In Cancer Screening, Why Not Tell the Truth?

John M Mandrola, MD

|January 12, 2016

An unpleasant emotion caused by the belief that something is dangerous. This is fear. This is cancer.
The motivation to screen for cancer, therefore, is easy to understand.
The problem: cancer screening has not worked. Recent reviews of the evidence show that current-day screening techniques do not save lives. Worse, in many cases, these good-intentioned searches bring harm to previously healthy people.
I realize this sounds shocking. It did to me, too. Millions of women and men have had their breasts squished, veins poked, lungs irradiated, and bowels invaded in the name of “health” maintenance. I’ve been scolded for forgoing PSA tests and colonoscopy — “you should know better, John.”
I know what you may be thinking. We have all heard the anecdotes — cases that are often celebrated in local news reports and hospital marketing material. People saved by early detection, and the opposite: the unscreened felled by late-stage disease.
Anecdotes, however compelling, are not evidence. When you pull up a chair, open your computer, take a breath, suspend past beliefs, and look for the evidence that screening saves lives, it simply isn’t there.
One reason that this many people (doctors and patients alike) have been misled about screening has been our collective attachment to the belief that if screening lowers disease-specific death rates, that would translate to lower overall mortality. That is: breast, lung, and colon cancer are bad diseases, so it makes sense that lowering death from those three types of cancer would extend life.
It is not so.
Facts, Not Fear
In a comprehensive review of the literature[1] published in the BMJ, Drs Vinay Prasad (Oregon Health Sciences University, Portland) and David Newman (School of Medicine at Mount Sinai, New York), along with journalist Jeanne Lenzer, find that disease-specific mortality is a lousy surrogate for overall mortality. They report that when a screening technique does lower disease-specific death rates, which is both uncommon and of modest degree, there are no differences in overall mortality.
The authors cite three reasons why cancer screening might not reduce overall mortality:
  • Screening trials were underpowered to detect differences. I’m no statistician, but doesn’t the fact that a trial requires millions of subjects to show a difference, mean there is little, if any, difference?
  • “Downstream effects of screening may negate any disease-specific gains.” My translation: harm. Dr Peter Gøtzsche (Nordic Cochrane Center, Copenhagen) wrote in a commentary[2] that “screening always causes harm. Sometimes it also leads to benefits, and sometimes these benefits outweigh the harms.” To understand harm resulting from screening, one need only to consider that a prostate biopsy entails sticking a needle through the rectum, or that some drugs used to treat breast cancer damage the heart.
  • Screening might not reduce overall mortality because of “off-target deaths.” An illustration of this point is provided by a cohort study[3]that found a possible increased risk of suicide and cardiovascular death in men in the year after being diagnosed with prostate cancer. People die — of all sorts of causes, not just cancer.
Let’s also be clear that this one paper is not an outlier. A group of Stanford researchers performed a systematic review and meta-analyses[4] of randomized trials of screening tests for 19 diseases (39 tests) where mortality is a common outcome. They found reductions in disease-specific mortality were uncommon and reductions in overall mortality were rare or nonexistent.
Drs Archie Bleyer and H Gilbert Welch (St Charles Health System, Central Oregon, Portland) reviewed Surveillance, Epidemiology, and End Results (SEER) data from 1976 through 2008 and concluded that “screening mammography has only marginally reduced the rate at which women present with advanced cancer and that overdiagnosis may account for nearly a third of all new breast cancer cases.”[5]Likewise, a Cochrane Database Systematic review[6] of eight trials and 600,000 women did not find an effect of screening on either breast cancer mortality or all-cause mortality. This evidence caused the Swiss medical board to abolish screening mammography.[7]
These are the data. It’s now clear to me that mass cancer screening does not save lives. But I’m still trying to understand how this practice became entrenched as public-health gospel. It has to be more than fear.
How We Say It Matters
Dr Gerd Gigerenzer (Max Planck Institute, Berlin, Germany) offered a clue in his editorial[8] accompanying the recently published literature review and analysis by Prasad and colleagues. He pointed to language and the ability of words to persuade. Instead of saying “early detection,” advocates might use the term “prevention.” This, Dr Gigerenzer says, wrongly suggests screening reduces the odds of getting cancer. Doesn’t looking for cancer increase the odds of getting the diagnosis of cancer?
Gigerenzer noted two other ways language is used to emphasize screening benefits over harms:
  • The reporting of benefits in relative, not absolute terms.
  • The equating of increases in 5-year survival rates with decreases in mortality.
I would add to this list of word misuse, the practice of referring to women sent to mammography screening as patients. They are not patients; they are well people.
Dr Gigerenzer agreed with the commonsense notion that overall mortality should be reported along with cancer-specific mortality. His editorial included a fact box on breast cancer early detection using mammography provided by the Harding Center for Risk Literacy. I challenge you to tell me why such text boxes should not be shown to people before they undergo screening,
Fixing a Public-Health Problem
Given these revelations, I conclude that we have a massive public-health problem. Any expert in problem solving will tell you the first step of getting out of hole is to stop digging. I see three obvious next steps:
The first action healthcare experts should take is to spread the word that there is nothing about the mass screening of healthy people for cancer that equates to health maintenance. Embrace clear language. Saying or implying that screening saves lives when there are no data to support it and lots to refute it undermines trust in the medical profession.
The second action healthcare experts should take is to stop wasting money on screening. If the evidence shows no difference in overall mortality, why pay for it? I’m not naive to the fact that use of clear language will decrease the number of billable procedures. I am not saying this will be easy. One first move that would be less painful would be to get rid of quality measures or incentives that promote screening.
I want to be clear; I’m not saying all cancer screening is worthless. People at higher baseline risk for cancer, such as those with a family history of cancer or environmental exposures, might derive more benefit than harm from screening. Prasad, Lenzer, and Newman say this group of patients would be a good place to spend future research dollars. That sounds reasonable. I also acknowledge that some people, even when presented with the evidence, will want to proceed with screening. We can argue about who should pay for non–evidence-based medical procedures.
The most important action that all of us (patients, nurses, doctors, and healthcare writers) should take is to learn from this revelation. There’s nothing bad about the fact that current-day screening tests don’t save lives. Cancer is a tough disease, and in some ways, it may be the natural order of cell biology. What’s bad about this medical reversal has been our blindness to the evidence.
We let what we believe become what we know. In clinical medicine, that should be a never event.


  1. Prasad V, Lenzer J, Newman DH. Why cancer screening has never been shown to “save lives”—and what we can do about it. BMJ. 2016;352:h6080. Article
  2. Gøtzsche PC. Commentary: Screening: a seductive paradigm that has generally failed us. Int J Epidemiol. 2015;44:278-280.Editorial
  3. Fang F, Keating NL, Mucci LA, et al. Immediate risk of suicide and cardiovascular death after a prostate cancer diagnosis: cohort study in the United States. J Natl Cancer Inst. 2010;102:307-314. Article
  4. Saquib N, Saquib J, Ioannidis JP. Does screening for disease save lives in asymptomatic adults? Systematic review of meta-analyses and randomized trials. Int J Epidemiol. 2015;44:264-277. Abstract
  5. Bleyer A, Welch HG. Effect of three decades of screening mammography on breast-cancer incidence. N Engl J Med. 2012;367:1998-2005. Article
  6. Gøtzsche PC, Jørgensen KJ. Screening for breast cancer with mammography. Cochrane Database Syst Rev. 2013;6:CD001877. Abstract
  7. Biller-Andorno N, Jüni P. Abolishing mammography screening programs? A view from the Swiss Medical Board. N Engl J Med. 2014;370:1965-1967. Editorial
  8. Gigerenzer G. Full disclosure about cancer screening. BMJ. 2016;352:h6967 Editorial

New Push Ties Cost of Drugs to How Well They Work

Source: Wall Street Journal

As drug costs rise, Express Scripts seeks new payment deals for some cancer medications

Tarceva has shown a smaller benefit in pancreatic cancer than in lung cancer.ENLARGE
Tarceva has shown a smaller benefit in pancreatic cancer than in lung cancer. PHOTO: JB REED/BLOOMBERG NEWS

Express Scripts Holding Co., a large manager of prescription-drug benefits for U.S. employers and insurers, is seeking deals with pharmaceutical companies that would set pricing for some cancer drugs based on how well they work.

