Update From the Medical Journals: October 2011 - What Your Doctor Is Reading - Harvard Commentaries

What's the latest news in the medical journals this month? Find out what your doctor is reading.

Men Should Stop Having the PSA Test
Women Should Have Fewer Pap Tests, Says New Guidelines
Studies Show Best Breast Cancer Treatments
More News in Brief: New Vaccine For Lung Cancer Improves Response to Treatment; Neurologists Update Recommendations for Treating Tremor; Saw Palmetto Does Not Help Prostate Symptoms; ADHD Diagnosis and Treatment May Start As Early As Age 4.

Almost two-thirds of men who are older than 50 have had at least one screening PSA (prostate specific antigen) test. This blood test checks for prostate cancer. But the PSA test has been controversial.

In 2010, the American Cancer Society said doctors should not automatically offer the test. Instead, according to that recommendation, they should talk with patients about how uncertain we are about the benefits of the test.

Now, the U.S. Preventive Services Task Force (USPFTF) says men at low risk for prostate cancer should not be screened at all. The test does more harm than good, according to the USPFTF. This group published a draft of its recommendations online October 7. The group is inviting readers to comment.

The PSA test mostly finds early-stage prostate cancer. Task force members cited a study that found two out of five cancers found after a PSA test were too slow growing to ever cause harm. About 90% of men diagnosed with prostate cancer are treated, and the number of lives saved is very small.

The treatment for prostate cancer often leaves men with long-term, undesirable side effects. These include loss of sexual function, incontinence (leaking urine), rectal spasms or urgency to have a bowel movement. The most common treatment for prostate cancer is surgery to remove the prostate. It is called prostatectomy. The chance of dying during this operation is about 1 in 200. The USPFTF points out, "The vast majority of men who are treated do not have prostate cancer death prevented or lives extended from that treatment." But men who are treated "are subjected to significant harms."

African-American men and men with a family history of prostate cancer (relatives who were younger than 65 when their cancers were found) are more likely to have aggressive cancers. Despite the extra risk, the USPSTF is not recommending screening for these men. The new recommendation does not apply to men who have symptoms such as difficulty urinating or blood in the urine. The PSA test might still be useful to check for cancer in men with symptoms.

Less than two weeks after its PSA test recommendation, the USPSTF published guidelines saying women should have fewer Pap tests. The guideline was released online by the USPSTF on October 18. A Pap test (also called a Papanicolaou smear) collects a sample of cells from the surface of the cervix to check for changes that can lead to cervical cancer.

After reviewing the evidence, the USPFTF says Pap tests save lives, but they also have drawbacks. First, having a Pap test usually means having a pelvic exam. Second, the test has a fairly high false-positive rate. After a positive result, the doctor will do a colposcopy. This procedure examines the cervix with a magnifying lens. Sometimes the doctor takes a sample of tissue (biopsy) for examination. The USPSTF says having Pap smears every three years is a good way to balance the risks and the benefits of the screening test.

Women ages 21 to 65 who have a normal Pap test can repeat the test once every three years. (Previously, women who had not yet had their first three Pap tests were told to have the test every year. Also, women who had multiple sexual partners and women who had any previous history of a sexually transmitted infection (STI) were advised to have yearly Pap tests. But in the new recommendation even these women can have the test once every three years.) If a woman has had her uterus removed, she does not need to continue having Pap tests.

The revised guidelines only apply to women who have normal Pap tests. Women who have had an abnormal Pap test should follow the existing recommendations for more frequent testing.

According to a new study, the breast cancer drug letrozole (Femara) does a better job of preventing the cancer from returning and increases survival time compared with the drug tamoxifen (Nolvadex and other brands). The journal Lancet Oncology published the results October 20.

The study involved more than 8,000 women with breast cancer. Compared with women who took tamoxifen, breast cancer survivors who took letrozole for five years were 20% less likely to die or have their cancer return in their first 12 years after their initial cancer treatment. Combining the two drugs was no better than getting letrozole alone. Letrozole and tamoxifen are given to patients whose cancers test positive for estrogen receptors on the cancer cells. This study will make letrozole the first choice for cancer drug treatment after surgery.

In a separate study published October 19, having radiation treatment after breast cancer surgery was shown to cut the risk of a recurrence in half for 10 years after treatment. Compared with women who did not get radiation, death rates for women who had the treatments were lower by about one-sixth 15 years after the treatments. This study looked at more than 10,000 breast cancer patients. It was published online by the Lancet. Radiation is usually recommended after surgery for breast cancer. This study will make that recommendation even stronger.

New Vaccine Improves Response to Lung Cancer Treatment. A new experimental vaccine appears to improve the response to chemotherapy for lung cancer and slow down the growth of cancer cells. This vaccine is being tested for use in non-small-cell lung cancer, the most common lung cancer type. In the study, published in Lancet Oncology, 148 patients with lung cancer received chemotherapy. Approximately half of them also received the vaccine. Those who also got the vaccine had slightly better results as a group. In the group with the vaccine, about 10% fewer people had progression in their cancer during the six months after treatment.

Neurologists Update Recommendations for Treating Tremor. The American Academy of Neurology has revised its guidelines for treating a condition called essential tremor. They were published October 19 in the journal Neurology. The condition causes the hand, head or voice to shake. It usually affects adults after age 40, and it can run in families. According to the experts who wrote the guideline, the best drugs to treat tremor are propranolol (Inderal), a blood pressure drug, and primidone (Mysoline), a medicine that is sometimes used to prevent seizures. Other helpful medicines are gabapentin (Neurontin), topiramate (Topamax), atenolol (Tenormin), sotalol (Betapace) and alprazolam (Xanax). For people with severe tremors that don't respond to medicines, surgery is an option.

Saw Palmetto Does Not Help Prostate Symptoms. An enlarged prostate is also called benign prostatic hypertrophy (BPH). It can cause symptoms such as slowness to start urinating, a weak urine stream or dribbling after urinating. Some men take an herbal dietary supplement called saw palmetto. This herb has been rumored by some people to relieve symptoms. A research study published September 28 in the Journal of the American Medical Association looked at how effective the herb actually is for treating symptoms. This was a well-designed randomized study of 369 men who were assigned to take either saw palmetto at a usual dose or a placebo pill. They did not know which pill they were taking. They were treated for 72 weeks (almost a year and a half). Saw palmetto had no measurable effect on urination symptoms compared with the placebo pills. The research concluded that saw palmetto was not helpful.

ADHD Diagnosis and Treatment May Start As Early As Age 4. The American Academy of Pediatrics (AAP) says that preschool is not too early to diagnose a child with the behavior problem known as ADHD (attention-deficit hyperactivity disorder). This was part of a report published in the October 17 issue of Pediatrics. ADHD causes impulsive behavior, excessive boisterousness or fidgeting, and difficulty paying attention to instructions. Children ages 4 to 5 who exhibit these behaviors should work with a psychologist to modify these behaviors as a first step in treatment. If behavior therapy does not help, the report recommends treatment with the medicine methylphenidate (Ritalin). Previously, this medicine has not been recommended for children at such a young age.

Mary Pickett, M.D. is an Associate professor at Oregon Health & Science University where she is a primary care doctor for adults. She supervises and educates residents in the field of Internal Medicine, for outpatient and hospital care. She is a Lecturer for Harvard Medical School and a Senior Medical Editor for Harvard Health Publications.