Transcript hot topics - Derby GP Specialty Training Programme

HDR PLANNING &
HOT TOPICS
Nov 3rd 2010
This Afternoon
• HDR Planning 14.00 – 15.15
• Tea break 15.15
• Hot topics 15.30 – 17.00
Planning
10/11/10
Prescribing and Ethics
L Higgs
17/11/10
Teenage Psychiatry and
LD
C Shukla
24/11/10
Clinical Governance
T Lawes
1/12/10
Urogynae/Menstrual
Problems
S Mathew
Mr Cust, Gynae
8/12/10
IBD
S Goes
Cons Gastroenterology TBC
15/12/10
CSA Preparation
E Parrott
22/12/10
Christmas Quiz
Ann Cox CAMHS
Hot Topics
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Pub quiz style
Split into 3 groups
Question and answers
Discussion
Top team each round will win a prize
Aims
• To consider the latest studies and how they influence our
prescribing in relation to:
- Aspirin
- Glucosamine
• To review the latest research into the use of PSA in screening for
prostate cancer
1) Aspirin
• Who do you think needs to be prescribed aspirin?
(as currently under debate....ignore diabetic patients, focus on
those with cardiovascular risk)
Aspirin – the study
• Lancet 2009: 373: 1849
• Antithrombotic Trialists Collaboration (ATTC) meta analysis
looked as use of aspirin in primary and secondary prevention.
• A large study
• All compared aspirin to placebo
• The outcomes were CV events and the rate of harm
Primary prevention
 Aspirin DOES NOT reduce the CV MORTALITY
 Aspirin DOES reduce CV EVENTS – but the risk reduction v small
(NNT 1666)
 HARMS for every 3333 treated over 12m there would be one
additional GI/extra cranial bleed (NNH 3333)
• DTB agree, current practice is recommended that:
– Aspirin shouldn’t be started for primary prevention
– In those already taking it – explain current evidence to patient.
Secondary Prevention
 Aspirin prevents 1 CV event per year for every 66 people treated
(NNT 66)
 Aspirin prevents 1 vascular death for every 344 people treated
 There was insufficient data to report on GI/extra-cranial bleeds or
haemorrhagic CVAs
• DTB
– Secondary prevention 75mg aspirin/day
– (no evidence of improved protection with increase dose – but
increased dose does increase GI haemorrhage risks)
Aspirin – Questions and Answers
• Who do you think needs to be prescribed aspirin?
- Not for primary prevention
- Secondary prevention require 75mg OD
- Secondary prevention would include those with TIA/stroke,
previous MI, angina.
2) Glucosamine
• Who should be prescribed glucosamine?
• What advice should you give a patient when commencing
treatment?
• In which patients is the use of glucosamine contraindicated?
Glucosamine
 Glucosamine is only indicated in patients with knee OA (DTB
2008; 46:81-4)
• NICE does not support the use of glucosamine in OA (NICE,
2008)
Derbyshire Medicines Management
May 2010 Advice
• A trial of glucosamine sulphate 1500mg once daily is
recommended as a treatment option in patients suffering from
osteoarthritis of the knee, after trying, or in conjunction with
paracetamol.
• Use may mean that potentially toxic NSAIDs or coxibs need not
be used.
• It may take several weeks for the full effect to be seen.
• If prescribed generically – the community pharmacy chooses the
brand to supply. Expensive brands cost up to £90 for a thirty day
supply
• Medicines Management recommends that glucosamine sulphate
is prescribed as the brand Valupak. Thirty days supply of the
1500mg strength costs only £2.83.
What should we tell patients?
• None of the clinical trails have shown glucosamine is particularly
effective
• It may reduced pain in some people
• It probably won’t improve function
• It’s unclear whether it has any long term effects (slowing disease
progression)
• Glucosamine in safe in most people – but there are CIs
• Glucosamine may take several weeks to work – trial for 3 months,
if pain is no better, consider stopping
Glucosamine - Questions and Answers
• Who should be prescribed glucosamine?
• Only those with knee OA
• What advice should you give a patient when commencing
treatment?
• May improve pain, probably won’t improve function, long term
effects unclear, if no improvement at 3 months – consider
stopping
• In which patients is the use of glucosamine contraindicated?
• Pregnant, breast feeding, allergic to shellfish and those on
warfarin
PSA Testing Questions
1) What percentage of men with a normal PSA have clinically
significant prostatic cancer?
2) What percentage of men with raised PSA will not have prostate
cancer?
3) List 3 advantages and 3 disadvantages of the PSA test
PSA
• PSA is a glycoprotein produced by the prostate
• The amount produced can increase due to malignant and benign
processes
PSA
• PSA has long been used in general practice.
• There is currently lots of debate over whom should have a PSA
test, there is no agreed criteria for testing.
• But, questions to consider;
– Could the PSA be a useful screening tool?
– Would screening reduce mortality?
BMJ 2009;339:b3537
• Looked specifically at how well PSA performs as a screening test
depending on cut off values chosen.
PSA cut off
3
4
5
Sensitivity
59%
44%
33%
Specificity
87%
92%
95%
+ve likelihood ratio
4.5
5.5
6.4
-ve likelihood ratio
0.47
0.61
0.70
• The authors concluded that additional biomarkers would be
needed before population screening should be introduced.
Systemic review of PSA screening –
BMJ 2010; 34:c4543
• Systemic review of PSA screening – BMJ 2010; 34:c4543
• Pooled results from 6 major PSA screening studies (inc. PLCO
and ERSPC)
• Meta-analysis of 387,286 men showed:
 Screening increased your risk of being given a diagnosis of
prostate cancer
 Screening had no impact on death from prostate cancer or overall
mortality
PLCO Screening Trial (NEJM 2009;
360: 1310-0)
• 76,000 men (aged 55-74) were randomised to usual care or
annual screening for prostate cancer
• 40-52% of the men in the control group had screening each year

