Commentary

Happy New Year, everyone! In early December, I attended the 2022 AGA Women’s Leadership Collaboration Conference to discuss strategies to promote gender equity in our profession. It was an inspiring weekend and reminded me how many talented individuals we have in the field of gastroenterology, all with fascinating personal and professional stories and much to contribute. I think I speak for all attendees in saying that it was a privilege to have the opportunity to interact with this amazing group of women leaders, reflect on our shared experiences and visions for the future of GI, and expand our networks.

This month we are excited to launch a new recurring feature in the newspaper and online – the Member Spotlight column. AGA has more than16,000 members from varied backgrounds. Yet the reality is that each of our individual networks is much smaller, and we would all benefit from learning more about one other and building a greater sense of community. To that end, starting with this issue, we will feature a different AGA member each month in our Member Spotlight column. The goal of this new feature is to recognize AGA members’ accomplishments across all career stages and practice settings, to highlight the diversity of our membership, and to help AGA members feel more connected by learning more about each other. Our inaugural Member Spotlight column highlights Patricia Jones, MD, associate professor at the University of Miami and an accomplished hepatologist. We thank Dr. Jones for sharing her story with us.

This will be a recurring monthly feature, so please consider nominating your colleagues (including trainees, practicing GIs in academics and community practice, those with non-traditional careers or unique pursuits outside of medicine, and others) to be featured in future Member Spotlight columns! It’s a great way for the nominee’s accomplishments to be recognized and to build a sense of community among the broader AGA membership. To submit a nomination, please send the nominee’s name, email, and a brief description of why you are nominating them to: [email protected]. We look forward to reviewing your submissions and hope you will use these Member Spotlights as an opportunity to strike up a conversation with someone new and expand your networks.

Megan A. Adams, MD, JD, MSc
Editor-in-Chief

Happy New Year, everyone! In early December, I attended the 2022 AGA Women’s Leadership Collaboration Conference to discuss strategies to promote gender equity in our profession. It was an inspiring weekend and reminded me how many talented individuals we have in the field of gastroenterology, all with fascinating personal and professional stories and much to contribute. I think I speak for all attendees in saying that it was a privilege to have the opportunity to interact with this amazing group of women leaders, reflect on our shared experiences and visions for the future of GI, and expand our networks.

This month we are excited to launch a new recurring feature in the newspaper and online – the Member Spotlight column. AGA has more than16,000 members from varied backgrounds. Yet the reality is that each of our individual networks is much smaller, and we would all benefit from learning more about one other and building a greater sense of community. To that end, starting with this issue, we will feature a different AGA member each month in our Member Spotlight column. The goal of this new feature is to recognize AGA members’ accomplishments across all career stages and practice settings, to highlight the diversity of our membership, and to help AGA members feel more connected by learning more about each other. Our inaugural Member Spotlight column highlights Patricia Jones, MD, associate professor at the University of Miami and an accomplished hepatologist. We thank Dr. Jones for sharing her story with us.

This will be a recurring monthly feature, so please consider nominating your colleagues (including trainees, practicing GIs in academics and community practice, those with non-traditional careers or unique pursuits outside of medicine, and others) to be featured in future Member Spotlight columns! It’s a great way for the nominee’s accomplishments to be recognized and to build a sense of community among the broader AGA membership. To submit a nomination, please send the nominee’s name, email, and a brief description of why you are nominating them to: [email protected]. We look forward to reviewing your submissions and hope you will use these Member Spotlights as an opportunity to strike up a conversation with someone new and expand your networks.

Megan A. Adams, MD, JD, MSc
Editor-in-Chief

Happy New Year, everyone! In early December, I attended the 2022 AGA Women’s Leadership Collaboration Conference to discuss strategies to promote gender equity in our profession. It was an inspiring weekend and reminded me how many talented individuals we have in the field of gastroenterology, all with fascinating personal and professional stories and much to contribute. I think I speak for all attendees in saying that it was a privilege to have the opportunity to interact with this amazing group of women leaders, reflect on our shared experiences and visions for the future of GI, and expand our networks.

This month we are excited to launch a new recurring feature in the newspaper and online – the Member Spotlight column. AGA has more than16,000 members from varied backgrounds. Yet the reality is that each of our individual networks is much smaller, and we would all benefit from learning more about one other and building a greater sense of community. To that end, starting with this issue, we will feature a different AGA member each month in our Member Spotlight column. The goal of this new feature is to recognize AGA members’ accomplishments across all career stages and practice settings, to highlight the diversity of our membership, and to help AGA members feel more connected by learning more about each other. Our inaugural Member Spotlight column highlights Patricia Jones, MD, associate professor at the University of Miami and an accomplished hepatologist. We thank Dr. Jones for sharing her story with us.

This will be a recurring monthly feature, so please consider nominating your colleagues (including trainees, practicing GIs in academics and community practice, those with non-traditional careers or unique pursuits outside of medicine, and others) to be featured in future Member Spotlight columns! It’s a great way for the nominee’s accomplishments to be recognized and to build a sense of community among the broader AGA membership. To submit a nomination, please send the nominee’s name, email, and a brief description of why you are nominating them to: [email protected]. We look forward to reviewing your submissions and hope you will use these Member Spotlights as an opportunity to strike up a conversation with someone new and expand your networks.

Megan A. Adams, MD, JD, MSc
Editor-in-Chief

With the introduction of the first US Food and Drug Administration (FDA)–approved medication for alopecia areata (AA)—the Janus kinase (JAK) inhibitor, baricitinib—there is an important focus on this disease in the literature and for practicing dermatologists. Known by all as an autoimmune genetic disease that causes relapsing and remitting nonscarring hair loss, AA is a condition where the psychological burden has been less widely recognized. Patients with AA have reported lower health-related quality of life scores compared to patients with other skin conditions, including psoriasis or atopic dermatitis. In addition, a lesser amount of scalp coverage is negatively correlated to health-related quality of life scores.¹ Patients with AA also have a 39% lifetime prevalence of major depressive disorder and generalized anxiety disorder.² The treatment of AA has been a hodgepodge of topical, intralesional, and systemic agents, all with indirect immunosuppressive or anagen prolongation effects. Now that there is an approved therapy for AA with more treatments likely to be approved in the near future, there must be a focus on real-world outcomes. With the dawn of a new era in the treatment of AA as well as new information showcasing an altered prevalence of AA in skin of color, highlighting disparities among this population may help ease challenges dermatologic providers will face.

Efficacy of Baricitinib in Different Races and Ethnicities

How will patients of different races and ethnicities respond to this new treatment, and how will their emotional health be affected? The 2 phase 3 pivotal trials showing efficacy of baricitinib in AA included Black and Latino patients but not in a way that is representative of the US population.³ Until recently, the most commonly used prevalence of AA in the United States was from the NHANES I study completed between 1971 and 1974, which was between 0.1% and 0.2%⁴ with minimal focus on race and ethnicity. Recent studies suggest that there may be increased prevalence of this condition in Black patients in the United States. These new findings raise concern around access to care and treatment and the need to tailor psychosocial interventions for populations that may not currently have these supports.

A large cross-sectional study published in 2020 demonstrated that these data remained similar, with a lifetime prevalence of 0.21%.⁵ Of the 45,016 participants—representative of the US population based on the 2015 US Census—the average age of AA patients was 41.2 years, with 61.3% being White and not of Hispanic origin.⁵ In recent years, other studies have challenged the narrative that AA predominantly affects White patients.^6-8 A different cross-sectional study utilizing National Alopecia Areata Registry data from 2002 to 2016 suggested that Black patients have greater odds of developing AA.⁶ In this study of 2645 cases of AA, the odds ratios of developing the condition were 1.36 for Blacks, 0.53 for Asians, and 0.83 for Hispanics compared with the referent White population. These results were consistent through the varying subtypes of AA.⁶ In a reply to these findings, Gonzalez and Fleischer⁷ analyzed data from the 2007 to 2016 National Ambulatory Medical Care Survey database with a focus on racial and ethnic prevalence of AA. This study concluded that Latino and non-White individuals had an increased likelihood of clinician visits for AA compared with White individuals.⁷

More evidence of the Black predominance of AA was demonstrated in a study published in 2018. In this large-scale study, 63,960 women from the Nurses’ Health Study (NHS) and 88,368 women from the Nurses’ Health Study II (NHSII) were included to examine prevalence of disease among these US women.⁸ Analysis showed increased odds of AA based on self-reported race in Black and Hispanic women. Lifetime incidence of AA was greater in Black women, with 2.63 and 5.23 in NHS and NHSII, respectively. It was hypothesized that hairstyling practices in Black and Hispanic women may cause AA to be more noticeable,⁸ which may drive patients to seek medical evaluation.

Feaster and McMichael⁹ published information on the epidemiology of AA in a busy hair loss clinic. This retrospective single-institution study of 265 pediatric and adult Black patients with AA seen over a 5-year period showed that patients aged 18 to 34 years were most likely to present for care, which accounted for 35.8% of the study population, followed by patients aged 10 to 17 years, which accounted for 15.1%. This study also found that females were the larger segment of AA patients, with an increased distribution of disease in young patients. Most of these patients (68.2%) had patchy hair loss, and the ophiasis pattern was seen in 15.1%.⁹ Although the pathogenesis of AA is linked to autoimmunity,¹⁰ the leading cause for these epidemiologic findings of increased prevalence in Black patients is still uncertain.

Baricitinib for AA

In June 2022, the FDA announced the first biologic drug approved for the treatment of AA—baricitinib. Baricitinib is an oral, selective, reversible inhibitor of JAK1 and JAK2.³ The phase 3 trials for baricitinib—BRAVE-AA1 (N=654) and BRAVE-AA2 (N=546)—were conducted between March 2019 and May 2020. In these double-blind, parallel-group, randomized, placebo-controlled trials, 33% of the patient population receiving baricitinib accomplished 80% or more scalp coverage at 36 weeks. The Severity of Alopecia Tool (SALT) score also decreased to 20 or less in 36 weeks. The BRAVE-AA1 and BRAVE-AA2 trials consisted of a total of 1200 patients, with only 98 identifying as Black. Of these 98 patients, 33 were randomly selected to receive placebo.³ With studies now suggesting that Black individuals have greater odds of AA compared with White individuals⁶ and Black patients being more likely to seek medical care for AA,⁷ the BRAVE-AA1 and BRAVE-AA2 study population did not allow for significant comparative data for Black patients. These studies did not document Latino patient involvement.³ Future studies in AA must recruit a diversified group of study participants to better reflect the patients with an increased likelihood of presenting with AA.

Other Treatments on the Horizon

Baricitinib likely will remain alone in its class for only a short time. Phase 3 trials have been completed for ritlecitinib, brepocitinib, and deuruxolitinib for AA. Ritlecitinib, an irreversible inhibitor of JAK3 and the tyrosine kinase expressed in hepatocellular carcinoma (TEC) kinase family, has met all end points in a phase 2b/3 study.¹¹ Brepocitinib is an oral tyrosine kinase 2/JAK1 inhibitor,¹² and deuruxolitinib is an investigational JAK1/2 inhibitor for AA.¹³

 

 

Insurance Coverage Considerations and Health Care Disparities

Prior authorizations have been the initial step for many drugs in varying fields of medical practice. A study completed in 2016 suggested that insurance coverage for biologics used in the treatment of psoriasis was becoming increasingly difficult.¹⁴ Prior authorization requirement rates increased from 16% of patients in 2009 to 75% in 2014. The decision time also increased from 3.7 days in 2009 to 6.7 days in 2014. The most common reason for delay in decisions and denials was due to step therapy.¹⁴ Insurance companies wanted many patients to try less expensive treatment options prior to “stepping up” to more expensive treatments. Although this may be the case in the treatment of psoriasis, the role of step therapy is unclear for patients with AA because there is only 1 FDA-approved medication. This sets out an ambiguous future for our patients with AA and approval for baricitinib.

The time required for the correspondence between insurance companies, clinic staff, and patients for drug approval may delay treatments, and not all providers have enough staff to coordinate and perform this work. For Black patients, who may present more frequently and with more severe disease,⁷ this could lead to a health care disparity due to the likelihood of the increased need for biologic treatment. Because Black patients have an increased likelihood of being uninsured or underinsured,¹⁵ this further decreases the chances of the most severe AA patients receiving the most helpful medication for their condition.

Many pharmaceutical companies have drug cost assistance programs that aim to provide support covering expensive medications for patients unable to afford them. Although this is a good first step, treatment with any JAK inhibitor potentially can be lifelong. Regarding the social determinants of health, it is known that access to medications does not solely depend on cost. Transportation and access to qualified health professionals are among the issues that create barriers to health care. Instilling long-term practices to ensure equal access to JAK inhibitors and treatment of AA may be the cornerstone to treating AA with equity. Whether we require pharmaceutical companies to make sure all patients have equal access to medications or provide community resources to hairstylists and federally qualified health centers, raising awareness and advocating for and creating attainable access to treatment modalities is imperative to providing well-rounded care to a diverse population.

With the introduction of the first US Food and Drug Administration (FDA)–approved medication for alopecia areata (AA)—the Janus kinase (JAK) inhibitor, baricitinib—there is an important focus on this disease in the literature and for practicing dermatologists. Known by all as an autoimmune genetic disease that causes relapsing and remitting nonscarring hair loss, AA is a condition where the psychological burden has been less widely recognized. Patients with AA have reported lower health-related quality of life scores compared to patients with other skin conditions, including psoriasis or atopic dermatitis. In addition, a lesser amount of scalp coverage is negatively correlated to health-related quality of life scores.¹ Patients with AA also have a 39% lifetime prevalence of major depressive disorder and generalized anxiety disorder.² The treatment of AA has been a hodgepodge of topical, intralesional, and systemic agents, all with indirect immunosuppressive or anagen prolongation effects. Now that there is an approved therapy for AA with more treatments likely to be approved in the near future, there must be a focus on real-world outcomes. With the dawn of a new era in the treatment of AA as well as new information showcasing an altered prevalence of AA in skin of color, highlighting disparities among this population may help ease challenges dermatologic providers will face.

Efficacy of Baricitinib in Different Races and Ethnicities

How will patients of different races and ethnicities respond to this new treatment, and how will their emotional health be affected? The 2 phase 3 pivotal trials showing efficacy of baricitinib in AA included Black and Latino patients but not in a way that is representative of the US population.³ Until recently, the most commonly used prevalence of AA in the United States was from the NHANES I study completed between 1971 and 1974, which was between 0.1% and 0.2%⁴ with minimal focus on race and ethnicity. Recent studies suggest that there may be increased prevalence of this condition in Black patients in the United States. These new findings raise concern around access to care and treatment and the need to tailor psychosocial interventions for populations that may not currently have these supports.

