Update From the Medical Journals: May 2012 - 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
Studies Prove that Osteoporosis Drugs Cause Atypical Femur Fractures
More News in Brief: CDC Tells Baby Boomers to Get Checked for Hepatitis C; Lung Scan Is Recommended for Heavy Smokers; One-Third of Working Americans Get Fewer than Six Hours of Sleep

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 (ACS) said doctors should not automatically offer the test. Instead, according to the ACS, they should talk with patients about how uncertain we are about the benefits of the test.

Now, the U.S. Preventive Services Task Force (USPSTF) 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. The journal Annals of Internal Medicine published this group's recommendations online May 21. The USPSTF had released a draft of this same recommendation in October. It invited comments from the public and from physicians. More than 3,000 were sent before the comment period ended.

The PSA test mostly finds early-stage prostate cancer. The task force made its recommendation after reviewing about 9,000 studies. In studies, two out of five cancers found by 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. In fact, researchers have not shown a difference in "all-cause" mortality (death from all causes considered together) from prostate cancer screening tests.

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 (prostatectomy). The chance of dying during this operation is about 1 in 200. The USPSTF points out that for prostate cancers found by screening, treatment doesn't prevent deaths or extend lives for most men. 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.

A stress fracture (also called "fatigue fracture") occurs when a bone becomes less flexible and less able to bend. It absorbs stress along a line of tension and eventually breaks in a fine straight line. It is possible for stress fractures to occur in the femur (the thigh bone). When this occurs, they are called atypical fractures of the femur.

Two years ago, the U.S. Food and Drug Administration (FDA) first notified doctors of a concern that osteoporosis drugs might be linked to these atypical fractures. The drugs are called "bisphosphonates." They include alendronate (Fosamax), risedronate (Actonel) and etedronate (Didronel). These medicines encourage bones to add mineral, which makes them more dense. They lower the risk for hip fracture. But the FDA said they might increase the risk for atypical fractures of the femur.

Last year, a study proved this to be true. This month another study confirmed the connection. On May 21, a study in the Archives of Internal Medicine reported on 477 patients who had femur fractures below the hip. Thirty-nine of them had atypical fractures. The others had a more classic fracture (a snapping or splintering of the bone, not a fine line) that we typically see with trauma. Eighty-two percent of the people who had atypical fractures were taking bisphosphonate drugs. Only 6% of people with typical fractures were taking bisphosphonates. The researchers divided patients into groups according to how long they had taken an osteoporosis drug. They analyzed the data and found that the odds of having an atypical fracture were much larger if a person had taken the drugs for at least five years.

Osteoporosis drugs strengthen bones, but the bones also become abnormally stiff. This study adds to evidence that bisphosphonate drug treatment has risks as well as benefits.

It seems likely that most of the benefit comes in the first several years of treatment. Most doctors limit the time of treatment with bisphosphonate drugs to five years or less. Most likely, this study will help that limit become a standard of practice. For people who have severe osteoporosis, several years of treatment with a bone-building medicine probably offers more benefit than risk.

CDC Tells Baby Boomers to Get Checked for Hepatitis C. On May 19, The U.S. Centers for Disease Control recommended that all baby boomers (anyone born from 1945 to 1965) have a one-time blood test to check for hepatitis C. This infection can cause silent damage for decades before eventually leading to liver failure (cirrhosis) or liver cancer.

It's estimated that 2 million of the 3.2 million Americans who are infected with the virus are baby boomers. About 3% of baby boomers test positive for the virus. The infection is especially common among people who have used injection drugs and have shared needles, or have received a blood transfusion.

Recently, treatment for hepatitis C has improved. Now, antiviral medicines can cure the virus in many people who have the infection.

Lung Scan Is Recommended for Heavy Smokers. The American College of Chest Physicians and the American Society of Clinical Oncology have agreed it might make sense to screen for lung cancer in very heavy smokers. The recommendation was released online May 20 by the Journal of the American Medical Association.

Lung cancers can be seen on an X-ray or a computed tomography (CT) scan. Small lung cancers are treatable with surgery. So should smokers get X-rays or CT scans? As a general rule, doctors don't screen for lung cancer with X-rays or CT scans unless a person has symptoms. Even in most smokers, these tests don't find enough early stage cancers to make using them worthwhile.

The test with the best track record for finding lung cancers is a special CT scan called low-dose computed tomography (LDCT). In studies, 1 out of every 100 smokers who has an LDCT has lung cancer. About 20% of smokers have some kind of abnormality on the test that required follow up tests or biopsy, even though most of them did not have cancer. Scans and biopsies have health risks, so experts agree that the test should only be used if your risk for lung cancer is high.

Based on the recommendation, here is who should be tested with a yearly LDCT: people 55 to 74 years old who have smoked the equivalent of a pack per day for 30 years (or 2 packs per day for at least 15 years) AND don't have any progressive illness that would shorten life expectancy. The recommendation specifically says this type of screening test should only be used if you have access to care at a large, skilled medical center (where there are radiologists who have specially trained in LDCT interpretation, lung and surgical specialists and doctors who can appropriately coordinate your care).

One-Third of Working Americans Get Fewer than Six Hours of Sleep. One of the goals of the public health campaign "Healthy People 2020" is to increase the number of adults who get enough sleep. The National Sleep Foundation recommends that healthy adults sleep seven to nine hours per day. But the U.S. Centers for Disease Control (CDC) has just analyzed the results of the 2010 National Health Interview Survey (NHIS). The CDC reported the findings in its April 27 issue of the Morbidity and Mortality Weekly Report. Thirty percent of workers are sleeping fewer than six hours each day. Experts consider this to be "insufficient."

Getting too little sleep on a regular basis has been associated with heart disease, obesity, unsafe driving and, of course, poor work performance and work safety. Given the large numbers of Americans who are sleep-deprived, sleep is a public health concern.

Moyer, Virginia A, MD, MPH, on behalf of the U.S. Preventive Services. "Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement." Annals of Internal Medicine. Published online at www.annals.org May 22, 2012.

Raphael P. H. Meier, MD; Thomas V. Perneger, MD; Richard Stern, MD; René Rizzoli, MD; Robin E. Peter, MD. "Increasing occurrence of atypical femoral fractures associated with bisphosphonate use." Archives of Internal Medicine. Published online May 21, 2012.

Peter B. Bach, MD, MAPP et al. "Benefits and harms of CT screening for lung cancer: A systematic review." Journal of the American Medical Association. Published online May 20, 2012.

"Short sleep duration among workers — United States, 2010." Morbidity and Mortality Weekly Report. April 27, 2012; 61(16); 281-285.

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.