The effort is part of a growing push for so-called pay-for-performance deals amid complaints about the rising price of medications, some of which cost more than $100,000 per patient a year.

Some insurers and prescription-benefit managers are pushing back by arguing that they should pay less when drugs don’t work well in certain patients. Drug companies are countering with pricing models of their own, such as offering free doses during a trial period.

Express Scripts this month told clients it is seeking deals with drug makers for differentiated pricing for certain cancer drugs based on how well they work against different types of tumors, Express Scripts Chief Medical Officer Steve Miller said in an interview. Currently, Express Scripts and most insurers pay the same per-unit rate for a cancer drug regardless of the type of cancer it is being used to treat.

Dr. Miller pointed to Tarceva, a drug co-marketed by Roche Holding AG and Astellas Pharma Inc., which has shown a smaller benefit in pancreatic cancer than in lung cancer. In one clinical trial, Tarceva extended the median survival of pancreatic cancer patients by less than two weeks versus placebo. In a separate trial, it prolonged survival among lung cancer patients by about 3 ½ months versus chemotherapy.

In an “indication-specific pricing” model, the per-pill cost of Tarceva would be lower for pancreatic-cancer patients than for lung-cancer patients, given the reduced efficacy, Dr. Miller said. Tarceva currently costs about $6,850 a month per patient, according to GoodRx, a website that tracks drug prices.

“One of the big frustrations has always been people paying top dollar for drugs that aren’t always giving them the best response,” Dr. Miller said. “If pharma is truly sincere about wanting value-based reimbursement, we now have the sophistication to do that.”


Although Dr. Miller used Tarceva as an example, he wouldn’t identify the drugs for which Express Scripts is seeking indication-specific pricing. The company has begun approaching drug makers about arranging such deals, which could go into effect for 2016, he said.

A spokeswoman for Roche’s Genentech unit said that when Tarceva was approved to treat pancreatic cancer in 2005, it was the first medicine approved for the disease in more than a decade. She said the drug is now rarely used to treat pancreatic cancer because other drugs have since been approved for the disease. She said Genentech would welcome a system of pricing a medicine based on how it performs in different indications—and has one in place in Italy—but there are challenges to doing so in the U.S., including fragmented patient-record systems.

Express Scripts has in recent years been a vocal critic of high drug prices, which the company has used to promote its services to potential customers as it competes against CVS Health Corp. and others to administer drug benefits for health insurers and large employers. Pharmacy-benefit managers also sometimes keep a portion of the rebates and discounts they negotiate from pharmaceutical companies.

Express Scripts’ approach would be similar to that proposed by Peter Bach, director of the Center for Health Policy and Outcomes at Memorial Sloan Kettering Cancer Center.

In an article published last year in the Journal of the American Medical Association, he suggested that in an indication-specific arrangement, the monthly price for Eli Lilly & Co.’s cancer drug Erbitux would plummet from $10,320 a patient to about $470 a patient for its least effective use, treating recurrent or metastatic head and neck cancer. The drug also is used to treat locally advanced head and neck cancer, as well as colorectal cancer.

A Lilly spokeswoman said Lilly supports efforts to make cancer drug reimbursement “better reflect treatment value for different patient populations,” and it is “exploring alternative options to accurately represent the value our medicines offer across multiple indications.”

Drug pricing has been “very hard for the payers to do anything about,” said Steven Pearson, president of the Institute for Clinical and Economic Review, a Boston nonprofit that evaluates cost-effectiveness in medicine. “Now they’re starting to think very hard about it, to look for practical ways to have more of an influence on pricing.”

It can be difficult for drug companies and payers to agree on terms of alternative payment deals—and to actually administer the deals.

Pay-for-performance contracts often involve tracking certain health measures and outcomes in specific patients, such as changes in blood-sugar levels for diabetes patients. The cost and complexity of such tracking can offset the benefits, and the number of such deals in the U.S. to date has been relatively small.

“They’re very data intensive to administer and track these,” says Larry Blandford, executive vice president and managing partner at Precision for Medicine, a consulting firm advising drug makers on dealing with payers.

U.S. insurers and pharmacy-benefit managers also push for simple price cuts, and sometimes win them in the form of rebates paid by manufacturers. But drug makers have been able to avoid big, across-the-board price cuts in the U.S. because the market is so fragmented, with multiple public and private payers, and because rebate contracts are typically confidential. That allows drug companies to minimize or avoid discounting certain drugs for some payers.

Some drug companies have explored their own variations of alternative pricing, such as annuity-style payments for very expensive drugs. This involves an upfront payment and then ongoing payments stretched out over several years based on how well the drug works in individual patients.

One example is Bluebird Bio Inc., which is developing an experimental gene therapy for rare diseases. At a health-care conference in February, Chief Executive Nick Leschly said that if the therapy makes it to market, he would consider asking insurers to make an upfront payment to cover costs and risk of development, plus additional ongoing payments if it works for a patient.

Other drug makers are trying different models. Since 2011, Acorda Therapeutics Inc. has provided its drug Ampyra, which can help multiple-sclerosis patients improve their walking, free for the first two months.

The reason: Studies have shown it only works in about 40% of patients, but there is no way to predict before starting therapy who will benefit. The two-months free program gives patients time to figure out if the drug is working—they usually know within several weeks, says Acorda Chief Executive Ron Cohen. If the drug works, the company begins charging the regular price, or about $21,000 a year per patient.

Acorda implemented the two-months free policy partly because some insurers were restricting its use. The two-months free program isn’t part of any contracts with insurers, but Dr. Cohen believes it sows goodwill among doctors and insurers.

“We saw that as a risk-sharing arrangement,” said Dr. Cohen.

He says “a significantly wider swath” of the drug industry is exploring alternative-pricing models than in the past. “A lot of the pressure emerges simply from the ongoing issues around the increasing cost of medicine,” he says.

Alnylam Pharmaceuticals Inc. would consider performance-based pricing if its experimental rare-disease drugs reach the market, CEO John Maraganore said in an interview. The company’s lead drug in development is a treatment for a rare disease called TTR-mediated amyloidosis. Regulators haven’t yet approved the drug for sale and Alnylam hasn’t set a price.

Mr. Maraganore said blood tests can measure the effectiveness of its experimental drug. “I think there are many opportunities for our medicines to be evaluated and potentially reimbursed on a performance basis,” he said. “We certainly would be open to that type of approach.”

The drug industry has made various stabs at alternative-pricing before. Several European state-run health systems have implemented pay-for-performance and indication-specific pricing arrangements with drug makers over the past decade. In the U.S., health insurer Cigna Corp. has signed deals that tie reimbursement for EMD Serono’s MS drug Rebif and Merck & Co.’s diabetes drug Januvia to certain patient outcomes.

Write to Peter Loftus at

El cáncer- los gorriones, los osos y las tortugas

By: Alberto Velazquez. TEDxUBA
Published on Dec 22, 2013

In the spirit of ideas worth spreading, TEDx is a program of local, self-organized events that bring people together to share a TED-like experience. At a TEDx event, TEDTalks video and live speakers combine to spark deep discussion and connection in a small group. These local, self-organized events are branded TEDx, where x = independently organized TED event. The TED Conference provides general guidance for the TEDx program, but individual TEDx events are self-organized.* (*Subject to certain rules and regulations).

