Study: IUDs, implants vastly more effective than the pill

2012-05-24

The small fraction of women who choose intrauterine devices (IUDs) or under-skin implants as their preferred method of birth control may be on to something: According to a new study, these long-acting forms of contraception are 20 times better at preventing unintended pregnancies than the Pill and other short-term methods.

The study, published this week in the New England Journal of Medicine, compared the effectiveness of various types of birth control in a group of about 7,500 sexually active women in the St. Louis area. Over a period of three years, 9.4% of women using birth control pills, patches, or vaginal rings became pregnant accidentally, compared to just 0.9% of women who opted for IUDs or implants.

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Why we need a good screening test for ovarian cancer

CNN conditions expert Dr. Otis Webb Brawley is the chief medical officer of the American Cancer Society, a world-renowned cancer expert and a practicing oncologist. He is also the author of the book, “How We Do Harm: A Doctor Breaks Ranks About Being Sick in America.”

(CNN) — Q: This week the U.S. Preventive Services Task Force issued preliminary guidelines for ovarian cancer screening. It recommends against routine screening saying that the risk of false positive diagnoses outweighs the benefits. How can this be and why is it so hard to find a good screening test for ovarian cancer?

A: The U,S. Preventive Services Task Force is a group of medical experts who assess the scientific literature on an issue, such as ovarian cancer screening, before making a recommendation. They do influence how doctors practice medicine.

The statement recommends against routine ovarian cancer screening because they find the evidence of harm associated with screening is greater than the evidence of benefit.

Unfortunately we do not have a good screening test for ovarian cancer, the fifth leading cause of cancer death in women. We need something as effective for ovarian cancer screening as pap smears are for cervix cancer screening.

It is a surprise to many that a screening test could be considered more harmful than helpful. The problem is routine ovarian cancer screening starts a cavalcade of medical procedures associated with harms that are greater than the ultimate benefits. Importantly, it is not that there is no benefit to ovarian cancer screening. The problem is there is not a “net benefit.”
Olympic gymnast battles cancer

The blood test CA 125 is elevated in about half of women who are known to have ovarian cancer. If effectively treated by surgery or chemotherapy, the CA 125 level in the blood goes down. It has been used for nearly three decades to follow progress in treatment.

This test was suggested for screening in the late 1980s. Screening is doing a test in asymptomatic patients who are not suspected of having the disease but are at risk because of age and gender. Very early on, many thought CA 125 would not work well as a screening test.

A teacher gave me this example more than 20 years ago and it still holds. It is dense in numbers, but I think it is followable. It illustrates how a public health physician thinks of a screening test and the trouble with CA 125.

A group of investigators tested the CA 125 blood test for screening in a group of 915 women average age 55, and a total of 36 or 3.9% were abnormal (a level greater than 35 U/ml). These women were evaluated for ovarian cancer and followed. Ultimately none had ovarian cancer.

What if one was to screen 100,000 women? That means 3.9% of the 100,000 or 3,900 women will have false positive findings. Using U.S. cancer incidence data, 13 women in the 100,000 would have ovarian cancer in a given year.

Given that most of the 13 women will be diagnosed with incurable advanced ovarian cancer, a fair assumption is six of the 3,900 will be diagnosed with a potentially curable ovarian cancer.

Given that CA 125 is positive in half of ovarian cancer patients, one would reasonably estimate that three of the six women with curable disease would be identified. That is three potential cures in the more than 3,900 women screened.

Of the 100,000 women, we expect 148 will die of cancer and nine of the 148 will be die because of ovarian cancer within a year of the screen.

That might sound worthwhile at face value, but lets look at the harms of screening. Most of the 3,900 women will get further testing. This consists mostly of ultrasounds and CAT scans. Several hundred will need to get laparoscopy or more invasive abdominal surgery for evaluation.

This is the area of greatest concern. One survey shows 14% of women over the age of 65 have complications after abdominal surgery. Surgical complications cause death in 1% to 2% of women over 65 and one-half of 1% of women over 50, Several hundred women will get abdominal surgery.

When done as a routine test it is quite easy to see that ovarian cancer screening could actually cause the death of more women than the number of women saved. Most of the women who have bad outcomes will not have ovarian cancer.

The gold standard for proving effectiveness of a screening test is a prospective randomized clinical trial comparing a screened group to a group that is not screened over time.

The U.S. National Cancer Institute began such a study in 1993 and published the result in 2011. The trial included 78,216 women aged 55 to 74. It randomly assigned 39,105 to screening and 39,111 to usual care. After an average of more than 12 years of follow-up, the groups had no difference in the ovarian cancer death rate. This means that the trial showed no evidence of routine screening saving lives.

CA 125 is not a good test for ovarian cancer screening, and ovarian cancer may not be a good cancer for screening. What we need is a test that flags fewer people who do not have the disease as suspicious of having the disease. It would be even better if the test found more than half of the women who have the disease. Screening also works better in cancers that tend to stay localized for longer periods of time. Many ovarian cancers spread throughout the abdomen very early in the life of the cancer when the tumor is still very small.

It is important to note that the task force addressed routine screening. The test can be appropriate for screening a woman known to be at high risk for ovarian cancer because of a family history. The test may also be appropriate in assessing a woman who has lower abdominal discomforts.

The opinions expressed in this article do not necessarily represent those of CNN, The American Cancer Society, or Emory University.

Child deaths: Preventable infections ‘the leading cause’

2012-05-14

Most deaths of young children around the world are from mainly preventable infectious causes, experts have said.

A US team, writing in the Lancet, looked at mortality figures from 2010.

They found two-thirds of the 7.6m children who died before their fifth birthday did so due to infectious causes – and pneumonia was found to be the leading cause of death.