A large cross-sectional study published in 2020 demonstrated that these data remained similar, with a lifetime prevalence of 0.21%.⁵ Of the 45,016 participants—representative of the US population based on the 2015 US Census—the average age of AA patients was 41.2 years, with 61.3% being White and not of Hispanic origin.⁵ In recent years, other studies have challenged the narrative that AA predominantly affects White patients.^6-8 A different cross-sectional study utilizing National Alopecia Areata Registry data from 2002 to 2016 suggested that Black patients have greater odds of developing AA.⁶ In this study of 2645 cases of AA, the odds ratios of developing the condition were 1.36 for Blacks, 0.53 for Asians, and 0.83 for Hispanics compared with the referent White population. These results were consistent through the varying subtypes of AA.⁶ In a reply to these findings, Gonzalez and Fleischer⁷ analyzed data from the 2007 to 2016 National Ambulatory Medical Care Survey database with a focus on racial and ethnic prevalence of AA. This study concluded that Latino and non-White individuals had an increased likelihood of clinician visits for AA compared with White individuals.⁷

More evidence of the Black predominance of AA was demonstrated in a study published in 2018. In this large-scale study, 63,960 women from the Nurses’ Health Study (NHS) and 88,368 women from the Nurses’ Health Study II (NHSII) were included to examine prevalence of disease among these US women.⁸ Analysis showed increased odds of AA based on self-reported race in Black and Hispanic women. Lifetime incidence of AA was greater in Black women, with 2.63 and 5.23 in NHS and NHSII, respectively. It was hypothesized that hairstyling practices in Black and Hispanic women may cause AA to be more noticeable,⁸ which may drive patients to seek medical evaluation.

Feaster and McMichael⁹ published information on the epidemiology of AA in a busy hair loss clinic. This retrospective single-institution study of 265 pediatric and adult Black patients with AA seen over a 5-year period showed that patients aged 18 to 34 years were most likely to present for care, which accounted for 35.8% of the study population, followed by patients aged 10 to 17 years, which accounted for 15.1%. This study also found that females were the larger segment of AA patients, with an increased distribution of disease in young patients. Most of these patients (68.2%) had patchy hair loss, and the ophiasis pattern was seen in 15.1%.⁹ Although the pathogenesis of AA is linked to autoimmunity,¹⁰ the leading cause for these epidemiologic findings of increased prevalence in Black patients is still uncertain.

Baricitinib for AA

In June 2022, the FDA announced the first biologic drug approved for the treatment of AA—baricitinib. Baricitinib is an oral, selective, reversible inhibitor of JAK1 and JAK2.³ The phase 3 trials for baricitinib—BRAVE-AA1 (N=654) and BRAVE-AA2 (N=546)—were conducted between March 2019 and May 2020. In these double-blind, parallel-group, randomized, placebo-controlled trials, 33% of the patient population receiving baricitinib accomplished 80% or more scalp coverage at 36 weeks. The Severity of Alopecia Tool (SALT) score also decreased to 20 or less in 36 weeks. The BRAVE-AA1 and BRAVE-AA2 trials consisted of a total of 1200 patients, with only 98 identifying as Black. Of these 98 patients, 33 were randomly selected to receive placebo.³ With studies now suggesting that Black individuals have greater odds of AA compared with White individuals⁶ and Black patients being more likely to seek medical care for AA,⁷ the BRAVE-AA1 and BRAVE-AA2 study population did not allow for significant comparative data for Black patients. These studies did not document Latino patient involvement.³ Future studies in AA must recruit a diversified group of study participants to better reflect the patients with an increased likelihood of presenting with AA.

Other Treatments on the Horizon

Baricitinib likely will remain alone in its class for only a short time. Phase 3 trials have been completed for ritlecitinib, brepocitinib, and deuruxolitinib for AA. Ritlecitinib, an irreversible inhibitor of JAK3 and the tyrosine kinase expressed in hepatocellular carcinoma (TEC) kinase family, has met all end points in a phase 2b/3 study.¹¹ Brepocitinib is an oral tyrosine kinase 2/JAK1 inhibitor,¹² and deuruxolitinib is an investigational JAK1/2 inhibitor for AA.¹³

 

 

Insurance Coverage Considerations and Health Care Disparities

Prior authorizations have been the initial step for many drugs in varying fields of medical practice. A study completed in 2016 suggested that insurance coverage for biologics used in the treatment of psoriasis was becoming increasingly difficult.¹⁴ Prior authorization requirement rates increased from 16% of patients in 2009 to 75% in 2014. The decision time also increased from 3.7 days in 2009 to 6.7 days in 2014. The most common reason for delay in decisions and denials was due to step therapy.¹⁴ Insurance companies wanted many patients to try less expensive treatment options prior to “stepping up” to more expensive treatments. Although this may be the case in the treatment of psoriasis, the role of step therapy is unclear for patients with AA because there is only 1 FDA-approved medication. This sets out an ambiguous future for our patients with AA and approval for baricitinib.

The time required for the correspondence between insurance companies, clinic staff, and patients for drug approval may delay treatments, and not all providers have enough staff to coordinate and perform this work. For Black patients, who may present more frequently and with more severe disease,⁷ this could lead to a health care disparity due to the likelihood of the increased need for biologic treatment. Because Black patients have an increased likelihood of being uninsured or underinsured,¹⁵ this further decreases the chances of the most severe AA patients receiving the most helpful medication for their condition.

Many pharmaceutical companies have drug cost assistance programs that aim to provide support covering expensive medications for patients unable to afford them. Although this is a good first step, treatment with any JAK inhibitor potentially can be lifelong. Regarding the social determinants of health, it is known that access to medications does not solely depend on cost. Transportation and access to qualified health professionals are among the issues that create barriers to health care. Instilling long-term practices to ensure equal access to JAK inhibitors and treatment of AA may be the cornerstone to treating AA with equity. Whether we require pharmaceutical companies to make sure all patients have equal access to medications or provide community resources to hairstylists and federally qualified health centers, raising awareness and advocating for and creating attainable access to treatment modalities is imperative to providing well-rounded care to a diverse population.

With the introduction of the first US Food and Drug Administration (FDA)–approved medication for alopecia areata (AA)—the Janus kinase (JAK) inhibitor, baricitinib—there is an important focus on this disease in the literature and for practicing dermatologists. Known by all as an autoimmune genetic disease that causes relapsing and remitting nonscarring hair loss, AA is a condition where the psychological burden has been less widely recognized. Patients with AA have reported lower health-related quality of life scores compared to patients with other skin conditions, including psoriasis or atopic dermatitis. In addition, a lesser amount of scalp coverage is negatively correlated to health-related quality of life scores.¹ Patients with AA also have a 39% lifetime prevalence of major depressive disorder and generalized anxiety disorder.² The treatment of AA has been a hodgepodge of topical, intralesional, and systemic agents, all with indirect immunosuppressive or anagen prolongation effects. Now that there is an approved therapy for AA with more treatments likely to be approved in the near future, there must be a focus on real-world outcomes. With the dawn of a new era in the treatment of AA as well as new information showcasing an altered prevalence of AA in skin of color, highlighting disparities among this population may help ease challenges dermatologic providers will face.

Efficacy of Baricitinib in Different Races and Ethnicities

How will patients of different races and ethnicities respond to this new treatment, and how will their emotional health be affected? The 2 phase 3 pivotal trials showing efficacy of baricitinib in AA included Black and Latino patients but not in a way that is representative of the US population.³ Until recently, the most commonly used prevalence of AA in the United States was from the NHANES I study completed between 1971 and 1974, which was between 0.1% and 0.2%⁴ with minimal focus on race and ethnicity. Recent studies suggest that there may be increased prevalence of this condition in Black patients in the United States. These new findings raise concern around access to care and treatment and the need to tailor psychosocial interventions for populations that may not currently have these supports.

A large cross-sectional study published in 2020 demonstrated that these data remained similar, with a lifetime prevalence of 0.21%.⁵ Of the 45,016 participants—representative of the US population based on the 2015 US Census—the average age of AA patients was 41.2 years, with 61.3% being White and not of Hispanic origin.⁵ In recent years, other studies have challenged the narrative that AA predominantly affects White patients.^6-8 A different cross-sectional study utilizing National Alopecia Areata Registry data from 2002 to 2016 suggested that Black patients have greater odds of developing AA.⁶ In this study of 2645 cases of AA, the odds ratios of developing the condition were 1.36 for Blacks, 0.53 for Asians, and 0.83 for Hispanics compared with the referent White population. These results were consistent through the varying subtypes of AA.⁶ In a reply to these findings, Gonzalez and Fleischer⁷ analyzed data from the 2007 to 2016 National Ambulatory Medical Care Survey database with a focus on racial and ethnic prevalence of AA. This study concluded that Latino and non-White individuals had an increased likelihood of clinician visits for AA compared with White individuals.⁷

More evidence of the Black predominance of AA was demonstrated in a study published in 2018. In this large-scale study, 63,960 women from the Nurses’ Health Study (NHS) and 88,368 women from the Nurses’ Health Study II (NHSII) were included to examine prevalence of disease among these US women.⁸ Analysis showed increased odds of AA based on self-reported race in Black and Hispanic women. Lifetime incidence of AA was greater in Black women, with 2.63 and 5.23 in NHS and NHSII, respectively. It was hypothesized that hairstyling practices in Black and Hispanic women may cause AA to be more noticeable,⁸ which may drive patients to seek medical evaluation.

Feaster and McMichael⁹ published information on the epidemiology of AA in a busy hair loss clinic. This retrospective single-institution study of 265 pediatric and adult Black patients with AA seen over a 5-year period showed that patients aged 18 to 34 years were most likely to present for care, which accounted for 35.8% of the study population, followed by patients aged 10 to 17 years, which accounted for 15.1%. This study also found that females were the larger segment of AA patients, with an increased distribution of disease in young patients. Most of these patients (68.2%) had patchy hair loss, and the ophiasis pattern was seen in 15.1%.⁹ Although the pathogenesis of AA is linked to autoimmunity,¹⁰ the leading cause for these epidemiologic findings of increased prevalence in Black patients is still uncertain.

Baricitinib for AA

In June 2022, the FDA announced the first biologic drug approved for the treatment of AA—baricitinib. Baricitinib is an oral, selective, reversible inhibitor of JAK1 and JAK2.³ The phase 3 trials for baricitinib—BRAVE-AA1 (N=654) and BRAVE-AA2 (N=546)—were conducted between March 2019 and May 2020. In these double-blind, parallel-group, randomized, placebo-controlled trials, 33% of the patient population receiving baricitinib accomplished 80% or more scalp coverage at 36 weeks. The Severity of Alopecia Tool (SALT) score also decreased to 20 or less in 36 weeks. The BRAVE-AA1 and BRAVE-AA2 trials consisted of a total of 1200 patients, with only 98 identifying as Black. Of these 98 patients, 33 were randomly selected to receive placebo.³ With studies now suggesting that Black individuals have greater odds of AA compared with White individuals⁶ and Black patients being more likely to seek medical care for AA,⁷ the BRAVE-AA1 and BRAVE-AA2 study population did not allow for significant comparative data for Black patients. These studies did not document Latino patient involvement.³ Future studies in AA must recruit a diversified group of study participants to better reflect the patients with an increased likelihood of presenting with AA.

Other Treatments on the Horizon

Baricitinib likely will remain alone in its class for only a short time. Phase 3 trials have been completed for ritlecitinib, brepocitinib, and deuruxolitinib for AA. Ritlecitinib, an irreversible inhibitor of JAK3 and the tyrosine kinase expressed in hepatocellular carcinoma (TEC) kinase family, has met all end points in a phase 2b/3 study.¹¹ Brepocitinib is an oral tyrosine kinase 2/JAK1 inhibitor,¹² and deuruxolitinib is an investigational JAK1/2 inhibitor for AA.¹³

 

 

Insurance Coverage Considerations and Health Care Disparities

Prior authorizations have been the initial step for many drugs in varying fields of medical practice. A study completed in 2016 suggested that insurance coverage for biologics used in the treatment of psoriasis was becoming increasingly difficult.¹⁴ Prior authorization requirement rates increased from 16% of patients in 2009 to 75% in 2014. The decision time also increased from 3.7 days in 2009 to 6.7 days in 2014. The most common reason for delay in decisions and denials was due to step therapy.¹⁴ Insurance companies wanted many patients to try less expensive treatment options prior to “stepping up” to more expensive treatments. Although this may be the case in the treatment of psoriasis, the role of step therapy is unclear for patients with AA because there is only 1 FDA-approved medication. This sets out an ambiguous future for our patients with AA and approval for baricitinib.

The time required for the correspondence between insurance companies, clinic staff, and patients for drug approval may delay treatments, and not all providers have enough staff to coordinate and perform this work. For Black patients, who may present more frequently and with more severe disease,⁷ this could lead to a health care disparity due to the likelihood of the increased need for biologic treatment. Because Black patients have an increased likelihood of being uninsured or underinsured,¹⁵ this further decreases the chances of the most severe AA patients receiving the most helpful medication for their condition.

Many pharmaceutical companies have drug cost assistance programs that aim to provide support covering expensive medications for patients unable to afford them. Although this is a good first step, treatment with any JAK inhibitor potentially can be lifelong. Regarding the social determinants of health, it is known that access to medications does not solely depend on cost. Transportation and access to qualified health professionals are among the issues that create barriers to health care. Instilling long-term practices to ensure equal access to JAK inhibitors and treatment of AA may be the cornerstone to treating AA with equity. Whether we require pharmaceutical companies to make sure all patients have equal access to medications or provide community resources to hairstylists and federally qualified health centers, raising awareness and advocating for and creating attainable access to treatment modalities is imperative to providing well-rounded care to a diverse population.

“It is one of life’s most self-evident truths that everything fades, that we fear the fading, and that we must live, nonetheless, in the face of the fear.” – Irvin D. Yalom, MD, Existential Psychotherapy, 1980

The email was titled simply, “A sorrowful note,” and I knew that someone had died. I held my breath and read as Dr. Jimmy Potash informed our entire department that Dr. Cait McFarland died in a car accident on December 7 while driving to work at West Cecil Health Center, Conowingo, Md., where she was director of psychiatry.

Sadness swelled as I remembered the outspoken resident who was interested in LGBTQ issues. Cait graduated from the Johns Hopkins residency program in 2020, she had recently married a social worker in the department, and the plan was for her to return to Hopkins full-time in July 2023 to be director of a clinic focused on mental health for people who are transgendered.

Sudden deaths are tragic and jarring and they call to the surface our losses from the past. These deaths don’t stand alone – I found myself thinking of my editor at Medscape, Dr. Bret Stetka, who died unexpectedly in August 2022, and then of Dr. Lidia Palcan Wenz, a psychiatrist I trained with, who died in a motor vehicle accident in 2004. Lidia’s husband also died in the accident, while their two young children in the back seat survived – this tragedy haunted me for some time. None of these people was close to me, but I am no stranger to the impact of unexpected death: My parents and brother all died from cardiac events, and any sudden death is a reminder of those losses.

Julia Riddle, MD, trained with Cait McFarland and was her close friend for years. “I don’t have a belief in ‘the afterlife’ but do like to think of the people that I have lost together in my memory – as if they are all suddenly in a new room together. And, with each loss, all the other occupants of that room come freshly to life again,” Dr. Riddle said.