Antigeno Prostatico Especifico: inutil para el cribado de cancer de prostata

Todavia desconozco en que idioma hay que escribir esto, pero por enesima  vez sale otro articulo que dice que la PSA,  no tiene ninguna utilidad en el cribado de cáncer de próstata y que sólo sirve para el seguimiento de pacientes con Cáncer de prostata. El tema es simple. Se trata de una prueba inespecifica, y el famoso antigeno es volumen-dependiente del tamaño de la prostata. Por ende, en la natural evolucion que tenemos los hombres la prostata se agranda con la edad. Por tanto, ningun valor sirve para diferenciar si ese agrandamiento se  debió a la hipertrofia prostática benigna, que también es muy común luego de los 65 años. Por otro lado, un viejo anatomista,  Testut, ya escribia en su tratado que data del año 1900, que en sus autopsias encontraba un 100% de cáncer de prostata en hombres  mayores de 80 años. En otras palabras, y aunque los urólogos se empeñen en poner al cancer de próstata como un grave problema de salud, colocandolo entre las primeras causas de muerte, la realidad indica, que nos morimos más con cáncer de próstata que por el cáncer mismo. Por ende es un buen marcador de la evolución del cáncer pero no tiene ninguna utilidad, escrito en Inglés (también ha sido escrito en castellano, catalán, portugues, francés, ruso, y seguramente en esperanto) por el  British Medical Journal.
Por ende tendremos que seguir lidiando con los expertos que aparecen en la prensa de todo el mundo, e intentan convencer a la gente de hacerse estos estudios desde los 50 años.

Utilizando una cohorte grande Seuca relacionada con un registro nacional de cáncer, los investigadores compararon los valores iniciales de PSA de aquellos que desarrollaron cáncer de próstata en el curso de 7 años post escrutinio, con otros hombres de similares características que no desarrollaron cáncer de próstata. La sobreposición de los valores de PSA frustraron los esfuerzos de los investigadores de encontrar un valor que tenga alta especificidad así como una sensibilidad del 50%. Sin embargo, notaron que un valor de PSA menor de 1 ng/mL virtualmente descarta el diagnóstico durante el período de seguimiento.

Debido a los resultados de este estudio, se podría decir que los datos sobre los costos y beneficios de las pruebas de PSA permanecen insuficientes para apoyar el escrutinio masivo.

Referencia: Benny Holmström, et al. Prostate specific antigen for early detection of prostate cancer: longitudinal study. BMJ. Septiembre 2009;339:b3537.

Using Evidence to Combat Overdiagnosis and Overtreatment: Evaluating Treatments, Tests, and Disease Definitions in the Time of Too Much

English: A Collection of Articles on Disease M...
English: A Collection of Articles on Disease Mongering in PLoS Medicine Español: Portada del monográfico publicado en Public Library of Science – Medicine sobre promoción de enfermedades (Photo credit: Wikipedia)


PLOS Medicine. 

  • Ray Moynihan

As a matter of urgency, the potential for overdiagnosis and related overtreatment should be routinely considered for inclusion in the introduction and discussion sections of reports of studies of therapies, studies of diagnostic test accuracy, systematic reviews of those studies, clinical guidelines, and changes to disease definitions (Box 1). Second, there is a clear need for more research—both original studies and reviews of studies—into the nature and extent of overdiagnosis and related overtreatment within specific conditions—as, for example, has occurred with studies on the risks associated with mammography [5]. Third, the potential harms associated with new treatments and tests, or expanded disease definitions, demand much greater attention in primary studies and reviews.

Box 1. Summary of Suggestions for Improving the Evidence Base to Combat Overdiagnosis and Related Overtreatment

  1. Routine consideration of overdiagnosis and related overtreatment in the introduction and discussion sections of primary studies and systematic review articles about tests and treatments
  2. More condition-specific studies and reviews on the risk of overdiagnosis and related overtreatment—e.g., diagnosis of pulmonary embolism
  3. More rigorous routine evaluation of potential harms of treatments, tests, and changes to disease definitions
  4. In studies and reviews of studies of therapies, clearer stratification by baseline risk, to better identify treatment thresholds where benefits are likely to outweigh harms
  5. In studies and reviews of studies of test accuracy, more clarity about which target condition or spectrum of a disease is being considered, with a shift from a dichotomous “disease/no disease” frame to a “spectrum of disease severity” frame, and a linking of test accuracy to consequences for treatment and patient outcomes
  6. Panels that review and change disease definitions that are free of conflicts, and routinely consider evidence for potential harms as well as potential benefits of the changes they propose

For evaluation of treatments, more clarity is required about the specific definitions of diseases being treated in primary treatment studies and subsequent systematic reviews. As per the recommendations of Kent and colleagues [11], clearer stratification of groups at varying degrees of baseline risk or disease stage is needed, to better identify treatment thresholds at which the harms of treatment start to outweigh benefits. Sometimes this will require re-analysis of large (e.g., pooled individual participant) datasets, underscoring the need for access to raw data from trials.

For primary studies and reviews of studies of diagnostic test accuracy, there is a need to make explicit exactly which stages or spectrum of a target disease is being considered—also referred to as the “target condition” [14]. Where possible, it may be desirable to shift the paradigm from a dichotomous frame—disease presence versus absence—to thinking about a spectrum of disease severity. Moreover, when diagnostic studies show improved detection (or exclusion) of specific disease stages, researchers should try to link the consequences of such improved diagnostic accuracy to subsequent treatment decisions. Ideally, the consequences of such changed treatment decisions for patient outcomes might also be addressed [16]. Such elaborations to conventional diagnostic test accuracy studies would help identify at what diagnostic disease spectrum thresholds subsequent treatments will do more good than harm.

And, finally, the need to improve the process of disease definition—with awareness of the dangers of overdiagnosis and overtreatment—is being increasingly accepted, with international organisations, including the Guidelines International Network, currently looking to develop new guidance. While a detailed debate will ensue in coming years, we believe several key principles might underpin the reform of how disease definitions are changed: panel members should be free of financial and reputational conflicts of interest; strong evidence, ideally from randomised trial data, should demonstrate that the use of new criteria will meaningfully reduce mortality and/or morbidity; and potential benefits and potential harms of labelling and treatment using the new criteria should be explicitly investigated and reported.


We offer these suggestions as part of the wider scientific debate underway on how to safely and fairly wind back the harms of too much medicine [17]. We are hopeful that a heightened attention to the dangers of overdiagnosis and related overtreatment may lead to an enhanced evidence base on these topics. This, in turn, will help produce fairer, more rational, and less wasteful health care systems, built on a reformed process of disease definition that offers diagnostic labels and medical interventions only to those likely to benefit from them.

Comparative evaluation of radiation treatments for clinically localized prostate cancer: an update

Source: Centers of Medicare

Table 1. Side-effects and effects on recovery ...
Table 1. Side-effects and effects on recovery of treatments for newly diagnosed prostate cancer. The Prostate Brachytherapy Advisory Group: (Photo credit: Wikipedia)

With the advent of the prostate-specific antigen (PSA) test in the 1990s, the lifetime risk of being diagnosed with prostate cancer in the United States has nearly doubled to twenty percent.  However, the risk of dying of prostate cancer remains at approximately three percent.  Once prostate cancer has been diagnosed, the decision on the best course of treatment can be complex.  Numerous factors can influence the decision on how to proceed, including that some prostate cancers grow so slowly they would likely never cause significant problems during a patient’s lifetime.  The adverse effects of the available interventions and how they affect quality of life must also be considered.

Download Technology Assessment  [PDF, 1MB]

Prevencion del cancer colorrectal

Pruebas de detección habituales previenen el cáncer colorrectal

MMWR, Apr 14, 2008 18:15:00 GMT



El cáncer colorrectal es el segundo tipo de cáncer que causa más muertes en Estados Unidos. Este cáncer afecta a hombres y mujeres de todos los grupos étnicos y raciales, pero es más común en las personas mayores de 50 años. El cáncer colorrectal se puede prevenir. Las pruebas periódicas pueden detectar pólipos en el colon que pueden ser retirados antes de convertirse en cáncer. Las personas de 50 años o más, con antecedentes familiares de este cáncer, deben ver al doctor para hacerse prueabas periódicas.

