Journals Watch - Arthritis and colorectal cancer

Too busy to read all the journals? Let Dr Alison Glenesk bring you up to date on the latest research.

Psychological distress in rheumatoid arthritis
Ann Rheum Dis 2012; 71: 192-7

It would not require a clinical trial to show that active arthritis might cause depression, but in this Dutch study, the researchers tried to establish whether the converse might be true.

A total of 545 patients with rheumatoid arthritis (RA), aged 18 to 83 years and 69% female, were studied for five years. The Thompson joint score (a marker of activity of arthritis) and the ESR were checked every six months and depression/anxiety every year.

Multilevel regression analysis was used. It was found that disease activity and current levels of psychological distress were correlated both concurrently and at six-month intervals.

Psychological stress was not, however, a risk factor for future exacerbations. The study did highlight the psychological burden that RA brings - rates for depression/anxiety are twice that in the general population.

The prognostic value of CT coronary angiography
Heart 2012; 98: 232-7

This Dutch multicentre prospective registry study aimed to assess the ageand gender- specific differences in the incidence of coronary artery disease in patients undergoing CT coronary angiography.

A total of 2,432 patients, mean age 57 and 56% male, underwent CT angiography for suspected coronary artery disease.

Patients were stratified into four groups: over and under 60, and male and female. The composite endpoint was cardiac death and non-fatal MI.

CT coronary angiography was normal in 41%, and showed non-significant coronary artery disease in 31% and significant coronary artery disease in the remaining 28%. During follow-up of median 819 days (range 482-1,142) a cardiovascular event occurred in 2.4%. The annualised rate was 1.1%. It was found that observations from CT coronary angiography predicted events in both groups of male patients and females over 60, but was of limited value in younger women.

This shows that CT of the coronary arteries could be a useful, non-invasive test for coronary artery disease.

BMI and survival after colorectal cancer diagnosis
J Clin Oncol 2012; 30(1): 42-52

We have become used to the idea that obesity is associated with a higher risk of cancer, but this study shows that it also affects survival. There are more than 1.1m colorectal cancer survivors in the US, and so far the only widely accepted prognostic factors relate to tumour characteristics.

Participants in this study reported weight and other risk factors at baseline in 1992-3, and at periodic intervals.

Between this time and mid-2007, 2,303 participants were diagnosed with non-metastatic colorectal cancer and were observed until December 2008.

Of the participants, 851 died during this period, 380 as a result of the cancer and 153 from cardiovascular disease.

Pre-diagnosis BMI of more than 30kg/m2 (mean seven years before diagnosis) compared with normal BMI was associated with a higher all-cause mortality (RR 1.3), colorectal cancer (RR 1.35) and cardiovascular (RR 1.68). The post-diagnosis BMI was not correlated.

It appears that this is yet another reason to promote a healthy lifestyle.

Identifying patients with suspected colorectal cancer
Br J Gen Pract 2012; DOI: 10.3399/bjgp12X616346

We are about to embark on a national campaign to improve our cancer survival rates, so this interesting piece of work seems well timed.

Early diagnosis of this common cancer helps to improve survival rates. The aim of this study was to produce a computer-based algorithm to quantify the risk of colorectal cancer in patients in primary care with and without symptoms.

Asymptomatic patients aged 30 to 84 years from 375 research practices were used for derivation, and 189 for validation of the algorithm. The primary endpoint was development of colorectal cancer in the next two years.

This occurred in 4,798 people out of 4.1m person-years of the study population.

Twenty potential risk factors were considered. The most strongly predictive were family history, rectal bleeding, abdominal pain, loss of appetite and loss of weight, with high alcohol intake and altered bowel habit important in males.

The derived algorithm explained 65% of variation in females and 67% in males.

The 10% of patients with the highest predicted risk contained 71% of all colorectal cancers diagnosed in the next two years.

The authors conclude that the algorithm shows good discrimination and calibration and could potentially be very useful in identifying those at highest risk.

Possible net harms of breast cancer screening
BMJ 2011; 343: d7627

This study aimed to answer the simple question: could breast screening do more harm than good?

In the 1980s, the Forrest Report led to the introduction of breast screening for women more than 50 years old.

A subsequent Cochrane review cast some doubt on the value of this initiative, pointing out the possibility of morbidity from false-negatives being treated, and psychological distress being caused.

Computer modelling followed two cohorts of 100,000 healthy women, one undergoing screening and the other not.

Pre-screening rates of breast cancer were applied to both groups.

The conclusion was that harms from screening largely offset the benefits up to 10 years, after which benefits accumulated rapidly, but much less than originally expected.

All this has polarised opinion in the profession and makes it difficult to advise patients. It appears that the controversy will continue for some time to come.

  • Dr Glenesk is a GP in Aberdeen and a member of our team who regularly review the journals

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

CPD IMPACT: EARN MORE CREDITS

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Perform a search for all of your patients with RA and administer a short questionnaire for depression.
  • Identify all of your patients diagnosed with cancer in the past year. How many did you refer urgently, and what were the early symptoms? You can also look at the percentage of your urgent referrals which resulted in a diagnosis of cancer.
  • Identify all the women diagnosed with breast cancer from your last round of screening. Are there any very early diagnoses? You could discuss these cases with a local breast surgeon.

     

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