Screening picked up more cancers than usual care

Mortality from prostate cancer was not reduced in those who
had been screened

Screening did not appear to pick up earlier tumours (similar
rates of all stages in control and screening group)
ERSPC (NEJM 2009; 360:1320-8)
• RCT 180,000 men aged 50-74 in 7 European countries.
• Randomised to “no screening” or to “PSA once every 4 years”
 Twice as many cancers were diagnosed in the screening group
compared to the control group
 Those who had undergone screening were 20% less likely to die of
prostate cancer
 Benefit of screening only seen in those aged 55 or more, not in those 5054
 There was a significant rate of over diagnosis (detecting tumours that
would never become clinically significant)
ERSPC (continued)
 1410 men would need to be screened to prevent one death from
prostate cancer
 48 additional cases of prostate cancer would need to be treated to
prevent one death from prostate cancer.
Comparing ERSPC and PCLO
• Different cut-off values for action (3ng/ml v 4ng/ml)
• Study population selection
• Improved prostate cancer treatment over the course of the PCLO
trial
• Follow up of PCLO may not have been long enough.
What do these trials mean to our
practice?
• National Screening Committee have recommended that a
prostate cancer screening programme should not be introduced in
the UK
• Men who ask for a PSA should continue to be offered the full
range of information to allow them to make an informed decision
PSA Summary
• PSA test has significant failings
• Screening MIGHT save lives, but we don’t know whether it
actually does any good...which is a far more important question.
• Treating men with clinically unimportant cancers exposed them to
harm with no benefits
• PSA should not be done routinely without discussing risks and
benefits with the patient
• A single PSA <1ng/ml in a man’s 60s largely rules out the risk of
clinically significant prostate cancer.
PSA Answers (1)
1) What percentage of men with a normal PSA have clinically
significant prostatic cancer?
• 20%
2) What percentage of men with raised PSA will not have prostate
cancer?
• 66%
PSA Answers (2)
3) List 3 advantages and 3 disadvantages of the PSA test
• Advantages
 Reassurance if result is normal
 May indicate cancer before symptoms present
 May find cancer at an early stage
 If treated may avoid worse outcomes, e.g. death
 Even if aggressive/advance cancer, treatment may prolong survival
• Disadvantages
 False negatives
 May have unnecessary tests and anxiety
 Cannot differentiate slowly growing ‘v’ aggressive cancers
 May cause unnecessary anxiety if it’s a slow, clinically insignificant ca
 48 men will undergo treatment to save one life
The End
• Questions?