Death is our shared destination in life, but sudden and unexpected deaths carry their own weight. There is no chance to tie up loose ends, to repair riffs, to say goodbye. Nothing is put in order, and the life that was to be lived goes on for some time as bills arrive, social and work events go unattended, vacations are canceled, and there is the awkward moment of running into someone who didn’t know your loved one has died.

Roger Lewin, MD, is a psychiatrist and writer in Towson, Md. He has both personal and professional experience with sudden death. “There is no way to prepare beforehand, so we have to get ready for what has already happened, and that is hard,” he said. “We invent a life for ourselves and others that extends into the future, and that gets interrupted.”

Most people become ill and die on a vaguely predictable schedule. There may be a chance to plan, to know and honor the wishes of the individual, and often there is the opportunity for loved ones to begin the grieving process gradually as death approaches. For those who are elderly, there may be a sense that this is the natural order of things – which may or may not temper the intensity of the grief for those who remain. If the person has suffered, the end may come with relief.

Still, I sometimes find myself surprised at the length and intensity of anguish that some people experience after losing a loved one who has lived a long and full life, who declined and suffered, but whose absence remains a gaping wound that takes years to form a scar.

Sudden death is not rare; accidents, homicide, and suicide are the top killers among young people, and cardiovascular deaths are number one among those who are older. Natural disasters and terrorist attacks can cause catastrophic numbers of sudden deaths and leave survivors to grieve not only the dead, but the loss of all that was familiar to them.

Psychiatry has been a bit lost as to how we approach grief. We often hear patients talk about anxiety surrounding death and illness, be it a fear of death or a longing for it. These fears can seem irrational – I am reminded of a patient who was afraid to eat romaine because of news reports that it was responsible for food poisoning in other states, but not Maryland, where the person lived. I found it odd that he worried about eating lettuce, but not about smoking two packs of cigarettes a day.

But our fears are like that – they move to what the media sensationalizes, or to what may be remote, because otherwise no one would get in a car or clear their walkway of snow. Life is most easily lived with a bit of denial: We shut out the reality that we can be here one moment, overscheduled and overwhelmed, with deadlines, mortgage payments, and summer vacation plans, oblivious to the fact that life may end at any moment. The early months of COVID-19 felt like a global game of Russian roulette, with each venture out a pull of the trigger and everyone’s defenses stripped bare.

While death belongs to us all, we relegate it to the disciplines of religion, philosophy, the arts, and psychology. Religion offers answers – whether a heaven, a hell, or continual reincarnation until the individual attains enlightenment, there is a destination. Perhaps it will be pleasant, perhaps not, and for some there is the hope that one gets to be the driver by having the right beliefs or doing good deeds, while others are comforted by the hope of being reunited with loved ones.

“The suddenness endures and the shock lasts – it’s like a meteor that creates a crater and we revisit it in different ways from different angles,” Dr. Lewin said. “It may leap on us unexpectedly, often many years later.”

Patients talk about death, and when their fears seem unrealistic we may long to reassure them, yet there is no reassurance and psychiatry grasps for how to help. Psychiatry has looked to draw lines for when normal grief crosses to abnormal. Is it an adjustment disorder, complicated grief, “prolonged” grief, pathology in need of medication and medicalization, or something one experiences individually, sometimes for a very long time even with treatment?

One justification for pathologizing “prolonged” reactions includes the fact that insurers will pay for treatment only if there is a diagnosis code, and shouldn’t people in distress be entitled to psychotherapy or medication? Yet there is something offensive about telling someone that they are mentally ill if they don’t grieve along a prescribed timeline, as much as there is about denying them the possible benefits of therapy or medication if they seek it, but are suffering in all the “right” ways. Psychiatry’s approach to death is inelegant at best.

In his poignant podcast series, All There Is, Anderson Cooper is tasked with sorting through his mother’s apartment after her death at age 95. In the course of packing up her belongings, he brings on other guests to talk about their emotional reactions to death. Mr. Cooper’s mother, Gloria Vanderbilt, died at an advanced age, but his father died after a brief cardiac illness when Mr. Cooper was a child, and his brother died by suicide when he was 21. He uses these experiences as a springboard to examine childhood losses, the aftermath of suicide, and the loneliness of grief.

“Loss and grief is this universal experience that we will all go through multiple times in our lives,” Mr. Cooper says, “And yet it leaves us feeling so alone and so separated from other people. At least it does me and has my entire life.”

When we talk about grief and loss, we talk about “getting over it,” or “moving on.” But loss doesn’t work that way – time usually eases the pain, leaving scars that are part of the road map for who we are on the journey that defines us.

Sudden death is hard, and the unexpected death of a young person is tragic. For Cait McFarland, there are the decades she won’t get to experience. For her family and friends, it may be excruciating, and for all the patients who have lost a psychiatrist, may time bring healing and peace.

The Dr. Caitlin McFarland Educational Fund for LGBTQI+ Mental Health is being established, and donations are being accepted at https://www.gofundme.com/f/in-memory-of-cait-mcfarland.

Dr. Miller is a coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore. She has disclosed no relevant financial relationships.

“It is one of life’s most self-evident truths that everything fades, that we fear the fading, and that we must live, nonetheless, in the face of the fear.” – Irvin D. Yalom, MD, Existential Psychotherapy, 1980

The email was titled simply, “A sorrowful note,” and I knew that someone had died. I held my breath and read as Dr. Jimmy Potash informed our entire department that Dr. Cait McFarland died in a car accident on December 7 while driving to work at West Cecil Health Center, Conowingo, Md., where she was director of psychiatry.

Sadness swelled as I remembered the outspoken resident who was interested in LGBTQ issues. Cait graduated from the Johns Hopkins residency program in 2020, she had recently married a social worker in the department, and the plan was for her to return to Hopkins full-time in July 2023 to be director of a clinic focused on mental health for people who are transgendered.

Sudden deaths are tragic and jarring and they call to the surface our losses from the past. These deaths don’t stand alone – I found myself thinking of my editor at Medscape, Dr. Bret Stetka, who died unexpectedly in August 2022, and then of Dr. Lidia Palcan Wenz, a psychiatrist I trained with, who died in a motor vehicle accident in 2004. Lidia’s husband also died in the accident, while their two young children in the back seat survived – this tragedy haunted me for some time. None of these people was close to me, but I am no stranger to the impact of unexpected death: My parents and brother all died from cardiac events, and any sudden death is a reminder of those losses.

Julia Riddle, MD, trained with Cait McFarland and was her close friend for years. “I don’t have a belief in ‘the afterlife’ but do like to think of the people that I have lost together in my memory – as if they are all suddenly in a new room together. And, with each loss, all the other occupants of that room come freshly to life again,” Dr. Riddle said.

Death is our shared destination in life, but sudden and unexpected deaths carry their own weight. There is no chance to tie up loose ends, to repair riffs, to say goodbye. Nothing is put in order, and the life that was to be lived goes on for some time as bills arrive, social and work events go unattended, vacations are canceled, and there is the awkward moment of running into someone who didn’t know your loved one has died.

Roger Lewin, MD, is a psychiatrist and writer in Towson, Md. He has both personal and professional experience with sudden death. “There is no way to prepare beforehand, so we have to get ready for what has already happened, and that is hard,” he said. “We invent a life for ourselves and others that extends into the future, and that gets interrupted.”

Most people become ill and die on a vaguely predictable schedule. There may be a chance to plan, to know and honor the wishes of the individual, and often there is the opportunity for loved ones to begin the grieving process gradually as death approaches. For those who are elderly, there may be a sense that this is the natural order of things – which may or may not temper the intensity of the grief for those who remain. If the person has suffered, the end may come with relief.

Still, I sometimes find myself surprised at the length and intensity of anguish that some people experience after losing a loved one who has lived a long and full life, who declined and suffered, but whose absence remains a gaping wound that takes years to form a scar.

Sudden death is not rare; accidents, homicide, and suicide are the top killers among young people, and cardiovascular deaths are number one among those who are older. Natural disasters and terrorist attacks can cause catastrophic numbers of sudden deaths and leave survivors to grieve not only the dead, but the loss of all that was familiar to them.

Psychiatry has been a bit lost as to how we approach grief. We often hear patients talk about anxiety surrounding death and illness, be it a fear of death or a longing for it. These fears can seem irrational – I am reminded of a patient who was afraid to eat romaine because of news reports that it was responsible for food poisoning in other states, but not Maryland, where the person lived. I found it odd that he worried about eating lettuce, but not about smoking two packs of cigarettes a day.

But our fears are like that – they move to what the media sensationalizes, or to what may be remote, because otherwise no one would get in a car or clear their walkway of snow. Life is most easily lived with a bit of denial: We shut out the reality that we can be here one moment, overscheduled and overwhelmed, with deadlines, mortgage payments, and summer vacation plans, oblivious to the fact that life may end at any moment. The early months of COVID-19 felt like a global game of Russian roulette, with each venture out a pull of the trigger and everyone’s defenses stripped bare.

While death belongs to us all, we relegate it to the disciplines of religion, philosophy, the arts, and psychology. Religion offers answers – whether a heaven, a hell, or continual reincarnation until the individual attains enlightenment, there is a destination. Perhaps it will be pleasant, perhaps not, and for some there is the hope that one gets to be the driver by having the right beliefs or doing good deeds, while others are comforted by the hope of being reunited with loved ones.

“The suddenness endures and the shock lasts – it’s like a meteor that creates a crater and we revisit it in different ways from different angles,” Dr. Lewin said. “It may leap on us unexpectedly, often many years later.”

Patients talk about death, and when their fears seem unrealistic we may long to reassure them, yet there is no reassurance and psychiatry grasps for how to help. Psychiatry has looked to draw lines for when normal grief crosses to abnormal. Is it an adjustment disorder, complicated grief, “prolonged” grief, pathology in need of medication and medicalization, or something one experiences individually, sometimes for a very long time even with treatment?

One justification for pathologizing “prolonged” reactions includes the fact that insurers will pay for treatment only if there is a diagnosis code, and shouldn’t people in distress be entitled to psychotherapy or medication? Yet there is something offensive about telling someone that they are mentally ill if they don’t grieve along a prescribed timeline, as much as there is about denying them the possible benefits of therapy or medication if they seek it, but are suffering in all the “right” ways. Psychiatry’s approach to death is inelegant at best.

In his poignant podcast series, All There Is, Anderson Cooper is tasked with sorting through his mother’s apartment after her death at age 95. In the course of packing up her belongings, he brings on other guests to talk about their emotional reactions to death. Mr. Cooper’s mother, Gloria Vanderbilt, died at an advanced age, but his father died after a brief cardiac illness when Mr. Cooper was a child, and his brother died by suicide when he was 21. He uses these experiences as a springboard to examine childhood losses, the aftermath of suicide, and the loneliness of grief.

“Loss and grief is this universal experience that we will all go through multiple times in our lives,” Mr. Cooper says, “And yet it leaves us feeling so alone and so separated from other people. At least it does me and has my entire life.”

When we talk about grief and loss, we talk about “getting over it,” or “moving on.” But loss doesn’t work that way – time usually eases the pain, leaving scars that are part of the road map for who we are on the journey that defines us.

Sudden death is hard, and the unexpected death of a young person is tragic. For Cait McFarland, there are the decades she won’t get to experience. For her family and friends, it may be excruciating, and for all the patients who have lost a psychiatrist, may time bring healing and peace.

The Dr. Caitlin McFarland Educational Fund for LGBTQI+ Mental Health is being established, and donations are being accepted at https://www.gofundme.com/f/in-memory-of-cait-mcfarland.

Dr. Miller is a coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore. She has disclosed no relevant financial relationships.

“It is one of life’s most self-evident truths that everything fades, that we fear the fading, and that we must live, nonetheless, in the face of the fear.” – Irvin D. Yalom, MD, Existential Psychotherapy, 1980

The email was titled simply, “A sorrowful note,” and I knew that someone had died. I held my breath and read as Dr. Jimmy Potash informed our entire department that Dr. Cait McFarland died in a car accident on December 7 while driving to work at West Cecil Health Center, Conowingo, Md., where she was director of psychiatry.

Sadness swelled as I remembered the outspoken resident who was interested in LGBTQ issues. Cait graduated from the Johns Hopkins residency program in 2020, she had recently married a social worker in the department, and the plan was for her to return to Hopkins full-time in July 2023 to be director of a clinic focused on mental health for people who are transgendered.

Sudden deaths are tragic and jarring and they call to the surface our losses from the past. These deaths don’t stand alone – I found myself thinking of my editor at Medscape, Dr. Bret Stetka, who died unexpectedly in August 2022, and then of Dr. Lidia Palcan Wenz, a psychiatrist I trained with, who died in a motor vehicle accident in 2004. Lidia’s husband also died in the accident, while their two young children in the back seat survived – this tragedy haunted me for some time. None of these people was close to me, but I am no stranger to the impact of unexpected death: My parents and brother all died from cardiac events, and any sudden death is a reminder of those losses.

Julia Riddle, MD, trained with Cait McFarland and was her close friend for years. “I don’t have a belief in ‘the afterlife’ but do like to think of the people that I have lost together in my memory – as if they are all suddenly in a new room together. And, with each loss, all the other occupants of that room come freshly to life again,” Dr. Riddle said.

Death is our shared destination in life, but sudden and unexpected deaths carry their own weight. There is no chance to tie up loose ends, to repair riffs, to say goodbye. Nothing is put in order, and the life that was to be lived goes on for some time as bills arrive, social and work events go unattended, vacations are canceled, and there is the awkward moment of running into someone who didn’t know your loved one has died.

Roger Lewin, MD, is a psychiatrist and writer in Towson, Md. He has both personal and professional experience with sudden death. “There is no way to prepare beforehand, so we have to get ready for what has already happened, and that is hard,” he said. “We invent a life for ourselves and others that extends into the future, and that gets interrupted.”

Most people become ill and die on a vaguely predictable schedule. There may be a chance to plan, to know and honor the wishes of the individual, and often there is the opportunity for loved ones to begin the grieving process gradually as death approaches. For those who are elderly, there may be a sense that this is the natural order of things – which may or may not temper the intensity of the grief for those who remain. If the person has suffered, the end may come with relief.

Still, I sometimes find myself surprised at the length and intensity of anguish that some people experience after losing a loved one who has lived a long and full life, who declined and suffered, but whose absence remains a gaping wound that takes years to form a scar.

Sudden death is not rare; accidents, homicide, and suicide are the top killers among young people, and cardiovascular deaths are number one among those who are older. Natural disasters and terrorist attacks can cause catastrophic numbers of sudden deaths and leave survivors to grieve not only the dead, but the loss of all that was familiar to them.

Psychiatry has been a bit lost as to how we approach grief. We often hear patients talk about anxiety surrounding death and illness, be it a fear of death or a longing for it. These fears can seem irrational – I am reminded of a patient who was afraid to eat romaine because of news reports that it was responsible for food poisoning in other states, but not Maryland, where the person lived. I found it odd that he worried about eating lettuce, but not about smoking two packs of cigarettes a day.

