Medicine
About a year ago, I co-authored an analysis in BMJ with Ronald Koretz, John Ioannidis, and Jeanne Lenzer that challenged the growing consensus about the value of routine, rather than risk-based, screening for hepatitis C virus in the "baby boomer" generation (the cohort of persons born from 1945 to 1965). We called for a point-of-entry randomized trial to test the hypothesis that screening the 60 million Americans in this age group and treating those who test positive for HCV will reduce deaths from liver disease and hepatocellular carcinoma. To my knowledge, no health agency or other organization has stepped forward to support such a trial, which leaves unanswered the critical question of whether the hundreds of billions of dollars that will ultimately be spent on $1000 antiviral pills as a result of widespread screening for hepatitis C (Medicare spent $9.2 billion on hepatitis C drugs in 2015) will lead to more population health benefits than harms.
In a recent editorial in American Family Physician, I explained why I continue to feel that family physicians should not be required to institute routine birth cohort screening for hepatitis C. Please read the whole piece if you can, but if you don't have a personal or institutional subscription to the journal, here is the bottom line:
In summary, recent innovations in identification and management of patients with HCV infection have left family physicians facing important unanswered questions. Is it worthwhile to modify practice workflows to prioritize screening for HCV in middle-aged and older adults without any known risk factors, who are more likely to be at risk of cardiovascular disease and cancer than HCV infection? In persons who test positive for HCV, who should be treated or referred for treatment, knowing that many will not benefit?
- Screening For Hepatitis C And Lung Cancer: Proceed With Caution
Most of my patients don't know (or if they know, don't particularly care) that I blog, but after practicing for nearly three years at the same Washington, DC practice, I am starting to see a few who specifically chose me to be their doctor because...
- Abandoning Risk Factor Assessment For Hiv And Hcv
During my family medicine training, I was taught about the importance of risk factor assessment in deciding what screening tests to order for patients seeking preventive health care. The principle is simple: to minimize false positives and their consequences,...
- Dissecting A Hepatitis C Screening Recommendation
After being banished from the public spotlight in 2010 and 2011 due to health reform politics, the evidence-generating operation known as the U.S. Preventive Services Task Force is finally making waves again. On Monday, the USPSTF got on board with...
- The Case Against Universal Hiv Screening - Part 1 Of 2
Today the U.S. Preventive Services Task Force released a draft statement that updates their previous (2005) recommendations on screening for HIV. Based on findings from a systematic review published in the Annals of Internal Medicine, the USPSTF now recommends...
- "the Best [colorectal Cancer Screening] Test Is The One That Gets Done"
Last week was a busy one for cancer screening. I could choose to criticize the Centers for Disease Control and Prevention's premature guidelines to screen all baby boomers for hepatitis C (which can lead to cirrhosis and liver cancer) or the less-than-sound...
Medicine
Persistent unanswered questions in screening for hepatitis C
About a year ago, I co-authored an analysis in BMJ with Ronald Koretz, John Ioannidis, and Jeanne Lenzer that challenged the growing consensus about the value of routine, rather than risk-based, screening for hepatitis C virus in the "baby boomer" generation (the cohort of persons born from 1945 to 1965). We called for a point-of-entry randomized trial to test the hypothesis that screening the 60 million Americans in this age group and treating those who test positive for HCV will reduce deaths from liver disease and hepatocellular carcinoma. To my knowledge, no health agency or other organization has stepped forward to support such a trial, which leaves unanswered the critical question of whether the hundreds of billions of dollars that will ultimately be spent on $1000 antiviral pills as a result of widespread screening for hepatitis C (Medicare spent $9.2 billion on hepatitis C drugs in 2015) will lead to more population health benefits than harms.
In a recent editorial in American Family Physician, I explained why I continue to feel that family physicians should not be required to institute routine birth cohort screening for hepatitis C. Please read the whole piece if you can, but if you don't have a personal or institutional subscription to the journal, here is the bottom line:
In summary, recent innovations in identification and management of patients with HCV infection have left family physicians facing important unanswered questions. Is it worthwhile to modify practice workflows to prioritize screening for HCV in middle-aged and older adults without any known risk factors, who are more likely to be at risk of cardiovascular disease and cancer than HCV infection? In persons who test positive for HCV, who should be treated or referred for treatment, knowing that many will not benefit?
Given current scientific uncertainties, limited resources, and evolving guidelines, a reasonable middle ground would be for family physicians to collaborate with subspecialty colleagues and focus HCV testing and therapy on patients who are most likely to have long-term complications from the infection, such as those with human immunodeficiency virus infection or type 2 diabetes mellitus, rather than instituting more broad screening and treating everyone who tests positive.
- Screening For Hepatitis C And Lung Cancer: Proceed With Caution
Most of my patients don't know (or if they know, don't particularly care) that I blog, but after practicing for nearly three years at the same Washington, DC practice, I am starting to see a few who specifically chose me to be their doctor because...
- Abandoning Risk Factor Assessment For Hiv And Hcv
During my family medicine training, I was taught about the importance of risk factor assessment in deciding what screening tests to order for patients seeking preventive health care. The principle is simple: to minimize false positives and their consequences,...
- Dissecting A Hepatitis C Screening Recommendation
After being banished from the public spotlight in 2010 and 2011 due to health reform politics, the evidence-generating operation known as the U.S. Preventive Services Task Force is finally making waves again. On Monday, the USPSTF got on board with...
- The Case Against Universal Hiv Screening - Part 1 Of 2
Today the U.S. Preventive Services Task Force released a draft statement that updates their previous (2005) recommendations on screening for HIV. Based on findings from a systematic review published in the Annals of Internal Medicine, the USPSTF now recommends...
- "the Best [colorectal Cancer Screening] Test Is The One That Gets Done"
Last week was a busy one for cancer screening. I could choose to criticize the Centers for Disease Control and Prevention's premature guidelines to screen all baby boomers for hepatitis C (which can lead to cirrhosis and liver cancer) or the less-than-sound...