EBM colorectal cancer sreening

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Colorectal cancer screening(CRC): EBM:

Mafikeng Provincial Hospital 10 th Feb. 2009 Dr. E. Mutunzi Colorectal cancer screening(CRC): EBM

Slide 2:

What is double blind? 2 Orthopaedic surgeons reading ECG Those who talk don’t know, those who know don’t talk I m going to talk because I don’t know…

Slide 3:

Why this topic? During a routine surgical WR with consulted, a senior Medical officer, red an abdominal CT Scan which showed a advanced CRC. He complained that the same patient has been screened negative with contract barium enema few weeks ago. He seemed suprised and not understanding what was going on.

Question:

Question For a 52 years old male, does barium enema effective in detecting colorectal cancer?

Evidence-Based Medicine Question ( which guided our literature search strategy):

P: 52 years old Male with CRC. Intervention: Barium enema Comparison: other screening tools Outcome: Morbidity and Mortality Evidence-Based Medicine Question ( which guided our literature search strategy)

Searching strategies:

Searching strategies Key words CRC screening; barium enema; CT Colonography; Colonoscopy; sensitivity; specificity… Medline, Pubmed, Cochrane library2006, Trip database, google schooler.

Search strategies:

Search strategies Pub med key words: CRC AND barium enema Results: 1.523 articles Limits setting Full test, Free Full Test, and Abstracts Dates: Published in the last 10 years Humans and Animals: human Gender: male Languages: English

Slide 8:

6. Subsets/ Journals - Core clinical journals - Pubmed central - Medline 7. Type of articles - Meta-analysis - RCTs - review 8. Age: >45 years Overall results: 22 articles 1 only- relevant- JAMA 2003

Slide 9:

Key words: CRC screening Pub med results: 65087 articles – too much After criteria limits: 377 articles Introducing words: Barium enema And Colonoscopy Results: 15 articles- no relevant

Slide 10:

Cochrane library 2006 Key words: CRC; double contrast barium enema; CT scan 7 articles – no relevant Google schooler Trip database

Slide 11:

Walsh J.M.E; Terdiman J.P Colorectal Cancer Screening: Scientific Review JAMA. 2003

General Consideration:

General Consideration CRC, 2 nd cause of death in the USA Morbidity: - Female: Lung ca, Breast ca, CRC - Male : Lung ca, Prostate ca, CRC Death from CRC is preventable=fact Effective, reliable, and safe screening method exist for decade Screening programs adopted by public, private and ONGs, but…?

Slide 13:

This article provides practicing physicians with an evidence-based review of the literature of the current status of the CRC screening. Systematic review: 1966-2002 High qualities studies: RCTs, Observational studies (OS). Diagnostic accuracy studies, if no RCTs or OS.

Method of Screening:

Method of Screening Faecal Occult Blood Testing (FOBTs) 3 large Randomized Controlled Trial (RCTs), conducted in Minnesota, UK and Denmark. Subjects (N): 250 000 Follow up to :18 years

Table 1. Summary of Clinical Trials of FOBTs :

Table 1. Summary of Clinical Trials of FOBTs Mandel et al Hardcastl at al Kronborg et al (US) UK (Denmark) N 46 551 150 251 61 933 Follow up, y 18 7.8 13 RR mortality 0.79 0.85 0.82 [0.62-0.97] [0.74-0.98] [0.69-0.97] ARR 4.6 0.8 1.8 NNS 217 1 250 555 Abbreviations - N: N ° of study population RR: Relative Risk ARR: Absolute risk reduction for CCR death per 1000 subjects NNS: N ° of subjects needed to screen to prevent CRC death

Refresher memory:

Refresher memory RR: is ratio of disease to exposed (screened) persons to that of unxposed. RR<1: The risk of disease is decreased by exposure (screening) ARR: EER-CER EER : Experimental Event Rate CER : Events in control group It is the inverse of NNT (1/NNT)

Flexible Sigmoidoscopy :

Flexible Sigmoidoscopy No completed large RCTs found 3 well-designed, retrospective case-controlled studies found.

Table 2. Case control studies of Mortality Reduction Associated with Sigmoidoscopy screening:

Table 2. Case control studies of Mortality Reduction Associated with Sigmoidoscopy screening Selby at al Newcomb et al Muller and Sonnenberg N(CRC) 261 66 4411 OR (95% CI) for 0.41 0.21 0.41 CRC death [0.25-0.69] [0.08-0.52] [0.33-0.5] OR: Odds ratio CI: Confidence interval

Colonoscopy screening:

Colonoscopy screening No RCTs study Cohort and cross-sectional studies indicated that colonoscopy is more sensitive than sigmoidoscopy or FOBT. Colonoscopy is considered the criterion standard in detecting colorectal cancers and adenomas.