But our fears are like that – they move to what the media sensationalizes, or to what may be remote, because otherwise no one would get in a car or clear their walkway of snow. Life is most easily lived with a bit of denial: We shut out the reality that we can be here one moment, overscheduled and overwhelmed, with deadlines, mortgage payments, and summer vacation plans, oblivious to the fact that life may end at any moment. The early months of COVID-19 felt like a global game of Russian roulette, with each venture out a pull of the trigger and everyone’s defenses stripped bare.

While death belongs to us all, we relegate it to the disciplines of religion, philosophy, the arts, and psychology. Religion offers answers – whether a heaven, a hell, or continual reincarnation until the individual attains enlightenment, there is a destination. Perhaps it will be pleasant, perhaps not, and for some there is the hope that one gets to be the driver by having the right beliefs or doing good deeds, while others are comforted by the hope of being reunited with loved ones.

“The suddenness endures and the shock lasts – it’s like a meteor that creates a crater and we revisit it in different ways from different angles,” Dr. Lewin said. “It may leap on us unexpectedly, often many years later.”

Patients talk about death, and when their fears seem unrealistic we may long to reassure them, yet there is no reassurance and psychiatry grasps for how to help. Psychiatry has looked to draw lines for when normal grief crosses to abnormal. Is it an adjustment disorder, complicated grief, “prolonged” grief, pathology in need of medication and medicalization, or something one experiences individually, sometimes for a very long time even with treatment?

One justification for pathologizing “prolonged” reactions includes the fact that insurers will pay for treatment only if there is a diagnosis code, and shouldn’t people in distress be entitled to psychotherapy or medication? Yet there is something offensive about telling someone that they are mentally ill if they don’t grieve along a prescribed timeline, as much as there is about denying them the possible benefits of therapy or medication if they seek it, but are suffering in all the “right” ways. Psychiatry’s approach to death is inelegant at best.

In his poignant podcast series, All There Is, Anderson Cooper is tasked with sorting through his mother’s apartment after her death at age 95. In the course of packing up her belongings, he brings on other guests to talk about their emotional reactions to death. Mr. Cooper’s mother, Gloria Vanderbilt, died at an advanced age, but his father died after a brief cardiac illness when Mr. Cooper was a child, and his brother died by suicide when he was 21. He uses these experiences as a springboard to examine childhood losses, the aftermath of suicide, and the loneliness of grief.

“Loss and grief is this universal experience that we will all go through multiple times in our lives,” Mr. Cooper says, “And yet it leaves us feeling so alone and so separated from other people. At least it does me and has my entire life.”

When we talk about grief and loss, we talk about “getting over it,” or “moving on.” But loss doesn’t work that way – time usually eases the pain, leaving scars that are part of the road map for who we are on the journey that defines us.

Sudden death is hard, and the unexpected death of a young person is tragic. For Cait McFarland, there are the decades she won’t get to experience. For her family and friends, it may be excruciating, and for all the patients who have lost a psychiatrist, may time bring healing and peace.

The Dr. Caitlin McFarland Educational Fund for LGBTQI+ Mental Health is being established, and donations are being accepted at https://www.gofundme.com/f/in-memory-of-cait-mcfarland.

Dr. Miller is a coauthor of “Committed: The Battle Over Involuntary Psychiatric Care” (Johns Hopkins University Press, 2016). She has a private practice and is assistant professor of psychiatry and behavioral sciences at Johns Hopkins University, Baltimore. She has disclosed no relevant financial relationships.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more informa tion, contact [email protected].

Lithium carbonate is a mood stabilizer that is effective in the treatment of bipolar disorder, particularly in controlling mania.¹ Lithium can reduce the risk of suicide,² treat aggression and self-mutilating behavior,³ and prevent steroid-induced psychosis.⁴ It also can raise the white cell count in patients with clozapine-induced leukopenia.⁵

To prevent or lower the risk of relapse, the therapeutic plasma level of lithium should be regularly monitored to ensure an optimal concentration in the CNS. The highest tolerable level of lithium in the plasma is 0.6 to 0.8 mmol/L, with the optimal level ranging up to 1.2 mmol/L.⁶ Regular monitoring of renal function is also required to prevent renal toxicity, particularly if the plasma level exceeds 0.8 mmol/L.⁷ Because of lithium’s relatively narrow therapeutic index, its interaction with other medications, such as angiotensin-converting enzyme inhibitors, diuretics, nonsteroidal anti-inflammatory drugs (NSAIDs), and carbamazepine, can also precipitate lithium toxicity.⁸ We describe a lesson learned from a case of lithium toxicity in an otherwise healthy patient with bipolar disorder.

Case report

An otherwise healthy 39-year-old woman diagnosed with bipolar type I disorder was receiving valproate sodium 600 mg/d and olanzapine 10 mg/d. Despite improvement in her mood, she gained 11.6 kg following 6 months of treatment. As a result, olanzapine was switched to aripiprazole 10 mg/d that was later increased to 15 mg/d, and sodium valproate was gradually optimized up to 1,000 mg/d. She later complained of hair thinning and hair loss so she self-adjusted her medication dosages, which resulted in frequent relapses. Her mood stabilizer was changed from sodium valproate to lithium 600 mg/d.

Unfortunately, after taking lithium for 15 days, she returned to us with fever associated with reduced oral intake, poor sleep, bilateral upper limb rigidity, and bilateral hand tremor. She also complained of extreme thirst and fatigue but no vomiting or diarrhea. She had difficulty falling asleep and slept for only 1 to 2 hours a day. Her symptoms worsened when a general practitioner prescribed NSAIDs for her fever and body ache. Her tremors were later generalized, which made it difficult for her to take her oral medications and disturbed her speech and movement.

On evaluation, our patient appeared comfortable and not agitated. She was orientated to time, place, and person. Her blood pressure was 139/89 mmHg, heart rate was 104 bpm, and she was afebrile. She was dehydrated with minimal urine output. She had coarse tremor in her upper and lower limbs, which were hypertonic but did not display hyperreflexia or clonus. There was no nystagmus or ataxia. A mental state examination showed no signs of manic, hypomanic, or depressive symptoms. She had slurred speech, and her affect was restricted.

Blood investigation revealed a suprathreshold lithium level of 1.70 mmol/L (normal: 0.8 to 1.2 mmol/L). Biochemical parameters showed evidence of acute kidney injury (urea: 6.1 mmol/L; creatinine: 0.140 mmol/L), with no electrolyte imbalance. There was no evidence of hypothyroidism (thyroid-stimulating hormone: 14.9 mIU/L; free thyroxine: 9.9 pmol/L), hyperparathyroidism, or hypercalcemia. Autoimmune markers were positive for antinuclear antibody (titre 1:320) and anti-double stranded DNA (76.8 IU/mL). Apart from hair loss, she denied other symptoms associated with autoimmune disease, such as joint pain, butterfly rash, or persistent fatigue. Other routine blood investigations were within normal limits. Her urine protein throughout admission had shown persistent proteinuria ranging from 3+ to 4+. Electrocardiogram (ECG) showed normal sinus rhythm with no T wave inversion or QT prolongation.

Continue to: A detailed family history...

A detailed family history later confirmed a strong family history of renal disease: her mother had lupus nephritis with nephrotic syndrome, and her brother had died from complications of a rapidly progressive glomerulonephritis. Her renal function prior to lithium initiation was within normal limits (urea: 4.0 mmol/L; serum creatinine: 78 µmol/L).

In the ward, lithium and aripiprazole were discontinued, and she was hydrated. Combined care with the psychiatric and medical teams was established early to safeguard against potential CNS deterioration. She showed marked clinical improvement by Day 3, with the resolution of coarse tremor and rigidity as well as normalization of blood parameters. Her lithium level returned to a therapeutic level by Day 4 after lithium discontinuation, and her renal profile gradually normalized. She was restarted on aripiprazole 10 mg/d for her bipolar illness and responded well. She was discharged on Day 5 with a referral to the nephrology team for further intervention.

Lessons learned

This case highlights the issue of lithium safety in susceptible individuals and the importance of risk stratification in this group of patients. Lithium is an effective treatment for bipolar I disorder and has also been used as adjunctive treatment for major depressive disorder, schizoaffective disorder, treatment-resistant schizophrenia, anorexia nervosa and bulimia nervosa, and the control of chronic aggression.⁹ Lithium is completely absorbed by the gastrointestinal tract following ingestion, is not metabolized, and is eliminated almost entirely by the kidneys (though trace amounts may be found in feces and perspiration).

In our case, a detailed family history of renal disease was not adequately explored until our patient presented with signs suggestive of lithium toxicity. Our patient had been prescribed lithium 600 mg/d as a maintenance therapy. Upon starting lithium, her baseline biochemical parameters were within normal limits, and renal issues were not suspected. The hair thinning and hair loss she experienced could have been an adverse effect of valproate sodium or a manifestation of an underlying autoimmune disease. Coupled with the use of NSAIDs that could have precipitated acute kidney injury, her poor oral intake and dehydration during the acute illness further impaired lithium excretion, leading to a suprathreshold plasma level despite a low dose of lithium. Therefore, before prescribing lithium, a thorough medical and family history is needed, supplemented by an evaluation of renal function, serum electrolytes, and thyroid function to determine the starting dosage of lithium. Routine vital sign assessment and ECG should also be conducted, and concurrent medications and pregnancy status should be confirmed before prescribing lithium. Regular lithium level monitoring is essential.

Measuring a patient’s estimated glomerular filtration rate (eGFR) is recommended to validate renal status¹⁰ and classify and stage kidney disease.¹¹ Combining eGFR with blood urea nitrogen, serum creatinine, and urine microscopic analysis further improves the prediction of renal disease in early stages. We recommend considering a blood test for autoimmune markers in patients with clinical suspicion of autoimmune disease, in the presence of suggestive signs and symptoms, and/or in patients with a positive family history (Table).

Before starting lithium, in addition to conducting a detailed clinical evaluation, information about symptoms and the risk of lithium toxicity should be discussed with patients.¹² Our case serves as a timely reminder that the lack of suggestive biochemical parameters of renal disease should not rule out an underlying renal disease, and a strong family history of renal disease should warrant suspicion of a possible autoimmune origin.

We suggest that future studies evaluate the risks of lithium toxicity in susceptible groups of patients, such as those with family history of renal disease.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more informa tion, contact [email protected].

Lithium carbonate is a mood stabilizer that is effective in the treatment of bipolar disorder, particularly in controlling mania.¹ Lithium can reduce the risk of suicide,² treat aggression and self-mutilating behavior,³ and prevent steroid-induced psychosis.⁴ It also can raise the white cell count in patients with clozapine-induced leukopenia.⁵

To prevent or lower the risk of relapse, the therapeutic plasma level of lithium should be regularly monitored to ensure an optimal concentration in the CNS. The highest tolerable level of lithium in the plasma is 0.6 to 0.8 mmol/L, with the optimal level ranging up to 1.2 mmol/L.⁶ Regular monitoring of renal function is also required to prevent renal toxicity, particularly if the plasma level exceeds 0.8 mmol/L.⁷ Because of lithium’s relatively narrow therapeutic index, its interaction with other medications, such as angiotensin-converting enzyme inhibitors, diuretics, nonsteroidal anti-inflammatory drugs (NSAIDs), and carbamazepine, can also precipitate lithium toxicity.⁸ We describe a lesson learned from a case of lithium toxicity in an otherwise healthy patient with bipolar disorder.

Case report

An otherwise healthy 39-year-old woman diagnosed with bipolar type I disorder was receiving valproate sodium 600 mg/d and olanzapine 10 mg/d. Despite improvement in her mood, she gained 11.6 kg following 6 months of treatment. As a result, olanzapine was switched to aripiprazole 10 mg/d that was later increased to 15 mg/d, and sodium valproate was gradually optimized up to 1,000 mg/d. She later complained of hair thinning and hair loss so she self-adjusted her medication dosages, which resulted in frequent relapses. Her mood stabilizer was changed from sodium valproate to lithium 600 mg/d.

Unfortunately, after taking lithium for 15 days, she returned to us with fever associated with reduced oral intake, poor sleep, bilateral upper limb rigidity, and bilateral hand tremor. She also complained of extreme thirst and fatigue but no vomiting or diarrhea. She had difficulty falling asleep and slept for only 1 to 2 hours a day. Her symptoms worsened when a general practitioner prescribed NSAIDs for her fever and body ache. Her tremors were later generalized, which made it difficult for her to take her oral medications and disturbed her speech and movement.

On evaluation, our patient appeared comfortable and not agitated. She was orientated to time, place, and person. Her blood pressure was 139/89 mmHg, heart rate was 104 bpm, and she was afebrile. She was dehydrated with minimal urine output. She had coarse tremor in her upper and lower limbs, which were hypertonic but did not display hyperreflexia or clonus. There was no nystagmus or ataxia. A mental state examination showed no signs of manic, hypomanic, or depressive symptoms. She had slurred speech, and her affect was restricted.

Blood investigation revealed a suprathreshold lithium level of 1.70 mmol/L (normal: 0.8 to 1.2 mmol/L). Biochemical parameters showed evidence of acute kidney injury (urea: 6.1 mmol/L; creatinine: 0.140 mmol/L), with no electrolyte imbalance. There was no evidence of hypothyroidism (thyroid-stimulating hormone: 14.9 mIU/L; free thyroxine: 9.9 pmol/L), hyperparathyroidism, or hypercalcemia. Autoimmune markers were positive for antinuclear antibody (titre 1:320) and anti-double stranded DNA (76.8 IU/mL). Apart from hair loss, she denied other symptoms associated with autoimmune disease, such as joint pain, butterfly rash, or persistent fatigue. Other routine blood investigations were within normal limits. Her urine protein throughout admission had shown persistent proteinuria ranging from 3+ to 4+. Electrocardiogram (ECG) showed normal sinus rhythm with no T wave inversion or QT prolongation.

Continue to: A detailed family history...

A detailed family history later confirmed a strong family history of renal disease: her mother had lupus nephritis with nephrotic syndrome, and her brother had died from complications of a rapidly progressive glomerulonephritis. Her renal function prior to lithium initiation was within normal limits (urea: 4.0 mmol/L; serum creatinine: 78 µmol/L).

In the ward, lithium and aripiprazole were discontinued, and she was hydrated. Combined care with the psychiatric and medical teams was established early to safeguard against potential CNS deterioration. She showed marked clinical improvement by Day 3, with the resolution of coarse tremor and rigidity as well as normalization of blood parameters. Her lithium level returned to a therapeutic level by Day 4 after lithium discontinuation, and her renal profile gradually normalized. She was restarted on aripiprazole 10 mg/d for her bipolar illness and responded well. She was discharged on Day 5 with a referral to the nephrology team for further intervention.

Lessons learned

This case highlights the issue of lithium safety in susceptible individuals and the importance of risk stratification in this group of patients. Lithium is an effective treatment for bipolar I disorder and has also been used as adjunctive treatment for major depressive disorder, schizoaffective disorder, treatment-resistant schizophrenia, anorexia nervosa and bulimia nervosa, and the control of chronic aggression.⁹ Lithium is completely absorbed by the gastrointestinal tract following ingestion, is not metabolized, and is eliminated almost entirely by the kidneys (though trace amounts may be found in feces and perspiration).

