AHCPR Report on Colorectal Cancer Screening

Most Americans do not receive screening for colorectal cancer even though evidence exists that reduction in colorectal cancer morbidity and mortality can be achieved through detection and treatment of early-stage colorectal cancers and the identification and removal of adenomatous polyps, according to a study sponsored by the Agency for Health Care Policy and Research (AHCPR). The report is based on a systematic review of about 3,500 citations from the scientific literature published between 1966 and 1994.

The screening tests analyzed in the report include fecal occult blood testing, 60-cm flexible sigmoidoscopy, fecal occult blood testing combined with flexible sigmoidoscopy, double-contrast barium enema and colonoscopy.

The following significant findings from the report have been excerpted from the summary:

• Colorectal cancer mortality can be reduced 15 to 33 percent by fecal occult blood testing and diagnostic evaluation and treatment for positive tests.

• 60-cm flexible sigmoidoscopy identifies nearly all cancers and polyps more than 1 cm in diameter and 75 to 80 percent of small polyps that are located in the portion of the bowel examined.

• Screening with flexible sigmoidoscopy can reduce colorectal cancer mortality risk. Sigmoidoscopy is associated with a 59 to 80 percent reduction in risk of death from cancer in the part of the colon examined by the rigid sigmoidoscope.

• Indirect evidence supports the use of double-contrast barium enema in screening for colorectal cancer.

• Screening colonoscopy offers the potential to both identify and remove cancers and premalignant lesions throughout the colon and rectum.

• Evidence suggests that detecting and removing polyps reduces the incidence of colorectal cancer and that detecting early cancers lowers mortality from colorectal cancer. Both double-contrast barium enema and colonoscopy detect polyps and colorectal cancer, but they have not been studied as screening tests.

• Evidence suggests a low level of awareness about the risks of colorectal cancer and its symptoms. Patients who understand the nature of the disease are more likely to participate in screening. Good communication between health care professionals and patients can enhance patient participation.

The report also covers future research needs. A summary of the report titled “Colorectal Cancer Screening” is available on the AHCPR Web site (http://www.ahcpr.gov). The full report may be obtained free from the AHCPR Publications Clearing-house by calling 800-358-9295 or by writing AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907.

Neighborhood Safety and Physical Inactivity

Persons living in neighborhoods that they perceive to be unsafe are less likely to engage in physical exercise such as walking than persons in safer areas, according to a report published in the February 26, 1999, issue of Morbidity and Mortality Weekly Report. The survey found that 39.3 percent of persons 18 to 64 years of age who live in neighborhoods they consider “not at all safe” reported no physical activity or exercise in the preceding month, compared with 30.5 percent of persons who live in areas they considered to be “extremely safe.” The difference was greater among persons over 65 years of age (63.1 percent versus 38.6 percent).

Overall, the prevalence of physical inactivity was highest among persons over 65 years of age, women, racial/ethnic minorities, persons with a high school education or less and persons with annual household incomes less than $20,000.

The report recommends public health action to provide for safe access to physical activity in neighborhoods. Older adults especially need to have access to safe places for exercise.

Use of Restraints and Seclusion Intervention

The American Hospital Association (AHA) and the National Association of Psychiatric Health Systems (NAPHS) have issued guidelines on use of restraint and seclusion interventions in psychiatric patients. The guidelines are based on existing principles and policies on behavior health already in place in most institutions. The principles identify seclusion and restraint as emergency interventions that aim to protect patients in danger of harming themselves or others.

Recent reports of death and injury from the use of restraint and seclusion interventions have prompted AHA and NAPHS to request that hospitals review their current policies and make sure they are appropriate. Prevention of injury and death is essential. Staff must be well trained and continually educated regarding the proper use of restraint and seclusion. Both organizations promote using seclusion and restraint as little as possible and only when less restrictive methods are not feasible.

Copies of the guidelines and more information can be obtained on the AHA Web site (http://www.aha.org) and on the NAPHS Web site (http://www.naphs.org).