Relacion entre IMC y cancer

Relación entre el IMC y el riesgo de cáncer

Renehan AW, Tyson M, Egger M, Heller RF, Zwahlen M. Body-mass index and incidence of cancer: a systematic review and meta-analysis of prospective observational studies. Lancet 2008; 336: 569-578.  R TC (s) PDF (s)


En numerosos estudios, el exceso de peso se ha relacionado con un incremento del riesgo de desarrollar determinados tumores. Sin embargo, la diversidad de localizaciones, tipos de estudios y medidas de resultado utilizadas dificultan la comparación de los datos.


Rervisar la relación entre el IMC y la fuerza de la asociación con determinados tumores e investigar las diferencias respecto al sexo y distintos grupos étnicos.

Perfil del estudio

Tipo de estudio: Metaanálisis

Área del estudio: Causa

Ámbito del estudio: Comunitario


Se llevó a cabo una búsqueda en Medline, Embase, las listas de referencias de los trabajos localizados y otras fuentes bibliográficas relevantes para localizar los estudios de cohortes (y los de casos y controles anidados dentro de éstos), publicados en cualquier idioma, en los que se investigaba la relación entre el IMC y la incidencia de 20 tipos diferentes de tumores en 15 localizaciones diferentes (colorrectal, gastroesofágico, hepatobiliar, leucemia, pulmonar, melanoma, mieloma, linfoma no hodgkiniano, leucemia, pancreático, renal, tiroideo, prostático, mamario, endometrial y ovárico.

Los criterios de inclusión fueron que se midiese el IMC al inicio del estudio, se registrase la incidencia de nuevos tumores en el seguimiento, que proporcionasen medidas de estimación del riesgo para al menos 3 categorías de IMC. Se excluyeron las publicaciones que no eran informes completos, los que sólo proporcionaban datos de mortalidad (en vez de incidencia) y los estudios sobre lesiones preneoplásicas. En función de su origen étnico, se clasificaron a los participantes como norteamericanos (>80% blancos), europeos-australianos, afroamericanos, asiáticos y multiétnicos.


Cumplieron los criterios de inclusión 141 artículos que aportaron datos de 76 estudios con 221 conjuntos de datos que supusieron más de 133 millones de personas-año de observación y 282.173 casos incidentes de cáncer. Más de la mitad de los trabajos y los de mayor tamaño se habían publicado a partir de 2004.

Los IMC elevados se asociaron a un mayor riesgo de presentar cáncer en numerosas localizaciones en ambos sexos (adenocarcinoma de esófago, tiroides, colon, riñón, mieloma y leucemia), así como en algunos tumores propios de la mujer (endometrio y mama en la postmenopausia). En cambio, el exceso de peso se asoció a un menor riesgo de cáncer de pulmón y de carcinoma escamoso de esófago. En estos casos, es posible que esta asociación se deba en gran parte al efecto de confusión del tabaco, que se asocia a un menor peso y a un mayor riesgo de estos tipos de tumores.

Tabla 1. Riesgo relativo para diferentes tipos de tumores por cada 5 kg/m2 de IMC.
Varones Mujeres
Adenocarcinoma de esófago 1,52 (1,33 a 1,74) 1,51 (1,31 a 1,74)
Tiroides 1,33 (1,04 a 1,70) 1,14 (1,06 a 1,23)
Colon 1,24 (1,20 a 1,28) 1,09 (1,05 a 1,13)
Renal 1,24 (1,15 a 1,34) 1,34 (1,25 a 1,43)
Hígado 1,24 (0,95 a 1,62) 1,07 (0,55 a 2,08)
Melanoma 1,17 (1,05 a 1,30) 0,96 (0,92 a 1,01)
Mieloma 1,11 (1,05 a 1,18) 1,11 (1,07 a 1,15)
Recto 1,09 (1,06 a 1,12) 1,02 (1,00 a 1,05)
Vesícula 1,09 (0,99 a 1,21) 1,59 (1,02 a 2,47)
Leucemia 1,08 (1,02 a 1,14) 1,17 (1,04 a 1,32)
Páncreas 1,07 (0,93 a 1,23) 1,12 (1,02 a 1,22)
Linfoma no hodgkiniano 1,06 (1,03 a 1,09) 1,07 (1,00 a 1,14)
Próstata 1,03 (1,00 a 1,07)
Gástrico 0,97 (0,88 a 1,06) 1,04 (0,90 a 1,20)
Pulmón 0,76 (0,70 a 0,83) 0,80 (0,66 a 0,97)
Escamoso de esófago 0,71 (0,60 a 0,85) 0,57 (0,47 a 0,69)
Endometrio 1,59 (1,50 a 1,68)
Mama (postmenopausia) 1,12 (1,08 a 1,16)
Ovario 1,03 (0,99 a 1,08)
Mama (premenopausia) 0,92 (0,88 a 0,97)

En los análisis de subgrupos, las asociaciones ente el IMC y el riesgo de cáncer fueron más fuertes para los varones que para las mujeres para el cáncer colorrectal y a la inversa para el cáncer renal. La mayor parte de las asociaciones fueron pareceidas para las diferentes áreas geográficas, pero para el cáncer de mama en la premenopausia se encontró una relación directa con el IMC para los estudios llevados a cabo en países asiáticos e inversa para el resto de las regiones geográficas. En los países asiáticos la relación entre el IMC y el cáncer de mama en la postmenopausia también fue mas fuerte que en las otras regiones.


Los autores concluyen que el IMC elevado se asocia a un mayor riesgo de sufrir determinados tumores y que esta asociación puede variar entre los dos sexos y para personas de diferentes orígenes étnicos.

Conflictos de interés

Uno de los autores ha recibido honorarios de varios laboratorios farmacéuticos. Financiado parcialmente por una beca de la British Medical Association.


En este estudio se confirma el hallazgo de estudios previos de que la presencia de obesidad se asocia a un mayor riesgo de desarrollar determinado tipo de tumores. El hecho de que para el mismo sólo se hayan utilizado los datos de estudios prospectivos limita la posibilidad de determinados sesgos como el del recuerdo selectivo. Por otro lado, el que sólo se hayan utilizado datos de incidencia permite limitar el efecto de otros factores como el peor pronóstico que presentan los obesos para determinados tipos de tumores, que pueden afectar a los estudios que se llevan a cabo con datos de mortalidad.

Una limitación de este estudio es que el análisis estadístico da como resultado un incremento de riesgo por cada unidad de IMC, pero es posible que el incremento de riesgo no sea lineal, puesto que en algunos estudios previos el exceso de riesgo de tumores se concentró en los pacientes con obesidades mórbidas. Por otro lado, tampoco permite analizar si, como en el caso de las enfermedades cardiovasculares, determinados tipos de obesidad, como la abdominal, se asocian a un mayor riesgo.

El hecho de que se dé esta asociación estadística no prueba por sí solo que esta relación sea causal. Irían a favor de una relación de este tipo la especificidad del efecto y el hecho de que en los estudios de intervención sobre la obesidad se detectase en las personas asignadas al grupo intervención una reducción de la incidencia de tumores malignos. Sin embargo, los estudios publicados de este tipo suelen tener unos efectos modestos y acostumbran a tener unos seguimientos no demasiado largos. No obstante, en un ensayo clínico llevado a cabo en pacientes con obesidad mórbida tratados mediante cirugía bariátrica en los pacientes asignados al grupo intervención la mortalidad fue inferior que en los asignados al grupo control y entre las enfermedades que presentaron una reducción importante de la mortalidad (próxima a la mitad) se encontraban los tumores.