Double-contrast Barium Enema:

Double-contrast Barium Enema No published evidence from CRTs available The sensibility of the test is estimated 50% (US National Polyp Study, double contrast enema and colonoscopy were compared in a surveillance population)

American cancer society / CRC screening recommendation:

American cancer society / CRC screening recommendation FOBTs- annually screening Stool DNA test – interval uncertain Double barium contrast enema – every 5 y, started at age 50 y. Flexible Sigmoidoscopy – every 5 y Colonoscopy – every 10 y Computed Tomography Colonography – every 5 y

COMMENT:

COMMENT CRC mortality can be reduced by screening all men and women aged 50 years or older for CRC. Several tests are available Direct and indirect evidence suggest that all tests are effective, but they differ by sensitivity, specificity, cost, and safety. The available evidence does not support choosing one test over an other.

Slide 23:

END OF EBM

Journal Club 1:

Journal Club 1 Why first-level health workers fail to follow guidelines for managing severe disease in children in the Coast Region, the United Republic of Tanzania Walter ND, Lyimo T, Skarbinski, Metta E, Kahigwa E, et al. Bull world Health Organ 2009;87:99-107

READER acronym :

READER acronym RELEVANCE EDUCATION APPLICABILITY DISCRIMINATION EVALUATION REACTION

RELEVANCE :

RELEVANCE This article deal with general practice Explore the issue of adhering to the WHO guidelines: IMCI The article has considerable practice input (PHC setting) The authors are not known academics, no qualification, no occupation, current post?

EDUCATION:

EDUCATION This article help police makers to have an understanding why 1 st level health workers fail to follow Guidelines for managing severe disease in children In doing so, police makers can be able to review their guidelines or initiate comprehensive training of health workers in managing severe disease in children – Good practice

APPLICABILITY:

APPLICABILITY This type of research can be done in our district (Ngaka Modiri Molema district) or country- technically yes But we do not know if our primary health caregivers do not follow the IMCI guidelines in managing children with severe disease (?study done) Perhaps possible, this study can be done in our setting

DISCRIMINATION:

DISCRIMINATION Title design problem why first-level health workers fail to follow guidelines for managing severe disease in children… Before even they find out if the guidelines are not followed, … Study design: Retrospective and prospective study – Mixed study- ? Study design bias - information bias?

Slide 30:

Quantitative? Qualitative study ? It sound both – mixed spice/soup! Ref: 10, 12, 16 – quantitative studies done showing no adherence of health workers to IMCI – why doing again quantitative study? ‘… the reasons health workers do not follow IMCI guidelines are unclear ’ – qualitative study was needed!

Slide 31:

Setting of the study – East Cost of Tanzania How many health centres are there? Are there only 8 health centres? How many dispensaries are there? 2 health facilities inaccessible…Selection Bias? Motivation of doing the research, source of findings?

Slide 32:

Selection criteria of 4 districts - First to implement the IMCI(2000) - Relatively good roads Selection bias? probable data collection 2 phases - retrospective case reviews, 6 weeks - prospective case reviews, 8 weeks See page 102, difference in p values

Slide 33:

Qualitative interviews with 30 health workers…why 30? Selection criteria?

Validity issues :

Validity issues p. 102:Table 2 Compare retro & prospective study in prospective study, ↑ sensitivity in detecting severely ill children…may be because the health workers are aware of study is undergoing – ?information bias p. 103 &104 Factors associated with referral Severe anaemia, (O.R:114; 95% CI:12-1049 ) Lethargy, (O.R:4.8; 95% CI:1,2-19 ) Small sample = Wide CI

EVALUATION:

EVALUATION The research is relevant but not well designed The findings can be incorporated into practice with caution This research should not be considered seriously – has poor score

REACTION:

REACTION The score given is 13/25. This mean that a paper has failed to fulfil the criteria so should be ignored.

SCORING SYSTEM:

SCORING SYSTEM Criteria score Relevance Not relevant to general practice 1 Allied to general practice 2 Only relevant to special general practice 3 Broadly relevant to all general practice 4 Relevant to me 5 Education Would certainly not influence my practice 1 Could possible influence behaviour 2 Would cause reconsideration of behaviour 3 Would probably alter behaviour 4 Would definitely change behaviour 5

Slide 38:

Applicability Impossible in my practice 1 Fundamental changes needed 2 Perhaps possible 3 Could be done with reorganisation 4 I could do that tomorrow 5 Discrimination Poor, descriptive study 1 Moderately good, descriptive study 2 Good descriptive study but method not reproducible 3 Good descriptive study with sound methodology 4 Single blind with attempts to control 5 Controlled single blind study 6 Double blind, controlled study with methodology problem 7 Double blind, controlled study with statistical deficiency 8 Sound scientific paper with minor faults 9 Scientifically excellent paper 10

END:

END AKISANTI SANA! THINK YOU VERY MUCH! MERCI BEAUCOUP! MURAKOZE! SIYABONGA!!

