Annals for Educators - May 2021
Authors: Christine Laine
Journal: Annals of Internal Medicine (2021)

Web ExclusivesMay 2021Annals for Educators - May 2021FREEChristine Laine, MD, MPHChristine Laine, MD, MPHSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202105180 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsIncorporating Baseline Breast Density When Screening Women at Average Risk for Breast Cancer. A Cost-Effectiveness AnalysisToward Risk-Based Breast Cancer ScreeningWomen with denser-than-average breasts have increased breast cancer risk and might benefit more from earlier and more frequent screening mammography. This study examines different breast cancer screening strategies based on breast density at age 40 years. The accompanying editorial argues that breast density should be combined with age and other risk factors when risk-based screening strategies are being developed.Use this article and the editorial to:Start your session with a multiple-choice question. We provide one below.Use the ACP guidance statement on breast cancer screening to compare the breast cancer screening recommendations from different organizations. Ask your learners to name well-established risk factors for breast cancer.Review several mammography reports from your institution to see how it reports breast density and how it advises women with dense breasts.The Proportion of SARS-CoV-2 Infections That Are Asymptomatic. A Systematic ReviewAsymptomatic infection seems to be a notable feature of SARS-CoV-2, but prevalence is uncertain. This review summarizes available evidence to estimate the proportion of persons infected with SARS-CoV-2 who never develop symptoms.Use this article to:Ask your learners to describe the key characteristics that distinguish systematic reviews from narrative reviews. This editorial will help guide the discussion. Ask your learners to describe the cases of asymptomatic SARS-CoV-2 infection they have seen over the course of the pandemic. How were these cases diagnosed?Review the current CDC recommendations for how to manage isolation of patients with asymptomatic infection and evaluation of their contacts. Clinical Decision Making During the COVID-19 PandemicThe authors apply principles for translating imprecision in diagnostic and therapeutic information into clinical decisions to address areas of uncertainty related to diagnosis, treatment, and prevention of COVID-19.Use this article to:Read each of the diagnosis scenarios included in the article aloud. Ask your learners, “Is the diagnosis of COVID-19 ruled out?”Review the definitions of sensitivity, specificity, and pretest probability.Read the treatment scenario included in the article aloud. Ask your learners, “Should the patient be treated with corticosteroids?”Discuss the quality of evidence for the effectiveness of corticosteroids.Read the prevention scenario included in the article aloud. Ask your learners, “Do you need to wear an N95 mask to provide better protection than a regular surgical mask from COVID-19?”Invite someone from your institution's infection control unit to the session to review your institution's policies regarding personal protective equipment during the pandemic.Public HealthSARS-CoV-2 Vaccines: Much Accomplished, Much to LearnIn this article, experts from the National Institute of Allergy and Infectious Diseases outline the current state of knowledge about COVID-19 vaccines.Use this article to:Review the mechanisms of the 3 COVID-19 vaccines that are currently available in the United States.Ask your learners to review the most common side effects of COVID-19 vaccines.Ask your learners if they are aware of any absolute contraindications to COVID-19 vaccination.CommunicationAddressing Mistrust About COVID-19 Vaccines Among Patients of ColorThis article suggests specific strategies and language that clinicians can use to address mistrust of COVID-19 vaccines among racial and ethnic minorities.Use this article to:Ask your learners about their experiences discussing COVID-19 vaccination with their patients.Discuss the reasons patients might be hesitant about vaccination.Review the communication strategies presented in the article and experiment with using them in a role-play activity.Firearm Safety Discussions Between Clinicians and U.S. Adults Living in Households With Firearms: Results From a 2019 National SurveyThis article reports the results of a 2019 U.S. national survey about discussions of firearm safety during clinical encounters with adults in firearm-owning households.Use this article to:Ask your learners if they routinely ask patients about the presence of firearms in their homes.Discuss whether questions about firearms should be a routine part of health assessment.Review strategies for effective communication about firearm safety in the context of a clinical encounter. This In the Clinic article