In our case, a detailed family history of renal disease was not adequately explored until our patient presented with signs suggestive of lithium toxicity. Our patient had been prescribed lithium 600 mg/d as a maintenance therapy. Upon starting lithium, her baseline biochemical parameters were within normal limits, and renal issues were not suspected. The hair thinning and hair loss she experienced could have been an adverse effect of valproate sodium or a manifestation of an underlying autoimmune disease. Coupled with the use of NSAIDs that could have precipitated acute kidney injury, her poor oral intake and dehydration during the acute illness further impaired lithium excretion, leading to a suprathreshold plasma level despite a low dose of lithium. Therefore, before prescribing lithium, a thorough medical and family history is needed, supplemented by an evaluation of renal function, serum electrolytes, and thyroid function to determine the starting dosage of lithium. Routine vital sign assessment and ECG should also be conducted, and concurrent medications and pregnancy status should be confirmed before prescribing lithium. Regular lithium level monitoring is essential.

Measuring a patient’s estimated glomerular filtration rate (eGFR) is recommended to validate renal status¹⁰ and classify and stage kidney disease.¹¹ Combining eGFR with blood urea nitrogen, serum creatinine, and urine microscopic analysis further improves the prediction of renal disease in early stages. We recommend considering a blood test for autoimmune markers in patients with clinical suspicion of autoimmune disease, in the presence of suggestive signs and symptoms, and/or in patients with a positive family history (Table).

Before starting lithium, in addition to conducting a detailed clinical evaluation, information about symptoms and the risk of lithium toxicity should be discussed with patients.¹² Our case serves as a timely reminder that the lack of suggestive biochemical parameters of renal disease should not rule out an underlying renal disease, and a strong family history of renal disease should warrant suspicion of a possible autoimmune origin.

We suggest that future studies evaluate the risks of lithium toxicity in susceptible groups of patients, such as those with family history of renal disease.

Editor’s note: Readers’ Forum is a department for correspondence from readers that is not in response to articles published in Current Psychiatry . All submissions to Readers’ Forum undergo peer review and are subject to editing for length and style. For more informa tion, contact [email protected].

Lithium carbonate is a mood stabilizer that is effective in the treatment of bipolar disorder, particularly in controlling mania.¹ Lithium can reduce the risk of suicide,² treat aggression and self-mutilating behavior,³ and prevent steroid-induced psychosis.⁴ It also can raise the white cell count in patients with clozapine-induced leukopenia.⁵

To prevent or lower the risk of relapse, the therapeutic plasma level of lithium should be regularly monitored to ensure an optimal concentration in the CNS. The highest tolerable level of lithium in the plasma is 0.6 to 0.8 mmol/L, with the optimal level ranging up to 1.2 mmol/L.⁶ Regular monitoring of renal function is also required to prevent renal toxicity, particularly if the plasma level exceeds 0.8 mmol/L.⁷ Because of lithium’s relatively narrow therapeutic index, its interaction with other medications, such as angiotensin-converting enzyme inhibitors, diuretics, nonsteroidal anti-inflammatory drugs (NSAIDs), and carbamazepine, can also precipitate lithium toxicity.⁸ We describe a lesson learned from a case of lithium toxicity in an otherwise healthy patient with bipolar disorder.

Case report

An otherwise healthy 39-year-old woman diagnosed with bipolar type I disorder was receiving valproate sodium 600 mg/d and olanzapine 10 mg/d. Despite improvement in her mood, she gained 11.6 kg following 6 months of treatment. As a result, olanzapine was switched to aripiprazole 10 mg/d that was later increased to 15 mg/d, and sodium valproate was gradually optimized up to 1,000 mg/d. She later complained of hair thinning and hair loss so she self-adjusted her medication dosages, which resulted in frequent relapses. Her mood stabilizer was changed from sodium valproate to lithium 600 mg/d.

Unfortunately, after taking lithium for 15 days, she returned to us with fever associated with reduced oral intake, poor sleep, bilateral upper limb rigidity, and bilateral hand tremor. She also complained of extreme thirst and fatigue but no vomiting or diarrhea. She had difficulty falling asleep and slept for only 1 to 2 hours a day. Her symptoms worsened when a general practitioner prescribed NSAIDs for her fever and body ache. Her tremors were later generalized, which made it difficult for her to take her oral medications and disturbed her speech and movement.

On evaluation, our patient appeared comfortable and not agitated. She was orientated to time, place, and person. Her blood pressure was 139/89 mmHg, heart rate was 104 bpm, and she was afebrile. She was dehydrated with minimal urine output. She had coarse tremor in her upper and lower limbs, which were hypertonic but did not display hyperreflexia or clonus. There was no nystagmus or ataxia. A mental state examination showed no signs of manic, hypomanic, or depressive symptoms. She had slurred speech, and her affect was restricted.

Blood investigation revealed a suprathreshold lithium level of 1.70 mmol/L (normal: 0.8 to 1.2 mmol/L). Biochemical parameters showed evidence of acute kidney injury (urea: 6.1 mmol/L; creatinine: 0.140 mmol/L), with no electrolyte imbalance. There was no evidence of hypothyroidism (thyroid-stimulating hormone: 14.9 mIU/L; free thyroxine: 9.9 pmol/L), hyperparathyroidism, or hypercalcemia. Autoimmune markers were positive for antinuclear antibody (titre 1:320) and anti-double stranded DNA (76.8 IU/mL). Apart from hair loss, she denied other symptoms associated with autoimmune disease, such as joint pain, butterfly rash, or persistent fatigue. Other routine blood investigations were within normal limits. Her urine protein throughout admission had shown persistent proteinuria ranging from 3+ to 4+. Electrocardiogram (ECG) showed normal sinus rhythm with no T wave inversion or QT prolongation.

Continue to: A detailed family history...

A detailed family history later confirmed a strong family history of renal disease: her mother had lupus nephritis with nephrotic syndrome, and her brother had died from complications of a rapidly progressive glomerulonephritis. Her renal function prior to lithium initiation was within normal limits (urea: 4.0 mmol/L; serum creatinine: 78 µmol/L).

In the ward, lithium and aripiprazole were discontinued, and she was hydrated. Combined care with the psychiatric and medical teams was established early to safeguard against potential CNS deterioration. She showed marked clinical improvement by Day 3, with the resolution of coarse tremor and rigidity as well as normalization of blood parameters. Her lithium level returned to a therapeutic level by Day 4 after lithium discontinuation, and her renal profile gradually normalized. She was restarted on aripiprazole 10 mg/d for her bipolar illness and responded well. She was discharged on Day 5 with a referral to the nephrology team for further intervention.

Lessons learned

This case highlights the issue of lithium safety in susceptible individuals and the importance of risk stratification in this group of patients. Lithium is an effective treatment for bipolar I disorder and has also been used as adjunctive treatment for major depressive disorder, schizoaffective disorder, treatment-resistant schizophrenia, anorexia nervosa and bulimia nervosa, and the control of chronic aggression.⁹ Lithium is completely absorbed by the gastrointestinal tract following ingestion, is not metabolized, and is eliminated almost entirely by the kidneys (though trace amounts may be found in feces and perspiration).

In our case, a detailed family history of renal disease was not adequately explored until our patient presented with signs suggestive of lithium toxicity. Our patient had been prescribed lithium 600 mg/d as a maintenance therapy. Upon starting lithium, her baseline biochemical parameters were within normal limits, and renal issues were not suspected. The hair thinning and hair loss she experienced could have been an adverse effect of valproate sodium or a manifestation of an underlying autoimmune disease. Coupled with the use of NSAIDs that could have precipitated acute kidney injury, her poor oral intake and dehydration during the acute illness further impaired lithium excretion, leading to a suprathreshold plasma level despite a low dose of lithium. Therefore, before prescribing lithium, a thorough medical and family history is needed, supplemented by an evaluation of renal function, serum electrolytes, and thyroid function to determine the starting dosage of lithium. Routine vital sign assessment and ECG should also be conducted, and concurrent medications and pregnancy status should be confirmed before prescribing lithium. Regular lithium level monitoring is essential.

Measuring a patient’s estimated glomerular filtration rate (eGFR) is recommended to validate renal status¹⁰ and classify and stage kidney disease.¹¹ Combining eGFR with blood urea nitrogen, serum creatinine, and urine microscopic analysis further improves the prediction of renal disease in early stages. We recommend considering a blood test for autoimmune markers in patients with clinical suspicion of autoimmune disease, in the presence of suggestive signs and symptoms, and/or in patients with a positive family history (Table).

Before starting lithium, in addition to conducting a detailed clinical evaluation, information about symptoms and the risk of lithium toxicity should be discussed with patients.¹² Our case serves as a timely reminder that the lack of suggestive biochemical parameters of renal disease should not rule out an underlying renal disease, and a strong family history of renal disease should warrant suspicion of a possible autoimmune origin.

We suggest that future studies evaluate the risks of lithium toxicity in susceptible groups of patients, such as those with family history of renal disease.

Editor’s note: This article was adapted with permission from a version originally published in the Ohio Psychiatric Physician Association’s newsletter, Insight Matters, Fall 2022.

Acknowledging and analyzing strengths, weaknesses, opportunities, and threats (SWOT) is an important tactic many organizations use to develop a strategic plan to grow, move forward, and thrive. A SWOT analysis can provide a “big picture” view of the status and the desired future directions not only for companies but for medical disciplines such as psychiatry. So here are my perspectives on psychiatry’s strengths, weaknesses, opportunities, and threats. It is a work in progress, and I welcome (and encourage) you to send additional items or comments to me at [email protected].

Strengths

• The American Psychiatric Association (APA) is the oldest medical professional organization, established in 1844 (3 years before the American Medical Association)¹
• Strong organizational structure and governance, and a “big tent” with several tiers of membership
• Effective, member-driven District Branches
• The medical identity at the core of psychiatry—we are psychiatric physicians²
• Escalating number of senior medical students choosing psychiatry as a career, far more than a decade ago
• High demand for psychiatrists in all settings around the country
• Increased compensation for psychiatrists (market forces of supply and demand)
• Psychiatry is continuously evolving and reinventing itself: seismic shifts in etiopathogenesis, disease conceptualization, terminology, and therapies (4 major shifts over the past century)³
• An abundant body of evidence supporting that all psychiatric disorders are brain disorders and transdiagnostic in nature⁴
• Many vibrant subspecialty societies
• Substantial number of Tier 1, evidence-based treatments
• Novel mechanisms of action and treatment strategies are being introduced on a regular basis for psychotic and mood disorders^5,6
• Advances in neuromodulation techniques to treat a wide spectrum of psychiatric disorders, including electroconvulsive therapy, transcranial magnetic stimulation, vagus nerve stimulation, transcranial direct current stimulation, deep brain stimulation, cranial electric stimulation, epidural cortical stimulation, focused ultrasound, low field magnetic stimulation, magnetic seizure therapy, and near infrared light therapy, with mechanisms that are electric, ultrasound, magnetic, or optical^7,8
• Psychiatric physicians develop wisdom by practicing psychiatry (ie, they become more empathic, tolerant of ambiguity, prosocial, introspective, aware of one’s strengths and limitations). Neuroplasticity in the frontal cortex is triggered by conducting psychotherapy⁹

Weaknesses

• Shrinking workforce due to a static number of residency training slots for 40 years¹⁰
• High rate of retirement by aging psychiatrists
• Persistent stigma around mental disorders despite massive scientific and medical advances¹¹
• Still no real parity! We need succinct laws with “teeth”¹²
• Demedicalization in the public sector, referring to psychiatric physicians as “providers” and labeling patients as “clients”²
• Not enough graduating residents choosing to do subspecialty fellowships (especially geriatric, addiction, psychosomatic psychiatry) to meet escalating societal needs
• Very low presence in rural areas (both psychiatrists and psychiatric hospitals)
• Persistent APA member apathy: only 10% to 15% vote in the APA national elections or volunteer to serve on committees
• Widespread member dissatisfaction with maintenance of certification
• Neuroscience advances are not being translated fast enough for practical clinical applications
• Many in the public at large do not realize psychiatric symptoms are generated from anomalous brain circuits or that psychiatric disorders are highly genetic but also have environmental and epigenetic etiologies
• The DSM diagnostic system needs a paradigm shift: it is still based on a menu of clinical signs and symptoms and is devoid of objective diagnostic measures such as biomarkers⁴
• Neuroscience literacy among busy psychiatric practitioners is insufficient at a time of explosive growth in basic and clinical neuroscience¹³
• No effective treatment for alcohol or substance use disorders despite their very high morbidity and mortality
• Major psychiatric disorders are still associated with significant disability (schizophrenia, bipolar disorder, major depressive disorder, anxiety disorders, eating disorders, substance use disorders)
• Suicide rate (other than opioid deaths) has continued to rise in the past 3 decades¹⁴

Opportunities

• Potentially momentous clinical applications of the neuroscience breakthroughs
• Collaborative care with primary care physicians and increasing colocalization
• Dramatic increase in public awareness about the importance of mental health due to the COVID-19 pandemic¹⁵
• Powerful new data management tools, including machine learning, artificial intelligence, super computers, big data, deep learning, nanotechnology, and metabolomics, all of which are expediting neurobiological discoveries¹⁶
• The potential of reclassifying psychiatric disorders as neurological disorders, which will improve reimbursement for patient health care and reduce stigma¹⁷
• Emergence of new mechanisms of action of disease etiology, such as microbiota, mitochondrial dysfunction, permeable blood-brain barrier, and neuroimmune dysregulation^18,19
• The advent and growth of “precision psychiatry”²⁰
• The tremendous potential of molecular genetics and gene therapy for psychiatric disorders, most of which are genetic in etiology
• Expanding applications of neuroimaging techniques, including morphological, spectroscopic, functional, diffusion tensor imaging, and receptor imaging²¹
• Epigenetic advances in neuropsychiatric disorders
• Remarkably powerful research methods, such as pluripotent cells (producing neurons from skin cells), optogenetics (activating genes with light), gene-wide association studies, CRISPR (clustered regularly interspaced short palindromic repeats, which serve as genetic scissors to remove and replace abnormal genes), and brain connectomics²²
• Psychiatry should develop and promote an “annual mental health checkup” for all age groups, similar to an annual physical exam²³
• Focus on the social determinants of health
• Address the unmet mental health needs of individuals who are members of minority groups
• Lobby ferociously for a much larger budget for the National Institute of Mental Health to advance funding for research of serious psychiatric brain disorders
• Remind Congress continuously that the cost of mental illness is $700 billion annually and costs can only be reduced by funding neurobiological research¹
• Partner with the pharmaceutical industry instead of demonizing them. They are the only entity that develops medication for psychiatry, where 80% of disorders have no FDA-approved drugs.²⁴ Without the pharmaceutical industry and the help of medications, many psychiatric patients would still be institutionalized and unable to lead a normal life. We must recognize the contributions of pharmaceutical companies to the health of our patients, similar to the warp speed development of vaccines for the deadly coronavirus
• Psychiatric clinicians must refer patients to clinical trials because without patients enrolling in FDA studies, no drug developments can take place
• Many “out-of-the-box” therapies are being developed, such as antiapoptotic therapy, microglia inhibition, mitochondrial repair, white matter fiber remyelination, neuroprotection, and reversing N-methyl-d-aspartate receptor hypofunction²⁵
• The emerging evidence that psychotherapy is in fact a biological treatment that induces brain changes (neuroplasticity) and can modulate the immune system²⁶
• Druggable genes, providing innovative new medications²⁷
• Reposition psychedelics as revolutionary new treatments²⁸
• Emphasize measurement-based care (rating scales), which can upgrade patient care²⁹
• Because psychosis is associated with brain tissue loss, just like heart attacks are associated with myocardium destruction, psychiatrists must act like cardiologists³⁰ and treat psychotic episodes urgently, like a stroke,³¹ to reduce the duration of untreated psychosis and improve patient outcomes