  1. Hu FB, Stampfer MJ, Manson JE, Grodstein F, Colditz GA, Speizer FE, Willett WC. Trends in the incidence of coronary heart disease and changes in diet and lifestyle in women. N Engl J Med 2000; 343: 530-537.  R TC PDF


Manuel Iglesias Rodal. Correo electrónico:

Shared care by paediatric oncologists and family doctors for long-term follow-up of adult childhood cancer survivors: a pilot study

Lancet Oncology 2008; 9:232-238



Dr Ria Blaauwbroek MD email address a Corresponding Author Information,   Wemke Tuinier RN a,   Prof Betty Meyboom-de Jong PhD b,   Prof Willem A Kamps PhD a   and   Aleida Postma PhD a



Since 75% of children with cancer will become long-term survivors, late effects of treatment are an ever increasing issue for patients. Paediatric oncologists generally agree that cancer survivors should be followed up for the remainder of their lives, but they might not be the most suitable health-care providers to follow up survivors into late adulthood. We designed a 3-year study to assess whether shared-care by paediatric oncologists and family doctors in the long-term follow-up of survivors of childhood cancers is feasible, whether a shared-care model is compatible with collection of data needed for registration of late effects, and how a shared-care model is assessed by survivors and family doctors.


In 2004 and 2005, adult survivors of childhood cancers were randomly chosen from eligible patients diagnosed with childhood cancer (excluding CNS tumours) or Langerhans-cell histiocytosis between January, 1968, and December, 1997, and recalled to the long-term follow-up (LTFU) clinic at the University Medical Centre Groningen, Groningen, Netherlands, where they underwent physical and clinical assessments by an on-site family doctor (visit 1). At this visit, assessments were done according to guidelines of the UK Children’s Cancer Study Group Late Effects Group, and late effects were graded by use of Common Terminology Criteria for Adverse Events (version 3). Follow-up assessments were done 1 year later in 2005 and 2006 by local family doctors (visit 2), who were asked to return data to the LTFU clinic. At this visit, the local family doctors were asked to complete a three-item questionnaire and patients were asked to complete a seven-item questionnaire about their satisfaction with the shared-care model. At the next consultation, which was planned for the end of the study (visit 3), the on-site family doctor advised patients about future follow-up on the basis of their individual risk of late effects. Main endpoints were numbers of participants, satisfaction ratings, and proportions of local family doctors who returned data that they obtained at visit 2 to the LTFU clinic.


133 individuals were chosen at random from 210 enrolled adult survivors. 123 of 133 (92%) randomly selected survivors and 115 of 117 (98%) of their family doctors agreed to participate in the share-care programme. 103 of 115 (90%) family doctors returned data to the LTFU clinic at visit 2. 89 of 101 (88%) of survivors were satisfied with this shared-care model, as were 94 of 115 (82%) family doctors; 18 of 115 (16%) family doctors had no views either way; and three of 115 (3%) family doctors were dissatisfied.


Shared-care by paediatric oncologists and family doctors is feasible for long-term follow-up of adult survivors of childhood cancers.


a. Department of Paediatrics, Division of Paediatric Oncology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
b. Department of General Practice, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands

Corresponding Author InformationCorrespondence to: Dr Ria Blaauwbroek, Department of Paediatrics, Division of Paediatric Oncology, University Medical Centre Groningen, University of Groningen, 9700 RB Groningen, Netherlands

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Relación entre los anticonceptivos orales y el cáncer de ovario

Collaborative Group on Epidemiological Studies of Ovarian Cancer. Ovarian cancer and oral contraceptives: collaborative reanalysis of data from 45 epidemiological studies including 23 257 women with ovarian cancer and 87 303 controls. Lancet 2008; 371: 303-314.  R   TC (s)   PDF (s)


El consumo de anticonceptivos orales se ha asociado a un menor riesgo de desarrollar un cáncer de ovario. Sin embargo, dado que el cáncer de ovario es frecuente después de la edad de utilización habitual de los anticonceptivos, la magnitud de este efecto protector dependerá de la persistencia de este efecto una vez se hayan abandonado.


Estudiar el efecto protector de los anticonceptivos orales sobre el cáncer de ovario durante su toma y tras el abandono de los mismos.

Perfil del estudio

Tipo de estudio: Metaanálisis

Área del estudio: Prevención

Ámbito del estudio: Comunitario


Se llevó a cabo una busqueda en Medline, Embase y PubMed para localizar los estudios publicados antes de 2006 en los que se habían incluido ≥100 casos de cáncer de ovario (40 en los estudios de cohortes) y que habían recogido datos sobre la historia reproductiva y el uso de anticonceptivos por parte de las mujeres participantes.

Se consiguieron los datos individuales de cada una de las participantes. Se consideraron casos las mujeres que habían desarrollado un cáncer de ovario tanto epitelial como no epitelial y como controles las no ovariectomizadas que no habían desarrollado la enfermedad. Otros datos analizados fueron los sociodemográficos, historia menstrual y reproductiva, utilización de anticonceptivos, tratamiento hormonal sustitutivo, datos somatométricos, los antecedentes familiares de cáncer de mama y de ovario y el consumo de tabaco y alcohol. Respecto al consumo de anticonceptivos, se recogió la información sobre la edad de inicio y fin del tratamiento y la duración total del mismo. En función de las fechas del tratamiento se les asignó una dosis de estrógenos y gestágenos que fuese representativa de la época.


En la búsqueda bibliográfica se identificaron 48 estudios y se pudieron conseguir los datos de 45, con un total de más de 23.000 casos de cáncer de ovario y más de 86.000 controles. La edad media del diágnostico fue de 56 años. El 31% de los casos y el 37% de los controles habían tomado anticonceptivos orales con una duración media del tratamiento de 4,4 y 5,5 años respectivamente, lo que supone un riesgo relativo de las usuarias respecto a las no usuarias de 0,73 (IC95% 0,70 a 0,76; P<0,0001). La reducción del riesgo fue superior cuanto más duró el tratamiento con los anticonceptivos (fig. 1), calculándose una reducción del 20% del riesgo por cada 5 años de tratamiento.

La reducción del riesgo conferida por los anticonceptivos disminuía a medida que aumentaban los años que hacía que se había abandonado el tratamiento (fig.2), pero seguía siendo significativa 30 años después de la cesación del mismo.

Los resultados no variaron en función de otros factores como la edad de la mujer al inicio del tratamiento o si éste se había iniciado antes o después del primer hijo. Tampoco se encontraron diferencias importantes en función del año en el que se habían tomado (indicador de la dosis de estrógenos que habían recibido). El porcentaje de reducción también fue similar para los tumores epiteliales y los no epiteliales, aunque dentro de los primeros, los tumores mucinosos parecían beneficiarse menos (12% de reducción por cada 5 años de tratamiento).


Ninguno declarado. Estudio financiado por Cancer Research UK y el Medical Research Council.

Conflictos de interés

Ninguno declarado. Estudio financiado por Cancer Research UK y el Medical Research Council.


El cáncer de ovario ocupa el 6º lugar en número de muertes ocasionadas por cáncer en mujeres. Se calcula que una de cada 100-150 mujeres desarrollará uno a lo largo de la vida. España ocupa un lugar intermedio en la incidencia y la mortalidad por este tumor. Su incidencia aumenta de forma importante a partir de los 40 años. Los principales factores de riesgo conocidos son genéticos y, por lo tanto, poco modificables. Se han descrito varios síndromes familiares que incrementan el riesgo de padecer este tumor, pero sólo suponen un 10% del total.

Se considera que son factores protectores los que disminuyen el número de ovulaciones a lo largo de la vida de la mujer: la multiparidad, la ligadura de trompas y la lactancia, entre otros. Hace tiempo que se ha descrito la asociación negativa entre la toma de anticonceptivos y la incidencia de cáncer de ovario. Los resultados de este estudio demuestran que esta protección se incrementa con la duración del tratamiento, se mantiene aparentemente aunque en las formulaciones más modernas se hayan reducido las dosis de estrógenos y, aunque tiende a disminuir con el paso del tiempo, es de larga duración. En base a estos resultados los autores calculan que los anticonceptivos orales previenen unos 30.000 casos anuales de cáncer de ovario.


  1. Franco EL, Duarte-Franco E. Ovarian cancer and oral contraceptives. Lancet 2008; 371: 277-278.   TC (s)   PDF (s)
  2. Grupo de trabajo sobre prevención del cáncer del PAPPS. Guía de Prevención del Cáncer en Atención Primaria. Barcelona: semFYC. 2000.