will help. DepressionThis article offers guidance for the diagnosis and treatment of major depressive disorder, including practical considerations for delivering optimal and efficient care for patients with depression.Use this article to:Ask your learners to describe the risk factors for depression.Review the U.S. Preventive Services Task Force recommendations on screening adults for depression.Ask your learners how they make the diagnosis of depression in their patients and then review the Patient Health Questionnaire (PHQ-2). Do they think they could incorporate this instrument into routine practice?Ask your learners what factors should prompt referral of a patient with depression to a mental health specialist.Discuss nonpharmacologic interventions to treat depression.Ask your learners about factors that should prompt consideration of antidepressant medications. Which medications do they typically prescribe if they are initiating antidepressant therapy in an outpatient?MKSAP 18 QuestionA 50-year-old woman is seen following screening digital mammography. She is asymptomatic and has no medical problems. Other than her age and sex, she has no additional risk factors for breast cancer and no family history of breast cancer. The mammogram report notes no suspicious lesions but indicates that the breasts are heterogeneously dense (density category C). On previous physical examination, vital signs and breast examination were normal.In addition to education on breast density, which of the following is the most appropriate adjunctive breast cancer screening?A. Breast MRIB. Digital breast tomosynthesisC. Repeat digital mammography in 6 monthsD. No further testingCorrect AnswerD. No further testingEducational ObjectiveAvoid adjunctive breast cancer screening in a low-risk patient with dense breast tissue.CritiqueThis patient should not undergo adjunctive screening. Breast density is an increasingly recognized risk factor for breast cancer. It is categorized by the Breast Imaging Reporting and Data System (BI-RADS) as (a) almost entirely fatty, (b) scattered areas of fibroglandular tissue, (c) heterogeneously dense, or (d) extremely dense. Women with dense breasts should be informed that high breast density is common (present in up to 50% of women) and increases breast cancer risk but not breast cancer–related mortality. Dense breasts also decrease the sensitivity of mammography. However, women with high breast density without additional risk factors may experience more harms than benefits from supplemental breast imaging. Although supplemental screening with ultrasonography or MRI may increase the cancer detection rate, the impact on important clinical outcomes is unknown. Up to 90% of positive results on supplemental ultrasonography and 66% to 97% of positive results on supplemental MRI are false-positive findings, which may result in additional testing or invasive procedures. Despite this, nearly a quarter of state legislatures mandate that patients be notified of breast density findings, and some specifically recommend adjunctive screening with ultrasonography.Women with dense breasts and other risk factors that impart a lifetime risk for breast cancer of 20% to 25% or higher, as calculated by models largely dependent on family history, should also undergo breast MRI in addition to screening mammography. The use of supplemental breast MRI in women who have less than a 20% lifetime risk for breast cancer is not currently supported by guidelines.Digital breast tomosynthesis creates a three-dimensional image of the breast. Clinical studies suggest that tomosynthesis may have a sensitivity equal to or exceeding the sensitivity of digital mammography in the detection of breast cancer in women with dense breasts and that tomosynthesis may decrease the recall rate from screening mammography. Despite these promising findings that may improve screening accuracy, there are no randomized trials or long-term follow-up data.Most major breast cancer screening guidelines promote biennial screening from age 50 to 75 years. No guideline recommends biannual digital mammography for patients whose only risk factor is high breast density.Key PointHigh breast density alone does not necessitate adjunctive breast imaging other than routine screening mammography.BibliographyMelnikow J, Fenton JJ, Whitlock EP, Miglioretti DL, Weyrich MS, Thompson JH, et al. Supplemental screening for breast cancer in women with dense breasts: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2016;164:268-78.Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics May 2021Volume 174, Issue 5Page: ED5KeywordsBreast cancerBreast cancer screeningCOVID-19Fire safetyFirearm injuriesMammographyMedical risk factorsSystematic reviewsUltrasound imagingVaccines ePublished: 18 May 2021 Issue Published: May 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...