Threats

• Antipsychiatry cults continue to disparage and attack psychiatry³²
• Health delivery systems are replacing psychiatric physicians with nurse practitioners to lower costs, regardless of quality and experience, and they inappropriately lump them together as “providers”²
• Psychologists continue to seek prescribing privileges with absurdly sketchy, predominantly online training supervised by other psychologists³³
• Many legislators and policymakers, as well as the public, still don’t understand the difference between psychiatrists and psychologists, and the extensively disparate medical training in quality and quantity
• A dearth of psychiatric physician-scientists because very few residents are pursuing research fellowships after training³⁴
• Disproportionate emphasis on clinical care and generating clinical revenue (relative value units) in academic institutions, with fewer tenure-track faculty members having protected time to write grants for federal or foundation grants to support their salaries and research operations³⁵
• Meager financial support for teaching in psychiatry departments
• Many seriously psychiatrically ill persons do not have access to psychiatric medical care (and often to primary care as well)
• Many in the public falsely believe psychiatric disorders are hopeless and untreatable, which perpetuates stigma
• Long-acting injectable antipsychotic formulations are not used early enough in patients with psychosis, who are known to have a high nonadherence rate with oral medications following discharge from their first hospitalization. This leads to many recurrences with multiple devastating consequences, including progressive brain tissue loss, treatment resistance, disability, incarceration, and suicide³⁶
• Many clinicians do not have full-text access to all studies indexed in PubMed, which is vital for lifelong learning in a rapidly growing medical discipline such as psychiatry
• Psychiatrists are often unable to prescribe medications shortly after they are approved by the FDA due to the insurance companies’ outrageous preauthorization racket that enforces a fail-first policy with cheaper generics, even if generic medications are associated with safety and tolerability problems³⁷
• The continued use of decades-old first-generation antipsychotic medications despite 32 published studies reporting their neurotoxicity and the death of brain cells³⁸

Using this analysis to benefit our patients

Despite its strengths, psychiatry must overcome its weaknesses, fend off its threats, and exploit its many opportunities. The only way to do that is for psychiatrists to unify and for the APA to provide inspired leadership to achieve the aspirational goals of our field. However, we must adopt “moonshot thinking”³⁹ to magnify the Ss, diminish the Ws, exploit the Os, and stave off the Ts of our SWOT, thereby attaining all our cherished and lofty goals. Ultimately, the greatest beneficiaries will be our patients.

Editor’s note: This article was adapted with permission from a version originally published in the Ohio Psychiatric Physician Association’s newsletter, Insight Matters, Fall 2022.

Acknowledging and analyzing strengths, weaknesses, opportunities, and threats (SWOT) is an important tactic many organizations use to develop a strategic plan to grow, move forward, and thrive. A SWOT analysis can provide a “big picture” view of the status and the desired future directions not only for companies but for medical disciplines such as psychiatry. So here are my perspectives on psychiatry’s strengths, weaknesses, opportunities, and threats. It is a work in progress, and I welcome (and encourage) you to send additional items or comments to me at [email protected].

Strengths

• The American Psychiatric Association (APA) is the oldest medical professional organization, established in 1844 (3 years before the American Medical Association)¹
• Strong organizational structure and governance, and a “big tent” with several tiers of membership
• Effective, member-driven District Branches
• The medical identity at the core of psychiatry—we are psychiatric physicians²
• Escalating number of senior medical students choosing psychiatry as a career, far more than a decade ago
• High demand for psychiatrists in all settings around the country
• Increased compensation for psychiatrists (market forces of supply and demand)
• Psychiatry is continuously evolving and reinventing itself: seismic shifts in etiopathogenesis, disease conceptualization, terminology, and therapies (4 major shifts over the past century)³
• An abundant body of evidence supporting that all psychiatric disorders are brain disorders and transdiagnostic in nature⁴
• Many vibrant subspecialty societies
• Substantial number of Tier 1, evidence-based treatments
• Novel mechanisms of action and treatment strategies are being introduced on a regular basis for psychotic and mood disorders^5,6
• Advances in neuromodulation techniques to treat a wide spectrum of psychiatric disorders, including electroconvulsive therapy, transcranial magnetic stimulation, vagus nerve stimulation, transcranial direct current stimulation, deep brain stimulation, cranial electric stimulation, epidural cortical stimulation, focused ultrasound, low field magnetic stimulation, magnetic seizure therapy, and near infrared light therapy, with mechanisms that are electric, ultrasound, magnetic, or optical^7,8
• Psychiatric physicians develop wisdom by practicing psychiatry (ie, they become more empathic, tolerant of ambiguity, prosocial, introspective, aware of one’s strengths and limitations). Neuroplasticity in the frontal cortex is triggered by conducting psychotherapy⁹

Weaknesses

• Shrinking workforce due to a static number of residency training slots for 40 years¹⁰
• High rate of retirement by aging psychiatrists
• Persistent stigma around mental disorders despite massive scientific and medical advances¹¹
• Still no real parity! We need succinct laws with “teeth”¹²
• Demedicalization in the public sector, referring to psychiatric physicians as “providers” and labeling patients as “clients”²
• Not enough graduating residents choosing to do subspecialty fellowships (especially geriatric, addiction, psychosomatic psychiatry) to meet escalating societal needs
• Very low presence in rural areas (both psychiatrists and psychiatric hospitals)
• Persistent APA member apathy: only 10% to 15% vote in the APA national elections or volunteer to serve on committees
• Widespread member dissatisfaction with maintenance of certification
• Neuroscience advances are not being translated fast enough for practical clinical applications
• Many in the public at large do not realize psychiatric symptoms are generated from anomalous brain circuits or that psychiatric disorders are highly genetic but also have environmental and epigenetic etiologies
• The DSM diagnostic system needs a paradigm shift: it is still based on a menu of clinical signs and symptoms and is devoid of objective diagnostic measures such as biomarkers⁴
• Neuroscience literacy among busy psychiatric practitioners is insufficient at a time of explosive growth in basic and clinical neuroscience¹³
• No effective treatment for alcohol or substance use disorders despite their very high morbidity and mortality
• Major psychiatric disorders are still associated with significant disability (schizophrenia, bipolar disorder, major depressive disorder, anxiety disorders, eating disorders, substance use disorders)
• Suicide rate (other than opioid deaths) has continued to rise in the past 3 decades¹⁴

Opportunities

• Potentially momentous clinical applications of the neuroscience breakthroughs
• Collaborative care with primary care physicians and increasing colocalization
• Dramatic increase in public awareness about the importance of mental health due to the COVID-19 pandemic¹⁵
• Powerful new data management tools, including machine learning, artificial intelligence, super computers, big data, deep learning, nanotechnology, and metabolomics, all of which are expediting neurobiological discoveries¹⁶
• The potential of reclassifying psychiatric disorders as neurological disorders, which will improve reimbursement for patient health care and reduce stigma¹⁷
• Emergence of new mechanisms of action of disease etiology, such as microbiota, mitochondrial dysfunction, permeable blood-brain barrier, and neuroimmune dysregulation^18,19
• The advent and growth of “precision psychiatry”²⁰
• The tremendous potential of molecular genetics and gene therapy for psychiatric disorders, most of which are genetic in etiology
• Expanding applications of neuroimaging techniques, including morphological, spectroscopic, functional, diffusion tensor imaging, and receptor imaging²¹
• Epigenetic advances in neuropsychiatric disorders
• Remarkably powerful research methods, such as pluripotent cells (producing neurons from skin cells), optogenetics (activating genes with light), gene-wide association studies, CRISPR (clustered regularly interspaced short palindromic repeats, which serve as genetic scissors to remove and replace abnormal genes), and brain connectomics²²
• Psychiatry should develop and promote an “annual mental health checkup” for all age groups, similar to an annual physical exam²³
• Focus on the social determinants of health
• Address the unmet mental health needs of individuals who are members of minority groups
• Lobby ferociously for a much larger budget for the National Institute of Mental Health to advance funding for research of serious psychiatric brain disorders
• Remind Congress continuously that the cost of mental illness is $700 billion annually and costs can only be reduced by funding neurobiological research¹
• Partner with the pharmaceutical industry instead of demonizing them. They are the only entity that develops medication for psychiatry, where 80% of disorders have no FDA-approved drugs.²⁴ Without the pharmaceutical industry and the help of medications, many psychiatric patients would still be institutionalized and unable to lead a normal life. We must recognize the contributions of pharmaceutical companies to the health of our patients, similar to the warp speed development of vaccines for the deadly coronavirus
• Psychiatric clinicians must refer patients to clinical trials because without patients enrolling in FDA studies, no drug developments can take place
• Many “out-of-the-box” therapies are being developed, such as antiapoptotic therapy, microglia inhibition, mitochondrial repair, white matter fiber remyelination, neuroprotection, and reversing N-methyl-d-aspartate receptor hypofunction²⁵
• The emerging evidence that psychotherapy is in fact a biological treatment that induces brain changes (neuroplasticity) and can modulate the immune system²⁶
• Druggable genes, providing innovative new medications²⁷
• Reposition psychedelics as revolutionary new treatments²⁸
• Emphasize measurement-based care (rating scales), which can upgrade patient care²⁹
• Because psychosis is associated with brain tissue loss, just like heart attacks are associated with myocardium destruction, psychiatrists must act like cardiologists³⁰ and treat psychotic episodes urgently, like a stroke,³¹ to reduce the duration of untreated psychosis and improve patient outcomes

Threats

• Antipsychiatry cults continue to disparage and attack psychiatry³²
• Health delivery systems are replacing psychiatric physicians with nurse practitioners to lower costs, regardless of quality and experience, and they inappropriately lump them together as “providers”²
• Psychologists continue to seek prescribing privileges with absurdly sketchy, predominantly online training supervised by other psychologists³³
• Many legislators and policymakers, as well as the public, still don’t understand the difference between psychiatrists and psychologists, and the extensively disparate medical training in quality and quantity
• A dearth of psychiatric physician-scientists because very few residents are pursuing research fellowships after training³⁴
• Disproportionate emphasis on clinical care and generating clinical revenue (relative value units) in academic institutions, with fewer tenure-track faculty members having protected time to write grants for federal or foundation grants to support their salaries and research operations³⁵
• Meager financial support for teaching in psychiatry departments
• Many seriously psychiatrically ill persons do not have access to psychiatric medical care (and often to primary care as well)
• Many in the public falsely believe psychiatric disorders are hopeless and untreatable, which perpetuates stigma
• Long-acting injectable antipsychotic formulations are not used early enough in patients with psychosis, who are known to have a high nonadherence rate with oral medications following discharge from their first hospitalization. This leads to many recurrences with multiple devastating consequences, including progressive brain tissue loss, treatment resistance, disability, incarceration, and suicide³⁶
• Many clinicians do not have full-text access to all studies indexed in PubMed, which is vital for lifelong learning in a rapidly growing medical discipline such as psychiatry
• Psychiatrists are often unable to prescribe medications shortly after they are approved by the FDA due to the insurance companies’ outrageous preauthorization racket that enforces a fail-first policy with cheaper generics, even if generic medications are associated with safety and tolerability problems³⁷
• The continued use of decades-old first-generation antipsychotic medications despite 32 published studies reporting their neurotoxicity and the death of brain cells³⁸

Using this analysis to benefit our patients

Despite its strengths, psychiatry must overcome its weaknesses, fend off its threats, and exploit its many opportunities. The only way to do that is for psychiatrists to unify and for the APA to provide inspired leadership to achieve the aspirational goals of our field. However, we must adopt “moonshot thinking”³⁹ to magnify the Ss, diminish the Ws, exploit the Os, and stave off the Ts of our SWOT, thereby attaining all our cherished and lofty goals. Ultimately, the greatest beneficiaries will be our patients.

Editor’s note: This article was adapted with permission from a version originally published in the Ohio Psychiatric Physician Association’s newsletter, Insight Matters, Fall 2022.

Acknowledging and analyzing strengths, weaknesses, opportunities, and threats (SWOT) is an important tactic many organizations use to develop a strategic plan to grow, move forward, and thrive. A SWOT analysis can provide a “big picture” view of the status and the desired future directions not only for companies but for medical disciplines such as psychiatry. So here are my perspectives on psychiatry’s strengths, weaknesses, opportunities, and threats. It is a work in progress, and I welcome (and encourage) you to send additional items or comments to me at [email protected].

