Latest news with #KennyLin
Medscape
23-05-2025
- Health
- Medscape
Save the USPSTF
Hi, everyone. I'm Dr Kenny Lin. I am a family physician and associate director of the Lancaster General Hospital Family Medicine Residency, and I blog at Common Sense Family Doctor . Imagine arriving at the office at the start of a full day, only to discover that someone has taken away your stethoscope, you no longer have access to your electronic health record or online clinical references, your medical assistant was terminated overnight without your consent, and your patients can no longer hear you. Welcome to the real-life nightmare that the US Preventive Services Task Force (USPSTF) is facing. Earlier this year, the Trump administration fired about half of the employees at the Agency for Healthcare Research and Quality (AHRQ) and planned a restructuring of the Department of Health and Human Services (HHS) that would eliminate the agency and fold it into a new Office of Strategy. In April, 45 former Task Force chairs, members, and scientific directors sent an extraordinary letter to the Secretary of HHS, Robert F. Kennedy, Jr, warning that these actions would effectively bring the USPSTF's work to a halt. A few weeks later, former USPSTF chair Alex Krist, MD, MPH, and colleagues echoed this message in a JAMA viewpoint. Although primary care clinicians use the USPSTF's preventive care recommendations every day, most are unaware of the extensive supporting cast that makes the development of these recommendations possible. Since the 1990s, Congress has tasked AHRQ with convening the USPSTF, protecting its scientific independence, providing personnel and funding to maintain and update more than 140 recommendations on 90 clinical topics, and supporting its communications with medical organizations and the public. I can testify from personal experience that all these functions are essential to creating and disseminating evidence-based guidelines for primary care; as a young family physician working at the AHRQ, I staffed the USPSTF from 2006 to 2010. The uncertain future of AHRQ is not the only threat to the Task Force's continued existence. Many physicians do not realize that the Patient Protection and Affordable Care Act (ACA) provision that mandates no-cost coverage of the USPSTF's recommended services is currently at risk. On April 21, 2025, the Supreme Court heard arguments regarding the appeal of a 2022 lawsuit against the federal government by plaintiffs who objected, for religious reasons, to paying for medications for HIV preexposure prophylaxis. The plaintiffs asserted that the ACA's mandate requiring insurers to cover preventive services with A or B grades is unconstitutional because USPSTF members are not nominated by the President or confirmed by the Senate; traditionally, members have been selected by the AHRQ Director and approved by the HHS Secretary. The preventive services at risk of losing coverage include, but are not limited to, screenings for breast cancer, colorectal cancer, perinatal depression, cervical cancer, intimate partner violence, lung cancer, HIV, and hepatitis B and C. This ruling would also affect no-cost coverage for medications to reduce breast cancer risk and statin use to prevent cardiovascular disease. Although the legal issues are arcane and complex, a ruling against the government could dissolve the USPSTF and jeopardize care for millions of Americans. A recent study found that 1 in 3 persons and nearly half of women received no-cost preventive services between 2018 to 2022 as a result of the ACA mandate. Researchers also conducted a modeling study to simulate the potential impact of this court ruling, and they found that losing access to no-cost colorectal cancer screenings could increase colorectal cancer incidence by 5.1% and colorectal cancer mortality by 9.1%. Furthermore, decreased screening participation could also lead to increased long-term health care costs, given increased cancer incidence and more intensive care requirements due to delayed diagnoses. The USPSTF's judgments are not perfect. On occasion, I have disagreed with its assessments, and I suspect that most family physicians have questioned a new or updated recommendation now and then. But it is clear that if the AHRQ is eliminated and its functions are not replaced, or if the Supreme Court strikes down the ACA's mandate and Congress does not act to preserve the USPSTF, we cannot ensure that evidence-based preventive care will remain affordable for everyone. In sum, our patients will suffer. Many physicians and health care professionals have shied away from engaging in policy debates regarding the size and structure of government in general and health agencies in particular. But when is it time to speak up? Dr Steven Woolf, a family physician and former USPSTF member, recently argued, 'To condone policies that the [medical] profession knows will compromise health — or to remain silent and look away — is to be complicit in putting population health at risk,' and 'We must draw the line when the science is clear that a policy will increase the risk of disease, complications, or premature death.' This is that time. I encourage you to contact your Congressional representatives to express your support for this vital organization and check if your state has enacted legislation to adopt the ACA's preventive services mandate into their state insurance code. Your voice matters. By advocating for the USPSTF, you are helping to protect health recommendations that benefit all Americans. Together, we can ensure that the work of the USPSTF continues to thrive and serve the health needs of our patients and communities.
