A retrospective chart review of all patients with UC undergoing colonoscopy screening at Hamilton Health Sciences from January 1980 to January 2005, was performed. Patients were classified by the extent of colonic disease: limited left-sided colitis (LSC), pancolitis and any disease extent with concurrent primary sclerosing cholangitis.
A total of 141 patients fulfilled eligibility criteria. They underwent 921 endoscopies, including 453 for surveillance, which were performed by 20 endoscopists. Overall, screening was performed on 90% of patients, and surveillance at the appropriate time in 74%. There was a statistically significant increase in the mean number of biopsies per colonoscopy after the guidelines were published (P
To determine the accuracy and feasibility of a monitoring tool completed by parents for screening at-risk and community infants and children for developmental problems.
We assessed 43 children following open-heart surgery and 68 community children (aged 4-36 mo) at prescribed intervals using the Ages and Stages Questionnaires (ASQ). Subjects were followed 3 years later (at age 5-6 yr) via telephone interview with their parents concerning developmental delay identified by physicians. Responses were confirmed by telephone interviews with family physicians. We then compared the results of the ASQ with the physician assessments.
Nine at-risk and 9 community children were lost to follow-up. The ASQ identified 4 of the 25 at-risk children as having developmental delay, while 2 of the 6 children assessed by a neurologist were identified as having developmental delay. The ASQ identified 2 of the 59 community children as having developmental delay, 1 of whom was assessed by a neurologist as having developmental delay. The ASQ had sensitivities of 75% in the at-risk group and 100% in the community group, and specificities of 95% and 90%, respectively. The parents were unanimous in their willingness to complete the assessments.
The ASQ is feasible, inexpensive, easy to use, and was appreciated by the parents. It is a sufficiently sensitive and specific monitoring tool that its use in cardiac follow-up programs and in community programs for healthy children is warranted. Although this tool should not be used to replace clinical assessment, it can be used to rationalize access to specialist developmental assessment services.
BACKGROUND: Sexually transmitted infections are leading causes of morbidity for Canadian Aboriginal women. To date, very few initiatives have been successful in screening, treating, and limiting these infections among these populations. OBJECTIVES: To evaluate the efficacy of universal screening, treatment and contact tracing as a means of capturing a more accurate count of chlamydia and gonorrhea prevalence and limiting transmission among Inuit communities. METHODS: 181 participants were screened for chlamydia and gonorrhea and interviewed in a cross-sectional survey (Aug-Sept/03). Information was collected on demographics, use of health services, sexual histories and STI knowledge among others. A random sample (n = 100) from the cross-sectional group was selected for the longitudinal cohort. Individuals were followed every two months post baseline for four visits (Oct/03-May/04). At each visit, participants were screened for chlamydia/gonorrhea. All positive cases and their partners were treated and contact tracing completed. Logistic Regression analysis and the McNemar Test of Correlated Proportions were used to analyze the data. RESULTS: Overall, 35 cases of chlamydia were detected, with 21 detected at baseline and 14 during follow-up. The baseline prevalence was 11.6% in comparison with 2.7% that was previously estimated. No gonorrhea was detected. The strongest factor associated with a positive chlamydia was having recent STI (OR 9.82, CI: 2.70, 35.77). CONCLUSIONS: Consistent with the literature, the results support the use of universal screening followed by prompt treatment and contact tracing in populations with greater than 10% chlamydia prevalence.
The objective of this study was to assess the association of sexually transmitted disease (STD)-related stigma on sexual health care behaviors, including Papanicolaou smears and STD testing/treatment, among women from a high-risk community.
Descriptive statistics were used to assess the association of demographics, sexual and drug-related risk behaviors, and 3 measures of STD-stigma (internal, social, and tribal stigma, the latter referring to "tribes" of womanhood) with sexual health care in the past year. Pearson's chi-square test and Mann-Whitney test were used to assess significance. Multivariate logistic models were used to determine the association of STD-stigma with sexual health care after controlling for other factors.
Lower internal stigma score was marginally associated with reporting an STD test in the past year [median score (interquartile range) for those reporting and not reporting an STD test were 0.79 (0.30-1.59) and 1.35 (0.67-1.93), respectively]. In an adjusted model, internal stigma retained a negative association with reporting of STD testing in the past year (adjusted odds ratio, 0.92; 95% confidence interval, 0.85-0.99).
