Primary Care's 2014 Lessons: The Research Changing Practice

Linda Brookes, MSc

Disclosures

December 18, 2014

In This Article

Mammography: Evidence for Cutting Back Grows but Professional Bodies Stand Firm

The "mammography wars" that broke out following the USPSTF's recommendation against universal breast cancer screening with mammography in women aged 40-49 years[36] continued in 2014. Most of the debate was focused on the findings from the 25-year update of the Canadian National Breast Screening Study, a randomized controlled trial begun in 1980, which concluded that annual mammography does not reduce breast cancer–specific mortality for women aged 40-59 beyond that with physical examination alone or usual care in the community.[37] The trial originally enrolled 89,835 women, aged 40-59 years, randomly assigned to mammography (five annual mammography screens) or control (no mammography). As shown in previous updates of the study, there was no difference in breast cancer mortality between the two groups. There was an excess of 106 breast cancer cases on the mammography arm of the trial compared with the control arm, implying that 22% the 484 screen-detected invasive breast cancers were overdiagnosed. This represented one overdiagnosed breast cancer for every 424 women who received mammography screening in the trial. These findings supported the authors' view that "the rationale for screening by mammography should be urgently reassessed by policy makers."[37]

This conclusion was largely rejected by US cancer and imaging societies,[38,39,40,41] and their guidelines still recommend annual screening with mammography starting at age 40.[42,43,44] However, with increasing evidence of fewer benefits and more potential harms associated with mammography,[45,46] most organizations stress the need for women to be presented with all necessary information to make their own decisions.[47]

Calls for Action Against Antimicrobial Resistance

In April the World Health Organization issued its report on antimicrobial resistance, warning that "a post antibiotic era—in which common infections and minor injuries can kill—far from being an apocalyptic fantasy, is instead a very real possibility for the 21st Century."[48] Resistance to common bacteria has reached alarming levels in many parts of the world so that in some settings, few, if any, of the available treatments options remain effective for common infections, according to the report. A later UK review predicted that deaths due to antimicrobial resistance could reach 10 million annually worldwide by 2050.[49]

According to Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, the problem of antimicrobial resistance can never be eliminated, but it has been exacerbated by misuse of antibiotics.[50] In a 2014 call to action, he proposed a multifaceted, global solution to the problem, "combining effective prevention, appropriate use of therapeutics, passive surveillance and active case-finding, and a robust, multisector research enterprise for development of drugs and diagnostics, including market-based incentives for industry."

The CDC recognized the urgency of the problem in the United States in its 2013 report,[51] noting that at least 2 million people acquire serious infections with bacteria that are resistant to at least one of the antibiotics designed to treat them, and that at least 23,000 people die each year as a direct result of these antibiotic-resistant infections. The CDC has launched the Detect and Protect Against Antibiotic Resistance Initiative (known as the AR Initiative) to raise awareness of the threat of antibiotic resistance and the importance of appropriate antibiotic prescribing and use, and to support the discovery of new antibiotics and new diagnostic tests.[52]

At government level, President Obama issued an executive order in September 2014 establishing a Task Force for Combating Antibiotic-Resistant Bacteria that is scheduled to submit a 5-year National Action Plan by February 2015.[53] This followed the presentation of a report on antibiotic resistance by the President's Council of Advisors on Science and Technology.[54,55]

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