One expert said it was very important to “translate such findings into action”.

The team from Johns Hopkins Bloomberg School of Public Health looked at data from a range of sources, including household surveys and registration systems for 193 countries. Mathematical modelling was used where data was incomplete.

They found child deaths had fallen by two million (26%) since 2000, and there have been significant reductions in leading causes of death including diarrhoea and measles – as well as pneumonia.

But they say there are still significant challenges.
International targets

Half of child deaths occurred in Africa – two thirds (2.6m) were due to infectious causes, including malaria and Aids.

In South East Asia, neonatal causes were the leading cause of death.

Five countries (India, Nigeria, Pakistan, Democratic Republic of Congo and China) accounted for almost half (3.75m) of deaths in children under five.

The researchers warn that very few countries will achieve international targets for improving child survival – the Millennium Development Goal (MDG) 4 – by the 2015 deadline.

Only tetanus, measles, and HIV/Aids have fallen enough to meet the target.

Writing in the Lancet, the researchers say: “Across all the previous and current rounds of causes of childhood death estimation, pneumonia and pre-term birth complications consistently rank as the leading causes at the global level.

“Africa and South East Asia are repeatedly the regions with the most deaths in children younger than five years.

“Our trend analysis shows that accelerated reductions are needed in the two major causes and in the two high-burden regions to achieve MDG4 by 2015.”

Should Pregnant Women Be Accommodated in the Workplace?

Earlier this week, a coalition of legislators introduced the Pregnant Workers Fairness Act, designed to encourage employers to make nice to their pregnant employees. If they need extra bathroom breaks or help lifting heavy things or a chair to sit in, employers shouldn’t balk.

But many are. Complaints about pregnancy-related work discrimination have soared 50% since 2000. Consider the case of Angie, a train conductor in Mississippi whose employer wouldn’t agree to accommodate her when she presented a doctor’s note limiting the amount of weight she should lift. Employees at her workplace routinely helped each other out, but her employer forced her to take three months of unpaid leave rather than assign her to lighter duty. She contacted an advice hotline maintained by Equal Rights Advocates (ERA), a nonprofit law firm that focuses on employment and educational equity for women, but there wasn’t much ERA could do in the absence of comprehensive laws championing pregnant women’s rights to reasonable accommodations in order to keep working.

(MORE: Jessica Simpson: Just Another Celeb Capitalizing on Her Pregnancy)

Just seven states — Connecticut, Hawaii, Louisiana, Alaska, Texas, Illinois and California — have some sort of pregnancy accommodation legislation; New York is in the process of trying to pass a law. California’s is among the most protective for pregnant women: it guarantees the right to job-protected — albeit unpaid — leave and mandates a pregnant woman’s right to be transferred to another position if medically necessary.

Given California’s generosity toward pregnant working women, one might wonder if litigation has gone gangbusters there in the 12 years since its law took effect. And that’s precisely the subject of a new report, Expecting a Baby, Not a Lay-Off: Why Federal Law Should Require the Reasonable Accommodation of Pregnant Workers, released Friday by ERA. It tracks all pregnancy discrimination cases filed in California since 2000 and finds that there just 23 — about two a year. The number of federal law discrimination charges have increased by 54% since 1997, but the charges filed in California dropped, perhaps because the law’s existence compelled employers to negotiate.

(MORE: Pregnant at Work? Why Your Job Could Be at Risk)

“At a time when American families are struggling to make ends meet, it’s imperative that we do everything we can to keep people in their jobs, and this is especially true for pregnant women on the verge of having another mouth to feed,” said U.S. Representative Jerrold Nadler (D-NY), one of the legislators who introduced the Pregnant Workers Fairness Act, in a statement.

Related legislation is particularly important to low-income workers, who tend to be those most impacted. Most women who file pregnancy discrimination claims work at lower-paying jobs in demanding physical environments. “We see that male firefighters who throw out their backs are given desk jobs, but women who are pregnant don’t get them,” says Noreen Farrell, ERA’s executive director. “There is an ability to provide accommodations, but employers don’t want to.”

The legislation is important because other protections out there — namely the Americans with Disabilities Act and the Pregnancy Discrimination Act (PDA), part of the Civil Rights Act — are limited in their application. The PDA, for example, requires employers to treat pregnant workers similarly to the way they treat other workers who may be sick or disabled. But it’s an apples-to-oranges comparison as most pregnant workers are neither sick nor disabled. “There is a gap in how these laws have been applied,” says Farrell. “Some employers say they will provide light duty for people who are injured on the job but not for pregnant women because they are not injured.”

(MORE: Study: Why Maternity Leave Is Important)

To further complicate matters, some workers are afraid to ask for accommodations for fear they’ll be placed on leave. “They don’t want to start taking leave months before they give birth,” says Farrell. The Family and Medical Leave Act of 1993 provides workers with just 12 weeks of job-protected leave. “They can’t risk starting leave at month three because by month seven, they’ve got no more time left. Even if their employer agrees to keep them on, they’re no longer getting paid.”

All of which is why ERA, along with a host of other organizations, is really hoping the Pregnant Workers Fairness Act will eventually get the seal of approval. “The law has allowed women to continue working at a time when they need to shore up their financial resources and continue to have company health care,” says Farrell. “It’s a win-win for businesses to be able to hang on to happy, well-trained employees.”

MORE: ‘The Pregnancy Project’: Why One Girl Decided to Fake Her Baby Bump

Bonnie Rochman is a reporter at TIME. Find her on Twitter at @brochman. You can also continue the discussion on TIME’s Facebook page and on Twitter at @TIME.

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