Medscape
13-05-2025
- Health
- Medscape
Colorectal Cancer Screening Choices: What's the Best FIT?
Hi, everyone. I'm Dr Kenny Lin. I am a family physician and associate director of the Lancaster General Hospital Family Medicine Residency, and I blog at Common Sense Family Doctor . Kenneth W. Lin, MD, MPH Not long after the US Preventive Services Task Force first recommended colonoscopy as a screening method in 2002, I started giving lectures that argued fecal immunochemical testing (FIT) was still a comparable option because patients generally find FIT more convenient than colonoscopy and the mortality benefit of FIT has been proven in several randomized controlled trials. However, over the past two decades, colonoscopy has become the most commonly used screening test for colorectal cancer in the United States. Newer noninvasive screening options that I discussed in a previous Medscape commentary are also being promoted as superior options to FIT. So, will FIT continue to play a role in colorectal cancer screening? In a word…absolutely. Several ongoing randomized trials are evaluating the efficacy of FIT vs screening colonoscopy. In the COLONPREV trial conducted in Spain, 57,000 adults at average risk for colorectal cancer aged 50-69 years of age were randomly assigned to receive an invitation for either a single colonoscopy or FIT every other year. According to results published last month in The Lancet , 55 people in the colonoscopy group and 60 people in the FIT group had died of colorectal cancer at the 10-year endpoint — a difference that was not statistically significant. There are two main drawbacks to this population-based study: Less than 40% of participants received either screening test, and more than 1 in 3 persons assigned to the colonoscopy group chose to have FIT instead. These issues are understandable, because a minority of eligible adults in Spain have routine colorectal cancer screening and colonoscopy plays a much smaller role as an initial screening test compared to its use in the United States. On the positive side, the study showed that 18% fewer people needed colonoscopy in the FIT group compared with the colonoscopy-first group, and there was no significant difference in cancer deaths. Although FITs are a widely available and cost-effective option for colorectal cancer screening, FIT efficacy is largely dependent on patient adherence and follow-up compliance; FIT is only effective if patients return stool samples to the lab and get a timely follow-up colonoscopy if they receive an abnormal result. Fortunately, there is a growing body of research focused on exploring strategies to enhance adherence to FIT. To evaluate patient sentiments regarding FIT screening, investigators in Iowa, North Carolina, and Texas distributed a questionnaire about five different FITs to patients who were scheduled for a screening or surveillance colonoscopy. The investigators found that study participants strongly preferred sample collection in a liquid vial as opposed to a card and made more errors with the latter type. The TEMPO trial also found that the language included in patient instructions can significantly affect follow-up compliance. The addition of one sentence suggesting a 2-week deadline for FIT return (rather than leaving it open-ended) increased overall test return rates and reduced the need to send reminders. Furthermore, results from a cluster randomized trial conducted across 28 clinics in rural Oregon indicate that mailed FIT outreach and telephone-based patient navigation following an abnormal FIT result improved colorectal cancer screening rates at 6 months and diagnostic colonoscopy completion rates at 1 year. These study findings have important applications for primary care practice. When reviewing colorectal cancer screening test choices with patients, family physicians can continue to recommend annual or biennial FIT as a comparable option to colonoscopy. If FIT is selected, we should provide a kit with liquid vial sample collection, if possible, and include a suggested return date in patient instructions. Finally, clinicians in leadership and population health management roles should advocate for cost-effective investments in patient navigation to enhance colorectal cancer screening and diagnostic colonoscopy completion rates, because these initiatives play a crucial role in preventing colorectal cancer deaths.