Journal Critic 2:

Journal Critic 2 Why do patients choose to consult homeopaths? An exploratory study Mclnton CDD and Ogunbanjo GA. SA Fam Pract 2008

Why this topic?:

Why this topic? In other words,… ‘ Why do patients cheat from their doctors/FP?’ Similarity… ‘why do wife/husband cheat from their husband/wife? Report suggested that patients choose to consult homeopaths without informing…

READER acronym :

READER acronym RELEVANCE EDUCATION APPLICABILITY DISCRIMINATION EVALUATION REACTION

RELEVANCE :

RELEVANCE This article deal with general practice Explore the consultation issues and the patient-doctor relationshi The authors are well known academics in the South Africa scientific circle The article has considerable practice input

EDUCATION:

EDUCATION This article help doctors to have an understanding why patients do choose to consult homeopath In doing so, the doctors can be able to change their behaviour vis a vis to their patients – Good practice

APPLICABILITY:

APPLICABILITY This type of research can be done in MPH practice (Polyclinic, Gateway clinic, and others departments)

DISCRIMINATION:

DISCRIMINATION This is a qualitative, descriptive study 8 free-attitude interviews were conducted using the exploratory question: ‘ why do you choose to consult a homeopath?’ Homeopath setting in Gauteng province Interview were done in English only-limitation -bias?=weakness of the study

Slide 49:

Triangulation of data was done by audio-recording of the interviews, and transcribed notes and field notes collected during interviews =strength of the study Saturation reached at 8 th interview The article were published in a peer reviewed journal – SA Fam Practice 2008

EVALUATION:

EVALUATION The research is relevant and can change the practice behaviour The findings can be incorporated into practice This research should be considered seriously – has good score

REACTION:

REACTION The score given 19/25. This mean that although not fulfilling all the criteria, a paper may be of interest. The article can be stored in the library for the public.

SCORING SYSTEM:

SCORING SYSTEM Criteria score Relevance Not relevant to general practice 1 Allied to general practice 2 Only relevant to special general practice 3 Broadly relevant to all general practice 4 Relevant to me 5 Education Would certainly not influence my practice 1 Could possible influence behaviour 2 Would cause reconsideration of behaviour 3 Would probably alter behaviour 4 Would definitely change behaviour 5

Slide 53:

Applicability Impossible in my practice 1 Fundamental changes needed 2 Perhaps possible 3 Could be done with reorganisation 4 I could do that tomorrow 5 Discrimination Poor, descriptive study 1 Moderately good, descriptive study 2 Good descriptive study but method not reproducible 3 Good descriptive study with sound methodology 4 Single blind with attempts to control 5 Controlled single blind study 6 Double blind, controlled study with methodology problem 7 Double blind, controlled study with statistical deficiency 8 Sound scientific paper with minor faults 9 Scientifically excellent paper 10

Summery: results of the study:

Summery: results of the study Approach of mainstream doctors they described the rushed, impersonal nature of the consultation – ’ They push number’, ‘very quickly’, ‘let me se 40, 50 patients very quickly’; short consultation- ’10, 15 minutes ’ doctors acted as if the ‘ knew everything ’, often did not explain things about illness, the treatment,… The mainstream medical approach was perceived to be reductionist and mechanistic- ‘ the way that I’ve been treated, and compartmentalized, that kind of thing, and dehuminised’… mainstream doctors being unapproachable and judgemental- …doctors forever telling me that it was all in my head’.

2. Approach of homeopath:

2. Approach of homeopath The relationship they had with their homeopath was far more important than what type of medication was used. Respect, person-to-person conversation, punctuality at work, allowing more time… = quality in homeopaths Homeopaths were found to be caring, interested and empathic. They were perceived being very supportive, holistically, being available telephonically and providing regular follow up. ‘ …it looks at people at multiple levels, at multiple layers… from the physical to the spiritual to the emotional to the psychological to the social’. ‘So they kind of get context before rushing to tell you what’s wrong’.

3. Risks of mainstream medicine and safety of homeopathy:

3. Risks of mainstream medicine and safety of homeopathy Side effects of ‘ harmful chemical’ medications ‘ my Asthavent, it gives me such bad heart palpitations…’ Homeopathic medicine, which considered ‘natural’ and is often prepared from plants, was considered as not having side effects and being safer in overdose.

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