Report on the Use of Marijuana as Medicine

A new report from the Washington-based Institute of Medicine (IOM), an arm of the National Academy of Sciences, notes that strong scientific evidence suggests that the active ingredients in marijuana (cannabinoids) are potentially effective in treating pain, nausea and the severe weight loss associated with acquired immunodeficiency syndrome. The report, requested by the White House Office of National Drug Control Policy, recommends the initiation of clinical trials of short duration with subjects who are most likely to benefit from this type of treatment. It also stressed that the IOM found no clear evidence that use of marijuana leads to other drug use. However, the IOM cautions that the benefits of smoking marijuana are limited because of the harmful effects of smoking. Therefore, smoking marijuana should only be recommended for terminally ill patients or those with debilitating symptoms that do not respond to approved medications. Data do not support the use of marijuana in the treatment of glaucoma.

The IOM calls for the development of standardized forms of cannabinoids that can be taken by inhaler or other methods. Review boards should oversee the drug's use. Voters in seven states have approved referendas in support of the legal medical use of marijuana. These states are Alaska, Arizona, California, Colorado, Nevada, Oregon and Washington.

“Marijuana has potential as medicine, but it is undermined by the fact that patients must inhale harmful smoke,” said Stanley Watson, M.D., co-principal investigator of the IOM study and research scientist at the University of Michigan, Ann Arbor. “Until researchers develop a safe and effective delivery system, caregivers must consider the health problems that result from smoking when deciding whether to recommend marijuana to patients.”

Copies of “Marijuana and Medicine: Assessing the Science Base” are available from the National Academy Press by calling 202-334-3313 or 800-624-6242. The report costs $44.95 plus shipping.

Update on Rate of Preterm Singleton Births

The overall rate of singleton preterm births has stabilized in recent years, although substantial changes in rates occurred in some racial/ethnic subgroups, according to a report from the Centers for Disease Control and Prevention (CDC) that analyzed data from 1989 to 1996. For this report, published in the March 12, 1999, issue of Morbidity and Mortality Weekly Report, preterm birth was defined as a live birth occurring at 17 to 36 weeks of gestation.

From 1989 to 1996, the preterm birth rate among singletons increased 0.3 percent (from 97.0 to 97.3 per 1,000 live-born infants). The singleton preterm birth rate increased 8 percent among non-Hispanic whites but decreased 10 percent among non-Hispanic blacks, 4 percent among Hispanics, 3 percent among American Indians/Alaskan natives and 2 percent among Asians/Pacific Islanders.

Maternal factors may have affected the trend in preterm birth rates. The percentage of singleton infants born to women over 35 years of age increased 43 percent during the same period, the percentage born to women who received prenatal care beginning in the first trimester increased 8 percent, and the percentage born to unmarried women increased 20 percent. Similar trends were observed in all racial/ethnic groups.

The CDC believes that additional studies exploring why preterm births are increasing among non-Hispanic whites and decreasing among non-Hispanic blacks may help health care professionals understand how to prevent preterm births.

Potential Risk with Glass Capillary Tubes

The U.S. Food and Drug Administration (FDA), the National Institute for Occupational Safety and Health (NIOSH) and the Occupational Safety and Health Administration (OSHA) have issued an alert regarding the potential risk of injury and infection from bloodborne pathogens because of accidental breakage of glass capillary tubes. To reduce the risk of injury caused by breakage of capillary tubes, the FDA, NIOSH and OSHA recommend that users consider collecting blood in devices less apt to break accidentally, including the following:

• Capillary tubes that are not made of glass.

• Glass capillary tubes wrapped in puncture-resistant film.

• Products that use a method of sealing that does not require manually pushing one end of the tube into putty to form a plug.

• Products that allow the blood hematocrit to be measured without centrifugation.

Although these organizations do not recommend specific products, the alert states that blood-collection devices with these characteristics are currently available. Copies of the alert and additional relevant information can be found on the following Web sites: http://www.fda.gov/cdrh/safety.html; http://www.cdc.gov/niosh/homepage.html; or http://www.osha-slc.gov/SLTC/needlestick. Information may also be obtained by calling NIOSH at 800-356-4674 or OSHA (attn: Edith Handelman) at 202-693-2120.