Manuel Iglesias Rodal. Correo electrónico:

Atlas de procedimientos en ginecologia oncologica

Atlas of Procedures in Gynecologic Oncology
By Douglas A. Levine, Richard R. Barakat, William J. Hoskins

  • Publisher: Informa Healthcare
  • Number Of Pages: 288
  • Publication Date: 2003-05-01
  • ISBN-10 / ASIN: 184184196X
  • ISBN-13 / EAN: 9781841841960
  • Binding: DVD

Book Description:

Expert practitioners at one of the world’s leading cancer centers have here collaborated on a practical guide to the procedures involved in gynecologic oncology. They explain the latest developments in both open and minimally invasive surgery. All the requisite procedures are comprehensively profiled, including cytoreduction, pelvic extenteration, brachytherapy and other treatments. The procedures are explained step-by-step and fully illustrated, with 800 color photographs. An accompanying CD-ROM provides over one hour of video clips with spoken commentary. Atlas of Procedures in Gynecologic Oncology is indispensable for clinicians and students in oncology and gynecology.


Medical Treatment of Advanced Testicular Cancer

Medical Treatment of Advanced Testicular Cancer Darren R. Feldman, MD; George J. Bosl, MD; Joel Sheinfeld, MD; Robert J. Motzer, MD
JAMA. 2008;299(6):672-684.

Context  The medical treatment of advanced testicular germ cell tumors has changed over the past 30 years, with long-term survival now achieved in the majority of patients. Clinicians need to be familiar with the available treatment regimens for testicular cancer and their associated toxic effects.

Objective  To review the treatments used for advanced testicular germ cell tumors and their associated short-term and long-term complications.

Evidence Acquisition  A search was performed of all English-language literature (1966 to October 2007) within the MEDLINE database using the terms neoplasms, germ cell, or embryonal or testicular neoplasms restricted to humans, drug therapy, complications, and mortality. The Cochrane Register of Controlled Trials Databases (through October 2007) was also searched using the terms testicular cancer or germ cell tumors. Bibliographies were reviewed to extract other relevant articles. One hundred eighty-six articles were selected based on pertinence to advanced testicular cancer treatment, associated complications, and late relapses with an emphasis on randomized controlled trials.

Data Synthesis  The treatment of advanced testicular germ cell tumors with cisplatin combination chemotherapy is based on risk stratification (good, intermediate, or poor prognosis) according to pretreatment clinical features of prognostic value. Clinical trials have demonstrated that approximately 90% of patients classified as having a good prognosis achieve a durable complete remission to either 4 cycles of etoposide and cisplatin or 3 cycles of cisplatin, etoposide, and bleomycin. Complete responses are achieved less frequently for patients with intermediate- and poor-risk germ cell tumors, in whom 4 cycles of bleomycin, etoposide, and cisplatin remains the standard of care. Second- and third-line programs, including high-dose chemotherapy, also have curative potential. Chronic toxicities associated with therapy include cardiovascular disease, infertility, and secondary malignancies. Late relapses may also occur.

Conclusions  Clinical trials have led to evidence-based treatment recommendations for advanced testicular cancer based on risk stratification. Clinicians should be familiar with the potential complications of these therapies.

Author Affiliations: Genitourinary Oncology Service, Division of Solid Tumor Oncology, Department of Medicine (Drs Feldman, Bosl, and Motzer) and Urology Service, Department of Surgery (Dr Sheinfeld), Memorial Sloan-Kettering Cancer Center, and Department of Medicine (Drs Bosl and Motzer) and Department of Surgery (Dr Sheinfeld) Weill Medical College of Cornell University, New York, New York.


This Week in JAMA
JAMA. 2008;299(6):607.

Testicular Cancer
Janet M. Torpy, Cassio Lynm, and Richard M. Glass
JAMA. 2008;299(6):718.

Las lesiones precancerosas mamarias causan preocupaciones innecesarias

Según los expertos, en la mayoría de casos, el carcinoma ductal in situ no se desarrolla.

Numerosas mujeres a las que se diagnostica una lesión precancerosa mamaria conocida como carcinoma ductal in suti (CDIS) se muestran muy ansiosas sobre su pronóstico, a pesar de que se exponen a un riesgo bajo de recurrencia o de desarrollar un carcinoma mamario invasivo.

El estudio, efectuado en el Dana-Farber Cancer Institute and Brigham & Women’s Hospital, de Boston, notó que el 28% de las participantes “creían que tenían un riesgo moderado a alto de diseminación de CDIS a otras partes del organismo, a pesar del hecho que el cáncer de mama metastásico se produce en el 1% de las diagnosticadas de CDIS”.

Más información: Journal of the National Cancer Institute 2008;doi.10.1093/jncl/djn046

La corrección temprana de la criptorquidia se asocia a un menor riesgo de cáncer testicular

Pettersson A, Richiardi L, Nordenskjold A, Kaijser M, Akre O. Age at Surgery for Undescended Testis and Risk of Testicular Cancer. N Engl J Med 2007; 356: 1835-1841.  R   TC (s)   PDF (s)


Es conocido que los niños que presentan una criptorquidia tienen un mayor riesgo de presentar un cáncer de testículo (CT) posteriormente, pero se desconoce si se debe a que se trata de testículos anormales de entrada o que la criptorquidia en sí misma es la causa del CT.


Estudiar la relación entre la edad de la corrección quirúrgica de la criptorquidia y el riesgo de desarrollar un CT.

Perfil del estudio

Tipo de estudio: Estudio de cohortes

Área del estudio: Pronóstico

Ámbito del estudio: Comunitario


Este estudio se llevó a cabo mediante la relación de los registros suecos de ingresos hospitalarios y de tumores, que incluyen todos los ingresos hospitalarios y tumores del país. Se incluyeron en la cohorte todos los pacientes que habían recibido un diagnóstico de criptorquidia entre 1964 y 1999 a los que se les había practicado una orquidiopexia a una edad <20 años. El periodo de observación se inició a 15 años años de edad o un año después de la orquidiopexia. Se compararon las tasas de incidencia de cáncer testicular observadas con las tasas estandarizadas de la población.


La cohorte se constituyó con 16.983 varones que habían sido intervenidos por una criptorquidia. El seguimiento medio fue de 12,4 años. La edad media de la intervención fue de 8,5 años. Se detectaron 56 casos de CT. El número de casos que corresponderían según las tasas de incidencia estandarizadas de la población general sería de 20. A lo largo de los años, la edad de la intervención se fue reduciendo.

La razón de incidencia estandarizada para los que se operaron antes de los 13 años de edad fue de 2,23 (IC95% 1,58 a 3,06) y, para los que se operaron después de esta edad, de 5,40 (CI95% 3,20 a 8,53). La razón de incidencia estandarizada también se redujo con el paso de los años, pero en todos ellos, fue superior para los que habían sido intervenidos antes de los 13 años.


Los autores concluyen que el tratamiento de la criptorquidia antes de la pubertad disminuye el riesgo de CT.

Conflictos de interés

Ninguno declarado. Financiado por becas del Swedish Cancer Society y el Swedish Research Council, entre otros.


La criptorquidia afecta a un 2-5% de los niños varones a término y, a los 12 meses de edad, en un 1% de los niños los testículos aún no han descendido. Estos niños tienen mayor riesgo de desarrollar CT. En un estudio se encontró que aproximadamente un 1,5% de los niños presentaban indicios de CT en el momento de la orquidiopexia, especialmente si presentaban otras malformaciones genitales, los testículos eran intraabdominales o tenían anomalías en el cariotipo. Existen dudas sobre si esta asociación se debe a un efecto deletéreo de la situación ectópica de los testículos o a que se trata de testículos anómalos de entrada. En los casos de cirptorquidia unilateral, en un 20% de los casos los tumores se dan en el testículo con un descenso normal, lo que apoyaría la idea de una anomalía subyacente.