Strengths

• The American Psychiatric Association (APA) is the oldest medical professional organization, established in 1844 (3 years before the American Medical Association)¹
• Strong organizational structure and governance, and a “big tent” with several tiers of membership
• Effective, member-driven District Branches
• The medical identity at the core of psychiatry—we are psychiatric physicians²
• Escalating number of senior medical students choosing psychiatry as a career, far more than a decade ago
• High demand for psychiatrists in all settings around the country
• Increased compensation for psychiatrists (market forces of supply and demand)
• Psychiatry is continuously evolving and reinventing itself: seismic shifts in etiopathogenesis, disease conceptualization, terminology, and therapies (4 major shifts over the past century)³
• An abundant body of evidence supporting that all psychiatric disorders are brain disorders and transdiagnostic in nature⁴
• Many vibrant subspecialty societies
• Substantial number of Tier 1, evidence-based treatments
• Novel mechanisms of action and treatment strategies are being introduced on a regular basis for psychotic and mood disorders^5,6
• Advances in neuromodulation techniques to treat a wide spectrum of psychiatric disorders, including electroconvulsive therapy, transcranial magnetic stimulation, vagus nerve stimulation, transcranial direct current stimulation, deep brain stimulation, cranial electric stimulation, epidural cortical stimulation, focused ultrasound, low field magnetic stimulation, magnetic seizure therapy, and near infrared light therapy, with mechanisms that are electric, ultrasound, magnetic, or optical^7,8
• Psychiatric physicians develop wisdom by practicing psychiatry (ie, they become more empathic, tolerant of ambiguity, prosocial, introspective, aware of one’s strengths and limitations). Neuroplasticity in the frontal cortex is triggered by conducting psychotherapy⁹

Weaknesses

• Shrinking workforce due to a static number of residency training slots for 40 years¹⁰
• High rate of retirement by aging psychiatrists
• Persistent stigma around mental disorders despite massive scientific and medical advances¹¹
• Still no real parity! We need succinct laws with “teeth”¹²
• Demedicalization in the public sector, referring to psychiatric physicians as “providers” and labeling patients as “clients”²
• Not enough graduating residents choosing to do subspecialty fellowships (especially geriatric, addiction, psychosomatic psychiatry) to meet escalating societal needs
• Very low presence in rural areas (both psychiatrists and psychiatric hospitals)
• Persistent APA member apathy: only 10% to 15% vote in the APA national elections or volunteer to serve on committees
• Widespread member dissatisfaction with maintenance of certification
• Neuroscience advances are not being translated fast enough for practical clinical applications
• Many in the public at large do not realize psychiatric symptoms are generated from anomalous brain circuits or that psychiatric disorders are highly genetic but also have environmental and epigenetic etiologies
• The DSM diagnostic system needs a paradigm shift: it is still based on a menu of clinical signs and symptoms and is devoid of objective diagnostic measures such as biomarkers⁴
• Neuroscience literacy among busy psychiatric practitioners is insufficient at a time of explosive growth in basic and clinical neuroscience¹³
• No effective treatment for alcohol or substance use disorders despite their very high morbidity and mortality
• Major psychiatric disorders are still associated with significant disability (schizophrenia, bipolar disorder, major depressive disorder, anxiety disorders, eating disorders, substance use disorders)
• Suicide rate (other than opioid deaths) has continued to rise in the past 3 decades¹⁴

Opportunities

• Potentially momentous clinical applications of the neuroscience breakthroughs
• Collaborative care with primary care physicians and increasing colocalization
• Dramatic increase in public awareness about the importance of mental health due to the COVID-19 pandemic¹⁵
• Powerful new data management tools, including machine learning, artificial intelligence, super computers, big data, deep learning, nanotechnology, and metabolomics, all of which are expediting neurobiological discoveries¹⁶
• The potential of reclassifying psychiatric disorders as neurological disorders, which will improve reimbursement for patient health care and reduce stigma¹⁷
• Emergence of new mechanisms of action of disease etiology, such as microbiota, mitochondrial dysfunction, permeable blood-brain barrier, and neuroimmune dysregulation^18,19
• The advent and growth of “precision psychiatry”²⁰
• The tremendous potential of molecular genetics and gene therapy for psychiatric disorders, most of which are genetic in etiology
• Expanding applications of neuroimaging techniques, including morphological, spectroscopic, functional, diffusion tensor imaging, and receptor imaging²¹
• Epigenetic advances in neuropsychiatric disorders
• Remarkably powerful research methods, such as pluripotent cells (producing neurons from skin cells), optogenetics (activating genes with light), gene-wide association studies, CRISPR (clustered regularly interspaced short palindromic repeats, which serve as genetic scissors to remove and replace abnormal genes), and brain connectomics²²
• Psychiatry should develop and promote an “annual mental health checkup” for all age groups, similar to an annual physical exam²³
• Focus on the social determinants of health
• Address the unmet mental health needs of individuals who are members of minority groups
• Lobby ferociously for a much larger budget for the National Institute of Mental Health to advance funding for research of serious psychiatric brain disorders
• Remind Congress continuously that the cost of mental illness is $700 billion annually and costs can only be reduced by funding neurobiological research¹
• Partner with the pharmaceutical industry instead of demonizing them. They are the only entity that develops medication for psychiatry, where 80% of disorders have no FDA-approved drugs.²⁴ Without the pharmaceutical industry and the help of medications, many psychiatric patients would still be institutionalized and unable to lead a normal life. We must recognize the contributions of pharmaceutical companies to the health of our patients, similar to the warp speed development of vaccines for the deadly coronavirus
• Psychiatric clinicians must refer patients to clinical trials because without patients enrolling in FDA studies, no drug developments can take place
• Many “out-of-the-box” therapies are being developed, such as antiapoptotic therapy, microglia inhibition, mitochondrial repair, white matter fiber remyelination, neuroprotection, and reversing N-methyl-d-aspartate receptor hypofunction²⁵
• The emerging evidence that psychotherapy is in fact a biological treatment that induces brain changes (neuroplasticity) and can modulate the immune system²⁶
• Druggable genes, providing innovative new medications²⁷
• Reposition psychedelics as revolutionary new treatments²⁸
• Emphasize measurement-based care (rating scales), which can upgrade patient care²⁹
• Because psychosis is associated with brain tissue loss, just like heart attacks are associated with myocardium destruction, psychiatrists must act like cardiologists³⁰ and treat psychotic episodes urgently, like a stroke,³¹ to reduce the duration of untreated psychosis and improve patient outcomes

Threats

• Antipsychiatry cults continue to disparage and attack psychiatry³²
• Health delivery systems are replacing psychiatric physicians with nurse practitioners to lower costs, regardless of quality and experience, and they inappropriately lump them together as “providers”²
• Psychologists continue to seek prescribing privileges with absurdly sketchy, predominantly online training supervised by other psychologists³³
• Many legislators and policymakers, as well as the public, still don’t understand the difference between psychiatrists and psychologists, and the extensively disparate medical training in quality and quantity
• A dearth of psychiatric physician-scientists because very few residents are pursuing research fellowships after training³⁴
• Disproportionate emphasis on clinical care and generating clinical revenue (relative value units) in academic institutions, with fewer tenure-track faculty members having protected time to write grants for federal or foundation grants to support their salaries and research operations³⁵
• Meager financial support for teaching in psychiatry departments
• Many seriously psychiatrically ill persons do not have access to psychiatric medical care (and often to primary care as well)
• Many in the public falsely believe psychiatric disorders are hopeless and untreatable, which perpetuates stigma
• Long-acting injectable antipsychotic formulations are not used early enough in patients with psychosis, who are known to have a high nonadherence rate with oral medications following discharge from their first hospitalization. This leads to many recurrences with multiple devastating consequences, including progressive brain tissue loss, treatment resistance, disability, incarceration, and suicide³⁶
• Many clinicians do not have full-text access to all studies indexed in PubMed, which is vital for lifelong learning in a rapidly growing medical discipline such as psychiatry
• Psychiatrists are often unable to prescribe medications shortly after they are approved by the FDA due to the insurance companies’ outrageous preauthorization racket that enforces a fail-first policy with cheaper generics, even if generic medications are associated with safety and tolerability problems³⁷
• The continued use of decades-old first-generation antipsychotic medications despite 32 published studies reporting their neurotoxicity and the death of brain cells³⁸

Using this analysis to benefit our patients

Despite its strengths, psychiatry must overcome its weaknesses, fend off its threats, and exploit its many opportunities. The only way to do that is for psychiatrists to unify and for the APA to provide inspired leadership to achieve the aspirational goals of our field. However, we must adopt “moonshot thinking”³⁹ to magnify the Ss, diminish the Ws, exploit the Os, and stave off the Ts of our SWOT, thereby attaining all our cherished and lofty goals. Ultimately, the greatest beneficiaries will be our patients.

Emergencies happen anywhere, anytime, and sometimes physicians find themselves in situations where they are the only ones who can help. Is There a Doctor in the House? is a new series telling these stories.
 

I live on the Maumee River in Ohio, about 50 yards from the water. I had an early quit time and came home to meet my wife for lunch. Afterward, I went up to my barn across the main road to tinker around. It was a nice day out, so my wife had opened some windows. Suddenly, she heard screaming from the river. It did not sound like fun.

She ran down to the river’s edge and saw a dad and three boys struggling in the water. She phoned me screaming: “They’re drowning! They’re drowning!” I jumped in my truck and drove up our driveway through the yard right down to the river.

My wife was on the phone with 911 at that point, and I could see them about 75-100 yards out. The dad had two of the boys clinging around his neck. They were going under the water and coming up and going under again. The other boy was just floating nearby, face down, motionless.

I threw my shoes and scrubs off and started to walk towards the water. My wife screamed at me, “You’re not going in there!” I said, “I’m not going to stand here and watch this. It’s not going to happen.”

I’m not a kid anymore, but I was a high school swimmer, and to this day I work out all the time. I felt like I had to try something. So, I went in the water despite my wife yelling and I swam towards them.

What happens when you get in that deep water is that you panic. You can’t hear anyone because of the rapids, and your instinct is to swim back towards where you went in, which is against the current. Unless you’re a very strong swimmer, you’re just wasting your time, swimming in place.

But these guys weren’t trying to go anywhere. Dad was just trying to stay up and keep the boys alive. He was in about 10 feet of water. What they didn’t see or just didn’t know: About 20 yards upstream from that deep water is a little island.

When I got to them, I yelled at the dad to move towards the island, “Go backwards! Go back!” I flipped the boy over who wasn’t moving. He was the oldest of the three, around 10 or 11 years old. When I turned him over, he was blue and wasn’t breathing. I put my fingers on his neck and didn’t feel a pulse.

So, I’m treading water, holding him. I put an arm behind his back and started doing chest compressions on him. I probably did a dozen to 15 compressions – nothing. I thought, I’ve got to get some air in this kid. So, I gave him two deep breaths and then started doing compressions again. I know ACLS and CPR training would say we don’t do that anymore. But I couldn’t just sit there and give up. Shortly after that, he coughed out a large amount of water and started breathing.

The dad and the other two boys had made it to the island. So, I started moving towards it with the boy. It was a few minutes before he regained consciousness. Of course, he was unaware of what had happened. He started to scream, because here’s this strange man holding him. But he was breathing. That’s all I cared about.

When we got to the island, I saw that my neighbor downstream had launched his canoe. He’s a retired gentleman who lives next to me, a very physically fit man. He started rolling as hard as he could towards us, against the stream. I kind of gave him a thumbs up, like, “we’re safe now. We’re standing.” We loaded the kids and the dad in the canoe and made it back against the stream to the parking lot where they went in.

All this took probably 10 or 15 minutes, and by then the paramedics were there. Life Flight had been dispatched up by my barn where there’s room to land. So, they drove up there in the ambulance. The boy I revived was flown to the hospital. The others went in the ambulance.

I know all the ED docs, so I talked to somebody later who, with permission from the family, said they were all doing fine. They were getting x-rays on the boy’s lungs. And then I heard the dad and two boys were released that night. The other boy I worked on was observed overnight and discharged the following morning.

Four or 5 days later, I heard from their pediatrician, who also had permission to share. He sent me a very nice note through Epic that he had seen the boys. Besides some mental trauma, they were all healthy and doing fine.

The family lives in the area and the kids go to school 5 miles from my house. So, the following weekend they came over. It was Father’s Day, which was kind of cool. They brought me some flowers and candy and a card the boys had drawn to thank me.

I learned that the dad had brought the boys to the fishing site. They were horsing around in knee deep water. One of the boys walked off a little way and didn’t realize there was a drop off. He went in, and of course the dad went after him, and the other two followed.

I said to the parents: “Look, things like this happen for a reason. People like your son are saved and go on in this world because they’ve got special things to do. I can’t wait to see what kind of man he becomes.”

Two or 3 months later, it was football season, and I got at a message from the dad saying their son was playing football on Saturday at the school. He wondered if I could drop by. So, I kind of snuck over and watched, but I didn’t go say hi. There’s trauma there, and I didn’t want them to have to relive that.

I’m very fortunate that I exercise every day and I know how to do CPR and swim. And thank God the boy was floating when I got to him, or I never would’ve found him. The Maumee River is known as the “muddy Maumee.” You can’t see anything under the water.

Depending on the time of year, the river can be almost dry or overflowing into the parking lot with the current rushing hard. If it had been like that, I wouldn’t have considered going in. And they wouldn’t they have been there in the first place. They’d have been a mile downstream.

I took a risk. I could have gone out there and had the dad and two other kids jump on top of me. Then we all would have been in trouble. But like I told my wife, I couldn’t stand there and watch it. I’m just not that person.

I think it was also about being a dad myself and having grandkids now. Doctor or no doctor, I felt like I was in reasonably good shape and I had to go in there to help. This dad was trying his butt off, but three little kids is too many. You can’t do that by yourself. They were not going to make it.

I go to the hospital and I save lives as part of my job, and I don’t even come home and talk about it. But this is a whole different thing. Being able to save someone’s life when put in this situation is very gratifying. It’s a tremendous feeling. There’s a reason that young man is here today, and I’ll be watching for great things from him.

A version of this article first appeared on Medscape.com.

Daniel Cassavar, MD, is a cardiologist with ProMedica in Perrysburg, Ohio.

Emergencies happen anywhere, anytime, and sometimes physicians find themselves in situations where they are the only ones who can help. Is There a Doctor in the House? is a new series telling these stories.
 

I live on the Maumee River in Ohio, about 50 yards from the water. I had an early quit time and came home to meet my wife for lunch. Afterward, I went up to my barn across the main road to tinker around. It was a nice day out, so my wife had opened some windows. Suddenly, she heard screaming from the river. It did not sound like fun.

She ran down to the river’s edge and saw a dad and three boys struggling in the water. She phoned me screaming: “They’re drowning! They’re drowning!” I jumped in my truck and drove up our driveway through the yard right down to the river.

My wife was on the phone with 911 at that point, and I could see them about 75-100 yards out. The dad had two of the boys clinging around his neck. They were going under the water and coming up and going under again. The other boy was just floating nearby, face down, motionless.

I threw my shoes and scrubs off and started to walk towards the water. My wife screamed at me, “You’re not going in there!” I said, “I’m not going to stand here and watch this. It’s not going to happen.”

I’m not a kid anymore, but I was a high school swimmer, and to this day I work out all the time. I felt like I had to try something. So, I went in the water despite my wife yelling and I swam towards them.

What happens when you get in that deep water is that you panic. You can’t hear anyone because of the rapids, and your instinct is to swim back towards where you went in, which is against the current. Unless you’re a very strong swimmer, you’re just wasting your time, swimming in place.

But these guys weren’t trying to go anywhere. Dad was just trying to stay up and keep the boys alive. He was in about 10 feet of water. What they didn’t see or just didn’t know: About 20 yards upstream from that deep water is a little island.

When I got to them, I yelled at the dad to move towards the island, “Go backwards! Go back!” I flipped the boy over who wasn’t moving. He was the oldest of the three, around 10 or 11 years old. When I turned him over, he was blue and wasn’t breathing. I put my fingers on his neck and didn’t feel a pulse.

So, I’m treading water, holding him. I put an arm behind his back and started doing chest compressions on him. I probably did a dozen to 15 compressions – nothing. I thought, I’ve got to get some air in this kid. So, I gave him two deep breaths and then started doing compressions again. I know ACLS and CPR training would say we don’t do that anymore. But I couldn’t just sit there and give up. Shortly after that, he coughed out a large amount of water and started breathing.

The dad and the other two boys had made it to the island. So, I started moving towards it with the boy. It was a few minutes before he regained consciousness. Of course, he was unaware of what had happened. He started to scream, because here’s this strange man holding him. But he was breathing. That’s all I cared about.