Most women had received a Papanicolaou smear in the past year, and none of the STD-stigma scales were associated with reporting this behavior. Internal stigma retained an association with not having any STD test or treatment. Although sexual stigma is a deeply rooted social construct, paying attention to how prevention messages and STD information are delivered may help remove one barrier to sexual health care.
Clinical preventive services have always been recognized by clinicians as an important part of primary care medicine, but for many years there has been some uncertainty as to the effectiveness of these maneuvers in preventing disease and exactly how and when they should be performed. The recent report of the U.S. Preventive Services Task Force provides a comprehensive review of the science base for preventive services and offers specific recommendations for clinicians on the appropriate delivery of screening tests, counseling interventions, immunizations, and other preventive services. The recommendations provide guidance on how to design an appropriate package of services based on the medical history and risk profile of each patient. This article describes the historical background behind the formation of the task force, its methodology and rationale, and the format of the final report, the "Guide to Clinical Preventive Services." The potential implications of this report and its limitations are also discussed.
Fetal alcohol syndrome and fetal alcohol spectrum disorder are common problems. In response to this problem the Canada Northwest FASD Research Network was established in 2005 by the Canada Northwest FASD Ministerial Partnership. This study was conducted to determine the FASD clinical activity in Canada Northwest.
The Network identified all clinical programs via Internet sites, provincial postings and professional word of mouth references that purported to do FASD assessments regularly using a multidisciplinary assessment team. Each of these programs was sent a questionnaire asking about clinical capacity, aggregate diagnostic results, team composition, time of clinical assessment and cost of assessment.
Of the 27 programs identified to receive the questionnaire 15 programs responded. These programs were determined to have evaluated about 85% of the patients evaluated by all the programs. The total 7 jurisdictional capacity for FASD diagnosis was 816 evaluations in 2005 and projected to be 975 in 2006. Selection methods for appointing patients for assessment seemed excellent as 23% of those assessed were found to have FAS or pFAS and another 44% had other forms of FASD. The most common professionals to participate in the team evaluations were Paediatricians, Clinical Psychologists, Speech and Language Pathologists and Occupational Therapists.
Clinics are developing in western and northern Canada to diagnose patients with FASD. Comparing the experiences of these clinics can help to determine the continued need to increase diagnostic capacity, standardize diagnostic approaches to assure consistency of approach and diagnosis across the sites and appropriately staff and fund the programs. Key words: FASD; diagnosis; Canada; clinics.
The efficacy of breast cancer screening in women age 40 to 49 years remains controversial.
To compare breast cancer mortality in 40- to 49-year-old women who received either 1) screening with annual mammography, breast physical examination, and instruction on breast self-examination on 4 or 5 occasions or 2) community care after a single breast physical examination and instruction on breast self-examination.
Individually randomized, controlled trial.
15 Canadian centers.
50 430 volunteers age 40 to 49 years, recruited from January 1980 to March 1985, who were not pregnant, had no previous breast cancer diagnosis, and had not had mammography in the preceding 12 months.
Breast physical examination and instruction on breast self-examination preceded random assignment of 25 214 women to receive mammography and annual mammography, breast physical examination, and breast self-examination and 25 216 women to receive usual community care with annual follow-up.
Verified breast cancer incidence and cohort mortality through 31 December 1993 and deaths from breast cancer through 30 June 1996.
The 105 breast cancer deaths in the mammography group and 108 breast cancer deaths in the usual care group yielded a cumulative rate ratio, adjusted for mammography done outside the study, of 1.06 (95% CI, 0.80 to 1.40). A total of 592 cases of invasive breast cancer and 71 cases of in situ breast cancer were diagnosed by 31 December 1993 in the mammography group compared with 552 and 29 cases, respectively, in the usual care group. The expected proportions of nonpalpable and small invasive tumors were detected on mammography.
After 11 to 16 years of follow-up, four or five annual screenings with mammography, breast physical examination, and breast self-examination had not reduced breast cancer mortality compared with usual community care after a single breast physical examination and instruction on breast self-examination. The study data show that true effects of 20% or greater are unlikely.
Comment In: Cancer Treat Rev. 2003 Feb;29(1):55-712633581
Comment In: Ann Intern Med. 2002 Sep 3;137(5 Part 1):361-212204022