PodMed Double T is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week. A transcript of the podcast is below the summary.
This week’s topics include testing for breast cancer mutations, peanut allergy treatment, aspirin use for prevention, and FIT testing for colorectal cancer screening
0:45 Easily treat children for peanut allergy?
1:46 Was able to reduce the response by 21%
2:44 Didn’t appear as good as other methods
3:12 Fecal immunochemical test in colorectal cancer
4:15 If you’re not going to use colonoscopy, do it annually
5:20 USPSTF recommendations for BRCA mutations
6:20 Autosomal dominant
7:20 Worry and anxiety increase with positive results
8:22 Bleeding risk with aspirin
9:22 Over 4400 major bleeding events
10:22 Engage patient in decision
11:20 Use EHR to employ
Elizabeth Tracey: Who should be tested for common breast cancer mutations?
Rick Lange, MD: Predicting bleeding risk with aspirin use.
Elizabeth: Is there a way to effectively and easily treat peanut allergy in kids?
Rick: And assessing for colorectal cancer without colonoscopy.
Elizabeth: That’s what we’re talking about this week on PodMed TT, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a medical journalist at Johns Hopkins, and this will be posted on March 8, 2019.
Rick: And I’m Rick Lange, President of the Texas Tech University Health Sciences Center in El Paso, where I’m also Dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, I’d like to turn to the Journal of the American Medical Association and take a look at this one I served up. Is there a way to easily treat children for peanut allergy? This is a big problem, a growing problem, and one we’ve talked about on a number of occasions. Most recently, we talked about feeding children small amounts of peanut protein in childhood and seeing whether that could ameliorate their allergy to peanut. In this case, they used something that’s different. They actually used a transdermal kind of an approach to see if they can reduce their allergic responses to peanut protein.
This was a randomized, double-blind placebo-controlled trial at 31 states and five countries — so pretty good — with an N of 356. None of these kids had had severe anaphylactic reactions in the past, although they were peanut allergic. They used a little patch on these kids that had a 250-mcg dose of peanut protein on it. They did it for 12 months and then they did a challenge. Basically, what they found out was that this 250-mcg peanut patch therapy was able to reduce the response 21.7%. It was not statistically significant. Even though, however, it didn’t meet that, it sure looks like this therapy that they’re calling epicutaneous immunotherapy could be effective.
Rick: We’ve also talked about two other ways. One is a oral immunotherapy and the other is underneath the tongue or sublingual immunotherapy. This peanut patch is a new way of delivering immunotherapy. Now it looked like it was beneficial. The response rate in those that received placebo was about 14% and those that received the patch about 35%, but it certainly didn’t reach the statistical standards that the authors and the FDA had agreed upon before. Adverse events were fairly common — usually local skin reactions to the patch. We’re going to say it’s a little bit more effective, but without head-to-head comparisons to oral and sublingual immunotherapy, it’s hard to say it’s as good as those; statistically it didn’t appear to be so, though.
Elizabeth: To me, it’s unclear why we need a patch when we know that the strategy of feeding increasing amounts of peanut protein is effective.
Rick: Well, you’re right. This would be just another way of delivering it and a little bit easier. It’s one tool in the armamentarium, but it’s not, in my opinion, as effective as the ones we’ve already reported on.
Elizabeth: Let’s turn from here, then, to something that does appear to be effective. That’s the fecal immunochemical test, the FIT test, in Annals of Internal Medicine, a look at that and its predictive value in colorectal cancer screening.
Rick: Previous studies have reported inconsistent performance of what’s called the fecal immunochemical test or FIT for detecting colorectal cancer and advanced adenomas. Why this particular test might be important is it’s our goal to make sure that 80% of individuals get screening for colorectal cancer, but a lot of people really aren’t interested in having colonoscopy, so right now we sit at about a screening rate not of 80%, but 60% or 65%.
So what fecal immunochemical testing or FIT testing does is it detects blood in the stool. In this study, they looked at 31 different studies, over 120,000 participants, using 18 different types of FIT. What they determined was it was fairly sensitive and fairly specific for detecting colorectal cancer, not quite as good for detecting adenomatous polyps. The recommendation is if you’re not going to use colonoscopies, you do FIT testing on an annual basis. In that case, the sensitivity and specificity will be even better. Secondly is we need to compare the different FIT tests.
Elizabeth: One factor that you didn’t mention, but we’ve talked about before with regard to colorectal cancer screening is that many people find a FIT test to be a good deal more palatable than colonoscopy or some of the other things. My question is, even with the somewhat compromised sensitivity and specificity, if more people are actually willing to undergo screening, I’m wondering if that would capture that population we’re trying to capture.
Rick: Absolutely, Elizabeth. And the people that are less likely to undergo colonoscopy screening are sometimes the people that need it the most, people that are underinsured or uninsured. If they can’t afford or don’t want to undergo colonoscopy, the FIT testing, especially the annual FIT testing, is a terrific alternative.
Elizabeth: And I’m guessing it’s going to get better and better over time.
Rick: There are different types of FIT tests. I think our next step is to compare those to see where we get the best sensitivity and best specificity.
Elizabeth: Let’s turn from here to the USPSTF’s recommendations regarding BRCA1 and 2 testing for women in an attempt to get their arms around breast cancer risk. I knew about the lifetime risk of developing breast cancer is 12% among women and 1.3% for ovarian cancer, and that the risks are higher for BRCA1 and 2 mutation carriers, and so accounts for 5% to 10% of breast cancer cases.