El tratamiento de la criptorquidia se basa en la orquidipexia, con la intención de restaurar la posición correcta de los testículos, preservar la fertilidad y hacer los testículos accesibles a la exploración. En estudios previos, la relación entre la edad a la que se practicó la orquidiopexia y el riesgo de CT han obtenido resultados no concluyentes. En este estudio, los niños en los que se llevó a cabo una orquidiopexia más temprana presentaron un menor riesgo de desarrollar un tumor, lo que apoyaría la idea de que la situación ectópica del testículo podría tener un efecto nocivo sobre el mismo. A la espera de alguna revisión sistemática sobre el tema, los resultados de este estudio irían a favor de un tratamiento temprano del cuadro.


  1. Cortes D, Visfeldt J, Moller H, Thorup J. Testicular neoplasia in cryptorchid boys at primary surgery: case series. BMJ 1999; 319: 888-889.   TC   PDF
  2. Swerdlow AJ, Higgins CD, Pike MC. Risk of cancer in cohort of boys with cryptorchidism. BMJ 1997; 314: 1507-1511.  R   TC
  3. Herrinton LJ, Zhao W, Husson G. Management of cryptorchism and risk of testicular cancer. Inf Terapéutica del SNS 2003; 157: 602-605.  R   TC   PDF


Manuel Iglesias Rodal. Correo electrónico:

Communication in Cancer Care

Communication in Cancer Care

With 6 Figures and 10 Tables
By Prof. Friedrich Stiefel,
ISBN 10 3-540-30757-5
Springer-Verlag Berlin Heidelberg

Communication in Cancer Care

Download Communication in Cancer Care

British Medical Journal. Vol. 336. Núm. 7636


Gates S, Fisher JD, Cooke MW, Carter YH, Lamb SEMultifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis. Págs. 130-133 R TC PDF

Graff MJL, Adang EMM, Vernooij-Dassen MJM, Dekker J, Jönsson L, Thijssen M et alCommunity occupational therapy for older patients with dementia and their care givers: cost effectiveness study. Págs. 134-138 R TC PDF

Underwood M, Ashby D, Cross P, Hennessy E, Letley L, Martin J et al on behalf of the TOIB study teamAdvice to use topical or oral ibuprofen for chronic knee pain in older people: randomised controlled trial and patient preference study. Págs. 138-142 R TC PDF


Dieppe POsteoarthritis of the knee in primary care. Págs. 105-106 TC (s) PDF (s)

Dixon JM, Montgomery DFollow-up after breast cancer. Págs. 107-108 TC (s) PDF (s)


Wilt TJ, N’Dow JBenign prostatic hyperplasia. Part 1—Diagnosis. Págs. 146-149 TC (s) PDF (s)


Järvinen TLN, Sievänen H, Khan KM, Heinonen A, Kannus PShifting the focus in fracture prevention from osteoporosis to falls. Págs. 124-126 TC PDF

Alonso-Coello P, López A, Guyatt G, Moynihan RDrugs for pre-osteoporosis: prevention or disease mongering?. Págs. 126-129 TC PDF

Práctica clínica

Wee B, Reynolds JH, Bleetman ARational Imaging: Imaging after trauma to the neck. Págs. 154-157 TC (s) PDF (s)

Incertidumbres en el cancer del cuello de utero y la vacuna contra el VPH

Articulo escrito por Juan Gervas.

En 2007 se ha comercializado de la vacuna contra el virus del papiloma humano, con la que se propone vacunar a niñas
de 11 y 12 años para la prevención primaria del cáncer de cuello de útero, dada la fuerte asociación entre el cáncer y algunos tipos oncogénicos del virus. La vacuna ha sido rápidamente incluida en los calendarios vacunales de la mayoría de los países desarrollados. En este texto se revisa el fundamento científico de dicha decisión. Son puntos clave: la ausencia de cambios en la epidemiología de la infección, la estabilidad o disminución del la incidencia y mortalidad del cáncer de cuello de útero, la falta de correlación entre respuesta inmunitaria serológica y la inmunidad natural, el impacto de la vacuna en la ecología del virus, las evaluaciones coste-efectividad que dependen de la duración desconocida  de la inmunización, la dependencia excesiva de la investigación financiada por la industria farmacéutica, y la necesidad de mantener la citología de cribado. Se precisaría más tiempo e información antes de introducir la vacunación en el calendario vacunal.

Biological therapy and other novel therapies in early-stage disease: are they appropriate?

Department of Medical Oncology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.

For nearly two decades, adjuvant chemotherapy has been the standard of care in patients with early-stage colon cancer at high risk of recurrence. Until now, treatment has been based on the use of cytotoxic drugs that have well-demonstrated efficacy in advanced colorectal cancer. Most recently, targeted biological agents [i.e., antibodies against the epidermal growth factor receptor and vascular endothelial growth factor] have become essential components of the palliative medical treatment of colorectal cancer. Proof of efficacy of these agents in advanced disease has led to the initiation of several trials testing epidermal growth factor receptor and vascular endothelial growth factor antibodies in the adjuvant setting. Although definitive results of ongoing adjuvant studies will not be available for 2 to 3 years, some oncologists might already inappropriately consider the use of these targeted agents as a component of adjuvant therapy in selected patients. Whether the results obtained in advanced colorectal cancer can be readily translated into a projected efficacy in early-stage colon cancer, however, is unclear. In addition, the long-term safety of biological agents in potentially surgically cured patients has not yet been established. This review discusses the potential caveats and concerns associated with the uncritical use of targeted agents as adjuvant therapy before their safety and efficacy in this setting has been indisputably established in definitive phase III trials.

PMID: 18006799 [PubMed – indexed for MEDLINE]

Retiro del Leuprolide del mercado

Bayer ha decidido discontinuar del mercado el producto para cancer de prostata Viadur(R) (leuprolide) por la disminucion de las ventas del mismo.

Viadur es un sistema de libaracion de leuprolide por medio de un implante de titanio, para manejar los sintomas de cancer avanzado de prostata. La decision no tiene nada que ver, segun la companhia, con problemas de seguridad o eficacia. Se retirara completamente del mercado para abril del 2008.

Fuente: National electronic Library for medicines



Dra Mabel Valsecia
Farmacologia – Medicina-Universidad Nacional del Nordeste
Centro Regional de Farmacovigilancia -UNNE (CRF-UNNE)
Grupo Argentino Para el Uso Racional de Medicamentos (Gapurmed)

The Lancet. Vol. 370. Núm. 76329

OriginalesQUASAR Collaborative GroupAdjuvant chemotherapy versus observation in patients with colorectal cancer: a randomised study. Págs. 2020-2029 R TC (s) PDF (s)


Cunningham D, Starling NAdjuvant chemotherapy of colorectal cancer. Págs. 1980-1981 TC (s) PDF (s)

Heneghan C, Perera RPrevention of hepatitis C in Japan: a lesson for us all. Págs. 1982-1983 TC (s) PDF (s)

Korenkov M; Sauerland SClinical update: bariatric surgery. Págs. 1988-1990 TC (s) PDF (s)


Maartens G, Wilkinson RJTuberculosis. Págs. 2030-2043 R TC (s) PDF (s)


Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole RChronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Págs. 2044-2053 R TC PDF

Lim SS, Gaziano TA, Gakidou E, Reddy KS, Farzadfar F, Lozano R, Rodgers APrevention of cardiovascular disease in high-risk individuals in low-income and middle-income countries: health effects and costs. Págs. 2054-2062 R TC PDF

AP al dia: Resumenes comentados

Eficacia y seguridad del rimonabant HTML PPT

¿Cuál ha sido el rendimiento en el tiempo de las vacunas sistemáticas? HTML PPT

Pronóstico de las personas que han sufrido un golpe de calor HTML PPT

Riesgo de cáncer de cérvix invasivo en mujeres intervenidas por lesiones intraepiteliales grado 3 HTML PPT

Que se dice en la blogosfera: Medicina 24

Fuente: Noticias 24

AP al dia: Resumenes comentados

En adultos con faringitis estreptocócicas de repetición, la amigdalectomía es eficaz para prevenir recaídas a corto plazo HTML PPT

Los pacientes con síndrome del intestino irritable tienen un mayor riesgo de ser sometidos a una apendicectomía negativa HTML PPT

La infección por virus del papiloma humano aumenta el riesgo de carcinoma escamoso orofaríngeo HTML PPT

¿Cuál es el valor de los síntomas de alarma de cáncer detectados en atención primaria? HTML PPT

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CT Scans: They are responsible for 2 per cent of all cancers

CT (computed tomography) scans are the cause of up to 2 per cent of all cancers.  The effect could be far worse among children, who are more sensitive to irradiation.

