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Results from the third large randomized trial of prostate cancer screening were . This new study has substantial methodological flaws, but the findings are still worthy of discussion. In the study, 189,000 men 50-69 years of age from England and Wales were randomized to receive either an invitation for one round of PSA screening or no such invitation. Importantly, just 36% of those invited for screening ended up receiving the test, whereas the authors estimate that 10-15% of control patients underwent PSA screening during the study period as part of routine care.
Despite the substantial amount of crossover, as anticipated, the diagnosis of prostate cancer was modestly more common after 10 years in the intervention versus control group (4.3% versus 3.6%). Somewhat surprisingly, however, patients in the screening group had similar rates of prostate cancer mortality as those in the control group (0.30 per 1000 person-years for the intervention group versus 0.31 for the control group).
These findings must be considered in context. There are two other large, long-term prostate cancer trials: a that also suffered from considerable crossover between groups, and a higher quality . The U.S. study, which involved six rounds of annual screening, failed to demonstrate a benefit of PSA screening, but has appropriately been criticized for the high crossover rate. The European study, which involved an average of 2.1 rounds of screening that were offered at an average interval of 4 years, found that after 13 years, approximately 781 men would need to be offered screening and 27 additional men would need to be diagnosed with prostate cancer to prevent one prostate cancer death. There was no benefit with respect to all-cause mortality benefit from screening in either trial.
On the whole, these findings suggest that most men, after being properly informed, will likely decide that PSA screening is more trouble than it's worth. Still, we support shared decision making, and believe some appropriately educated men may opt to be screened if they have a strong family history of prostate cancer or another compelling reason to seek screening.
Aromatherapy for Nausea
We are always fascinated by the possibility of using non-oral treatments that might confer less side effects (see Gordy Schiff et al.'s classic JAMA piece, ""). So, we were intrigued to learn of a small randomized controlled trial published in Annals of Emergency Medicine assessing the benefit of smelling or vomiting in the emergency department. These preliminary results suggest that smelling a pad soaked in isopropyl alcohol might be just as effective as oral ondansetron. While we await a larger trial to confirm these findings, it may make sense in certain situations to give this readily available, simple, and benign intervention a try before turning to an oral antiemetic.
Making Sense of the Data on Acupuncture
In a great "Head to Head" from The BMJ, we hear two . One of the experts argues that we ought to recommend acupuncture for managing chronic pain because, although hard data supporting its benefits are limited, it is "a relatively safe and moderately effective intervention for a wide range of common chronic pain conditions ... for those patients who choose it and who respond well, it considerably improves health related quality of life, and it has much lower long term risk for them than non-steroidal anti-inflammatory drugs. It may be especially useful for chronic musculoskeletal pain and osteoarthritis in elderly patients, who are at particularly high risk from adverse drug reactions."
The other argues against it, explaining: "after decades of research and hundreds of acupuncture pain trials, including thousands of patients, we still have no clear mechanism of action, insufficient evidence for clinically worthwhile benefit, and possible harms."
To date, most of the literature suggests that acupuncture is no better than placebo therapy, but it is better than no therapy at all -- i.e., acupuncture may lead to improvements through a placebo effect. Some patients clearly feel that they benefit, and as a result will be less likely to use medications with the potential for adverse effects. Overall, we are more compelled by proponents of acupuncture, though both viewpoints are persuasive.
Administrative Waste
Our Slow Medicine blog focuses primarily on wasteful clinical services, but according to the latest data, administrative waste in the U.S. appears to be substantially more prevalent than clinical waste. A February study in found that "in a large academic healthcare system, the estimated costs of billing and insurance-related activities ranged from $20 for a primary care visit to $215 for an inpatient surgical procedure, representing 3% to 25% of professional revenue." These high administrative costs are particularly noteworthy in light of the fact that the health system in this study used a popular certified electronic health records (EMR) system. One of the primary motivations for widespread EMR adoption was to facilitate billing and reduce administrative costs – with large .
Another recent analysis, also from JAMA, concluded that contrary to conventional wisdom, higher healthcare expenditures in the U.S. are not largely driven by higher utilization of clinical services. Rather, "prices of labor and goods, including pharmaceuticals and devices, and administrative costs appeared to be the main drivers of the differences in spending."
Though we believe "slower," more parsimonious care would be better for patients and more efficient, these results suggest that widespread adoption of the "Slow Medicine" philosophy might have only a modest impact on healthcare costs, which are largely affected by factors outside of the clinician's control.
"Updates in Slow Medicine" applies the latest medical research to support a thoughtful approach to clinical care. It is produced by , of Harvard Medical School, and , of the Keck School of Medicine at the University of Southern California. To learn more, .