The other number I thought was really informative is that among that type of breast cancer that’s called triple negative, which is associated with the worst prognosis. 69% of triple negative cases of breast cancer are among carriers of BRCA1 and 2 mutations. And of course, in 2015, 240,000+ women developed breast cancer in the United States. Over 41,000 died from the disease, and ovarian cancer also associated with these mutations is the fifth leading cause of cancer death among U.S. women.
What about BRCA1 and 2 mutations? While these are what we call autosomal-dominant mutations, it still turns out that there’s what’s called incomplete penetrance, so that even among carriers, we can’t say with 100% certainty, “You are going to develop breast or ovarian cancer.” Having said that, I would say, gosh, if I had a family history, that’s, of course, the big factor that drives people into this kind of testing, I would have testing.
In this set of recommendations, they took a look at all the randomized, controlled trials. They said, “Hey, what kind of testing is out there? What happens when we use it?” Their conclusion was that risk assessment with familial risk models can be used to guide referrals, that it is accurate. Genetic counseling should be employed to reduce breast cancer worry, anxiety, and depression. The testing increases women’s understanding of their risk and decreases their intention for inappropriate mutation testing.
Once the testing has been done and a woman knows her results, worry and anxiety do increase for women with positive results, as we would expect. What about the utilization of tamoxifen or raloxifene and aromatase inhibitors among those who are known to have these particular mutations? And, also, what about bilateral mastectomy which some people choose to undergo, or having their ovaries removed? I guess the jury is still out. This, to me, sounds like a place where women really need to talk with their physicians about their own personal choices.
Rick: Who should and shouldn’t be screened? They recommend against routine screening unless a woman has a family or personal history or an ethnicity that is associated with BRCA1 or BRCA2 gene abnormalities. Those would be individuals that have somebody in the family with a breast cancer diagnosis before the age of 50. They’ve had bilateral breast cancer or breast and ovarian cancer or even male members with breast cancer.
Elizabeth: Would you like to move on, then, to your last one?
Rick: Yes, let’s talk about bleeding risk associated with aspirin.
Elizabeth: Okay. That’s in Annals of Internal Medicine.
Rick: We spend a lot of time talking about using aspirin for primary prevention of cardiovascular disease. The individuals that are most likely to benefit are those that have high risk or risk factors for those. We’ve talked about things like diabetes, cigarette smoking, a family history, but what’s been missing is assessing the bleeding risk of individuals, again, for primary prevention, and how to weigh that in terms of deciding what the benefit of aspirin versus the harms associated with that.
What these investigators did was they tried to specifically address that. They assessed a bleeding risk prediction or score for men and women based upon a large study cohort of over 385,000 persons between the ages of 30 to 79. These were people in New Zealand, and they had their cardiovascular risk assessed between 2007 and 2016. Now during that time period, there were over 4,400 major bleeding events and 7% of those bleeding events were fatal.
And here’s what they determined. The risk factors associated with bleeding: age, cigarette smoking, diabetes, cancer, whether the person had a prior bleeding event, a history of peptic ulcer disease, alcohol-related conditions, chronic liver disease, or were on a number of medications that would either treat blood pressure, peptic ulcer disease, non-steroidal anti-inflammatory medication, steroids, or even antidepressants.
Knowing that, this information, they can actually plug it into their risk calculator to determine what the estimated risk or the annual risk is of bleeding. What this will help primary care physicians do is when they see a person who otherwise they’re assessing whether they should be on aspirin or not is assess what the benefit is of aspirin in terms of preventing heart attacks or strokes or the risk associated with that. And with that information, let the patient be involved in that decision-making process.
Elizabeth: I sure wish somebody would come up with the last word on aspirin. I’m just guessing that in the 15 years that we’ve been recording I know we’ve talked about this at least 10 times. We’ve come out on either side of the fence, I bet you, fairly evenly distributed.
Rick: It’s iterative, because the more that we use it, the more we learn about it. We’ve talked about the fact that in low-risk individuals — that is low risk for cardiovascular disease — the bleeding risk may outweigh the benefit of it. Knowing these 19 different variables contribute to the bleeding risk, we can actually assess that more accurately. Now most physicians aren’t going to have time to sit down with 19 different risk factors and plug them into a computer, so I hope the electronic medical record will help, because most of these things can be gathered from the electronic medical record.
We ought to be able to push a button and say, “What’s the patient’s cardiovascular risk and how will aspirin benefit them? What’s their bleeding risk and how could aspirin harm them?” We should be able to do that fairly easily over the upcoming years.
Elizabeth: Hmm. And for right now, what would you say would be an indication for aspirin in someone?
Rick: If for secondary prevention — they’re known to have cardiovascular disease — aspirin can be beneficial. For individuals that are using it for primary prevention, those that are an intermediate or high risk of cardiovascular disease, probably beneficial. In the low-risk individual, these are the ones I think you need to assess whether they have any of these other conditions, and if they’re an increase of bleeding risk, I’m not sure the benefit of aspirin outweighs the risk in those individuals.
Elizabeth: And I’m going to say you haven’t heard the last word on this [LAUGHTER] folks. On that note, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.
Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.