The scans, which seem to especially cause cancers of the lungs and colon, produce a radiation dose similar to that of the atom bombs that were dropped over Hiroshima and Nagasaki in 1945.

Each scan produces a radiation dose of around 15 mSv in an adult, and 30 mSv in a newborn child, and as standard treatment is for two to three scans, the overall dose reaches 45 mSv.  Survivors of Nagasaki and Hiroshima were exposed to doses slightly below 50 mSv.

Around 11 per cent of all CT scans are carried out on children to determine if they have appendicitis, and researchers fear that, even if they do not develop cancer immediately, they are still at greater risk as adults as their radiation load continues to increase.

In the US alone, 62 million scans are performed every year, mainly to check on seizures, chronic headaches and trauma, an extraordinary increase since 1980 when just 3 million scans were performed.

Researchers from Columbia University Medical Center in New York base their cancer estimates on radiation exposure from survivors of the atomic bomb blasts, and from a major study into the health of 400,000 workers in the nuclear industry.
They also reckon that up to a third of all CT scans are unnecessary or could be replaced by safer technology such as ultrasound.

If that’s so, it means that 20 million adults and 1 million children are unnecessarily irradiated every year in the US – and also being exposed to the risk of cancer.

(Source: New England Journal of Medicine, 2007; 357: 2277-84).

Cribado de cancer cervical en adolescentes: a veces menos es mas

Clinical Practice Guideline Watch

Cervical Cancer Screening in Adolescents: Sometimes Less Is More

Updated guidelines state that HPV DNA testing has no role in the management of adolescents with abnormal Pap smears.

Elucidation of the link between cervical cancer and infection with high-risk types of human papillomavirus (HPV) has led to increased use of HPV DNA testing in the management of women with abnormal Pap smears. However, 80% of female adolescents become HPV DNA positive soon after their first sexual encounters, with the vast majority of these infections clearing spontaneously within 2 years. Hence, HPV DNA testing in adolescents with abnormal cervical cytology would lead to the referral of many adolescents for colposcopy even though they are at low risk for cervical cancer.

In 2006, the American Society for Colposcopy and Cervical Pathology (ASCCP) convened a consensus conference to update its evidence-based guidelines for managing women with abnormal cervical cancer screening tests. Based on current data on the ubiquity and natural history of HPV infection in teenagers and results from the National Cancer Institute–sponsored Atypical Squamous Cells of Undetermined Significance (ASC-US) Low-Grade Squamous Intraepithelial Lesion (LSIL) Triage Study (ALTS), the consensus conference recommended that HPV DNA testing should not be used to manage adolescents with abnormal Pap smears.

New recommendations for adolescents (age, ≤20) are as follows:

  • Adolescents with ASC-US should undergo repeat Pap smears every 12 months. At 12 months, only adolescents with high-grade squamous intraepithelial lesion (HSIL) or greater should be referred for colposcopy. At 24 months, only those with ASC-US or greater should be referred for colposcopy.
  • Adolescents with LSIL should undergo repeat Pap smears every 12 months. At 12 months, only those with HSIL need to be referred for colposcopy. At 24 months, only those with ASC-US or greater should be referred.
  • In adolescents with either ASC-US or LSIL, “HPV DNA testing is unacceptable . . . and if inadvertently performed, should not influence management.”

Comment: Implementation of these recommendations will save money (the cost of an HPV DNA test can exceed US$100). In addition, teenagers will no longer need to worry about carrying a “high-risk” (cancer-causing) strain of HPV. Copies of the guidelines complete with algorithms can be downloaded from the American Society for Colposcopy and Cervical Pathology website.

When it comes to managing adolescents with abnormal Pap smears, doing less is better than doing more.

Alain Joffe, MD, MPH, FAAP

Published in Journal Watch Pediatrics and Adolescent Medicine December 12, 2007


Wright TC Jr et al. 2006 consensus guidelines for the management of women with abnormal cervical cancer screening tests. Am J Obstet Gynecol 2007 Oct; 197:346.

Medline abstract (Free)


2006 consensus guidelines for the management of women with abnormal cervical cancer screening tests.

Wright TC Jr, Massad LS, Dunton CJ, Spitzer M, Wilkinson EJ, Solomon D; 2006 American Society for Colposcopy and Cervical Pathology-sponsored Consensus Conference.

Department of Pathology, College of Physicians and Surgeons of Columbia University, New York, NY 10032, USA.

A group of 146 experts representing 29 organizations and professional societies met September 18-19, 2006, in Bethesda, MD, to develop revised evidence-based, consensus guidelines for managing women with abnormal cervical cancer screening tests. Recommendations for managing atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesion (LSIL) are essentially unchanged. Changes were made for managing these conditions in adolescents for whom cytological follow-up for 2 years was approved. Recommendations for managing high-grade squamous intraepithelial lesion (HSIL) and atypical glandular cells (AGC) also underwent only minor modifications. More emphasis is placed on immediate screen-and-treat approaches for HSIL. Human papillomavirus (HPV) testing is incorporated into the management of AGC after their initial evaluation with colposcopy and endometrial sampling. The 2004 Interim Guidance for HPV testing as an adjunct to cervical cytology for screening in women 30 years of age and older was formally adopted with only very minor modifications.

PMID: 17904957 [PubMed – indexed for MEDLINE]

National Guidelines Clearinghouse

American College of RadiologyIncidentally discovered adrenal mass.American Urological Association Education and Research, IncGuideline for the management of clinically localized prostate cancer: 2007 update.

Association of Coloproctology of Britain and IrelandGuidelines for the management of colorectal cancer.

Finnish Medical Society DuodecimAcne.

Finnish Medical Society DuodecimBenign prostatic hyperplasia.

University of Texas at Austin School of Nursing, Family Nurse Practitioner ProgramEvaluation and management of obstructing cerumen.

University of Texas at Austin School of Nursing, Family Nurse Practitioner ProgramEvaluation, management and treatment of sunburn in adults.

University of Texas at Austin School of Nursing, Family Nurse Practitioner ProgramManagement of human bite wounds.

AP al dia: Resumenes comentados

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Los corticoides inhalados para el tratamiento del asma durante el embarazo no aumentan el riesgo de malformaciones HTML PPT

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Un 1% de la población tiene neutropenia y es más frecuente en personas de raza negra HTML PPT

British Medical Journal. Vol. 335. Núm. 7630


Reeves GK, Pirie K, Beral V, Green J, Spencer E, Bull D et alCancer incidence and mortality in relation to body mass index in the Million Women Study: cohort study. Págs. 1134 R TC PDF

Lane JA, Howson J, Donovan JL, Goepel JR, Dedman DJ, Down L et alDetection of prostate cancer in unselected young men: prospective cohort nested within a randomised controlled trial. Págs. 1139 R TC PDF


Ilic D, Green SScreening for prostate cancer in younger men. Págs. 1105-1106 TC (s) PDF (s)

Calle EEObesity and cancer. Págs. 1107-1108 TC (s) PDF (s)

Wildman MJ, Sanderson C, Groves J, Reeves BC, Ayres J, Harrison D et alImplications of prognostic pessimism in patients with chronic obstructive pulmonary disease (COPD) or asthma admitted to intensive care in the UK within the COPD and asthma outcome study (CAOS): multicentre observational cohort study. Págs. 1132 R TC PDF


Spence D, Melville CVaginal discharge. Págs. 1147-1151 TC (s) PDF (s)

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