When we got to the island, I saw that my neighbor downstream had launched his canoe. He’s a retired gentleman who lives next to me, a very physically fit man. He started rolling as hard as he could towards us, against the stream. I kind of gave him a thumbs up, like, “we’re safe now. We’re standing.” We loaded the kids and the dad in the canoe and made it back against the stream to the parking lot where they went in.

All this took probably 10 or 15 minutes, and by then the paramedics were there. Life Flight had been dispatched up by my barn where there’s room to land. So, they drove up there in the ambulance. The boy I revived was flown to the hospital. The others went in the ambulance.

I know all the ED docs, so I talked to somebody later who, with permission from the family, said they were all doing fine. They were getting x-rays on the boy’s lungs. And then I heard the dad and two boys were released that night. The other boy I worked on was observed overnight and discharged the following morning.

Four or 5 days later, I heard from their pediatrician, who also had permission to share. He sent me a very nice note through Epic that he had seen the boys. Besides some mental trauma, they were all healthy and doing fine.

The family lives in the area and the kids go to school 5 miles from my house. So, the following weekend they came over. It was Father’s Day, which was kind of cool. They brought me some flowers and candy and a card the boys had drawn to thank me.

I learned that the dad had brought the boys to the fishing site. They were horsing around in knee deep water. One of the boys walked off a little way and didn’t realize there was a drop off. He went in, and of course the dad went after him, and the other two followed.

I said to the parents: “Look, things like this happen for a reason. People like your son are saved and go on in this world because they’ve got special things to do. I can’t wait to see what kind of man he becomes.”

Two or 3 months later, it was football season, and I got at a message from the dad saying their son was playing football on Saturday at the school. He wondered if I could drop by. So, I kind of snuck over and watched, but I didn’t go say hi. There’s trauma there, and I didn’t want them to have to relive that.

I’m very fortunate that I exercise every day and I know how to do CPR and swim. And thank God the boy was floating when I got to him, or I never would’ve found him. The Maumee River is known as the “muddy Maumee.” You can’t see anything under the water.

Depending on the time of year, the river can be almost dry or overflowing into the parking lot with the current rushing hard. If it had been like that, I wouldn’t have considered going in. And they wouldn’t they have been there in the first place. They’d have been a mile downstream.

I took a risk. I could have gone out there and had the dad and two other kids jump on top of me. Then we all would have been in trouble. But like I told my wife, I couldn’t stand there and watch it. I’m just not that person.

I think it was also about being a dad myself and having grandkids now. Doctor or no doctor, I felt like I was in reasonably good shape and I had to go in there to help. This dad was trying his butt off, but three little kids is too many. You can’t do that by yourself. They were not going to make it.

I go to the hospital and I save lives as part of my job, and I don’t even come home and talk about it. But this is a whole different thing. Being able to save someone’s life when put in this situation is very gratifying. It’s a tremendous feeling. There’s a reason that young man is here today, and I’ll be watching for great things from him.

A version of this article first appeared on Medscape.com.

Daniel Cassavar, MD, is a cardiologist with ProMedica in Perrysburg, Ohio.

Emergencies happen anywhere, anytime, and sometimes physicians find themselves in situations where they are the only ones who can help. Is There a Doctor in the House? is a new series telling these stories.
 

I live on the Maumee River in Ohio, about 50 yards from the water. I had an early quit time and came home to meet my wife for lunch. Afterward, I went up to my barn across the main road to tinker around. It was a nice day out, so my wife had opened some windows. Suddenly, she heard screaming from the river. It did not sound like fun.

She ran down to the river’s edge and saw a dad and three boys struggling in the water. She phoned me screaming: “They’re drowning! They’re drowning!” I jumped in my truck and drove up our driveway through the yard right down to the river.

My wife was on the phone with 911 at that point, and I could see them about 75-100 yards out. The dad had two of the boys clinging around his neck. They were going under the water and coming up and going under again. The other boy was just floating nearby, face down, motionless.

I threw my shoes and scrubs off and started to walk towards the water. My wife screamed at me, “You’re not going in there!” I said, “I’m not going to stand here and watch this. It’s not going to happen.”

I’m not a kid anymore, but I was a high school swimmer, and to this day I work out all the time. I felt like I had to try something. So, I went in the water despite my wife yelling and I swam towards them.

What happens when you get in that deep water is that you panic. You can’t hear anyone because of the rapids, and your instinct is to swim back towards where you went in, which is against the current. Unless you’re a very strong swimmer, you’re just wasting your time, swimming in place.

But these guys weren’t trying to go anywhere. Dad was just trying to stay up and keep the boys alive. He was in about 10 feet of water. What they didn’t see or just didn’t know: About 20 yards upstream from that deep water is a little island.

When I got to them, I yelled at the dad to move towards the island, “Go backwards! Go back!” I flipped the boy over who wasn’t moving. He was the oldest of the three, around 10 or 11 years old. When I turned him over, he was blue and wasn’t breathing. I put my fingers on his neck and didn’t feel a pulse.

So, I’m treading water, holding him. I put an arm behind his back and started doing chest compressions on him. I probably did a dozen to 15 compressions – nothing. I thought, I’ve got to get some air in this kid. So, I gave him two deep breaths and then started doing compressions again. I know ACLS and CPR training would say we don’t do that anymore. But I couldn’t just sit there and give up. Shortly after that, he coughed out a large amount of water and started breathing.

The dad and the other two boys had made it to the island. So, I started moving towards it with the boy. It was a few minutes before he regained consciousness. Of course, he was unaware of what had happened. He started to scream, because here’s this strange man holding him. But he was breathing. That’s all I cared about.

When we got to the island, I saw that my neighbor downstream had launched his canoe. He’s a retired gentleman who lives next to me, a very physically fit man. He started rolling as hard as he could towards us, against the stream. I kind of gave him a thumbs up, like, “we’re safe now. We’re standing.” We loaded the kids and the dad in the canoe and made it back against the stream to the parking lot where they went in.

All this took probably 10 or 15 minutes, and by then the paramedics were there. Life Flight had been dispatched up by my barn where there’s room to land. So, they drove up there in the ambulance. The boy I revived was flown to the hospital. The others went in the ambulance.

I know all the ED docs, so I talked to somebody later who, with permission from the family, said they were all doing fine. They were getting x-rays on the boy’s lungs. And then I heard the dad and two boys were released that night. The other boy I worked on was observed overnight and discharged the following morning.

Four or 5 days later, I heard from their pediatrician, who also had permission to share. He sent me a very nice note through Epic that he had seen the boys. Besides some mental trauma, they were all healthy and doing fine.

The family lives in the area and the kids go to school 5 miles from my house. So, the following weekend they came over. It was Father’s Day, which was kind of cool. They brought me some flowers and candy and a card the boys had drawn to thank me.

I learned that the dad had brought the boys to the fishing site. They were horsing around in knee deep water. One of the boys walked off a little way and didn’t realize there was a drop off. He went in, and of course the dad went after him, and the other two followed.

I said to the parents: “Look, things like this happen for a reason. People like your son are saved and go on in this world because they’ve got special things to do. I can’t wait to see what kind of man he becomes.”

Two or 3 months later, it was football season, and I got at a message from the dad saying their son was playing football on Saturday at the school. He wondered if I could drop by. So, I kind of snuck over and watched, but I didn’t go say hi. There’s trauma there, and I didn’t want them to have to relive that.

I’m very fortunate that I exercise every day and I know how to do CPR and swim. And thank God the boy was floating when I got to him, or I never would’ve found him. The Maumee River is known as the “muddy Maumee.” You can’t see anything under the water.

Depending on the time of year, the river can be almost dry or overflowing into the parking lot with the current rushing hard. If it had been like that, I wouldn’t have considered going in. And they wouldn’t they have been there in the first place. They’d have been a mile downstream.

I took a risk. I could have gone out there and had the dad and two other kids jump on top of me. Then we all would have been in trouble. But like I told my wife, I couldn’t stand there and watch it. I’m just not that person.

I think it was also about being a dad myself and having grandkids now. Doctor or no doctor, I felt like I was in reasonably good shape and I had to go in there to help. This dad was trying his butt off, but three little kids is too many. You can’t do that by yourself. They were not going to make it.

I go to the hospital and I save lives as part of my job, and I don’t even come home and talk about it. But this is a whole different thing. Being able to save someone’s life when put in this situation is very gratifying. It’s a tremendous feeling. There’s a reason that young man is here today, and I’ll be watching for great things from him.

A version of this article first appeared on Medscape.com.

Daniel Cassavar, MD, is a cardiologist with ProMedica in Perrysburg, Ohio.

This holiday season, I am looking forward to spending some time with family, as I have in the past. As I have chatted with others, many friends are looking forward to events that are potentially larger and potentially returning to prepandemic type gatherings.

Gathering is important and can bring joy, sense of community, and love to the lives of many. Unfortunately, the risks associated with gathering are not over. We are currently facing what many are calling a “tripledemic” as our country faces many cases of respiratory syncytial virus (RSV), COVID-19, and influenza at the same time.

During the first week of December, cases of influenza were rising across the country¹ and were rising faster than in previous years. Although getting the vaccine is an important method of influenza prevention and is recommended for everyone over the age of 6 months with rare exception, many have not gotten their vaccine this year.
 

Influenza

Thus far, “nearly 50% of reported flu-associated hospitalizations in women of childbearing age have been in women who are pregnant.” We are seeing this at a time with lower-than-average uptake of influenza vaccine leaving both the pregnant persons and their babies unprotected. In addition to utilizing vaccines as prevention, isolating when ill, cleaning surfaces, and practicing good hand hygiene can all decrease transmission.

RSV

In addition to rises of influenza, there are currently high rates of RSV in various parts of the country. Prior to 2020, RSV typically started in the fall and peaked in the winter months. However, since the pandemic, the typical seasonal pattern has not returned, and it is unclear when it will. Although RSV hits the very young, the old, and the immunocompromised the most, RSV can infect anyone. Unfortunately, we do not currently have a vaccine for everyone against this virus. Prevention of transmission includes, as with flu, isolating when ill, cleaning surfaces, and washing hands.²

COVID-19

Of course, the effects of the COVID-19 pandemic are also still here as well. During the first week of December, the CDC reported rising cases of COVID across the country. Within the past few months, there have been several developments, though, for protection. There are now bivalent vaccines available as either third doses or booster doses approved for all persons over 6 months of age. As of the first week of December, only 13.5% of those aged 5 and over had received an updated booster.

There is currently wider access to rapid testing, including at-home testing, which can allow individuals to identify if COVID positive. Additionally, there is access to medication to decrease the likelihood of severe disease – though this does not take the place of vaccinations.

If anyone does test positive for COVID, they should follow the most recent quarantine guidelines including wearing a well-fitted mask when they do begin returning to activities.³

With rising cases of all three of these viruses, some may be asking how we can safely gather. There are several things to consider and do to enjoy our events. The first thing everyone can do is to receive updated vaccinations for both influenza and COVID-19 if eligible. Although it may take some time to be effective, vaccination is still one of our most effective methods of disease prevention and is important this winter season. Vaccinations can also help decrease the risk of severe disease.

Although many have stopped masking, as cases rise, it is time to consider masking particularly when community levels of any of these viruses are high. Masks help with preventing and spreading more than just COVID-19. Using them can be especially important for those going places such as stores and to large public gatherings and when riding on buses, planes, or trains.
 

In summary

Preventing exposure by masking can help keep individuals healthy prior to celebrating the holidays with others. With access to rapid testing, it makes sense to consider testing prior to gathering with friends and family. Most importantly, although we all are looking forward to spending time with our loved ones, it is important to stay home if not feeling well. Following these recommendations will allow us to have a safer and more joyful holiday season.

Dr. Wheat is a family physician at Erie Family Health Center and program director of Northwestern University’s McGaw Family Medicine residency program, both in Chicago. Dr. Wheat serves on the editorial advisory board of Family Practice News. You can contact her at [email protected].

References

1. Centers for Disease Control and Prevention. Influenza (flu). [Online] Dec. 1, 2022. [Cited: 2022 Dec 10.] https://www.cdc.gov/flu/index.htm.

2. Respiratory syncytial virus. Respiratory syncytial virus infection (RSV). [Online] Oct. 28, 2022. [Cited: 2022 Dec 10.] https://www.cdc.gov/rsv/index.html.

3. COVID-19. [Online] Dec. 7, 2022. [Cited: 2022 Dec 10.] https://www.cdc.gov/coronavirus/2019-ncov/index.html.

This holiday season, I am looking forward to spending some time with family, as I have in the past. As I have chatted with others, many friends are looking forward to events that are potentially larger and potentially returning to prepandemic type gatherings.

Gathering is important and can bring joy, sense of community, and love to the lives of many. Unfortunately, the risks associated with gathering are not over. We are currently facing what many are calling a “tripledemic” as our country faces many cases of respiratory syncytial virus (RSV), COVID-19, and influenza at the same time.

During the first week of December, cases of influenza were rising across the country¹ and were rising faster than in previous years. Although getting the vaccine is an important method of influenza prevention and is recommended for everyone over the age of 6 months with rare exception, many have not gotten their vaccine this year.
 

Influenza

Thus far, “nearly 50% of reported flu-associated hospitalizations in women of childbearing age have been in women who are pregnant.” We are seeing this at a time with lower-than-average uptake of influenza vaccine leaving both the pregnant persons and their babies unprotected. In addition to utilizing vaccines as prevention, isolating when ill, cleaning surfaces, and practicing good hand hygiene can all decrease transmission.

RSV

In addition to rises of influenza, there are currently high rates of RSV in various parts of the country. Prior to 2020, RSV typically started in the fall and peaked in the winter months. However, since the pandemic, the typical seasonal pattern has not returned, and it is unclear when it will. Although RSV hits the very young, the old, and the immunocompromised the most, RSV can infect anyone. Unfortunately, we do not currently have a vaccine for everyone against this virus. Prevention of transmission includes, as with flu, isolating when ill, cleaning surfaces, and washing hands.²

COVID-19

Of course, the effects of the COVID-19 pandemic are also still here as well. During the first week of December, the CDC reported rising cases of COVID across the country. Within the past few months, there have been several developments, though, for protection. There are now bivalent vaccines available as either third doses or booster doses approved for all persons over 6 months of age. As of the first week of December, only 13.5% of those aged 5 and over had received an updated booster.

There is currently wider access to rapid testing, including at-home testing, which can allow individuals to identify if COVID positive. Additionally, there is access to medication to decrease the likelihood of severe disease – though this does not take the place of vaccinations.

If anyone does test positive for COVID, they should follow the most recent quarantine guidelines including wearing a well-fitted mask when they do begin returning to activities.³

With rising cases of all three of these viruses, some may be asking how we can safely gather. There are several things to consider and do to enjoy our events. The first thing everyone can do is to receive updated vaccinations for both influenza and COVID-19 if eligible. Although it may take some time to be effective, vaccination is still one of our most effective methods of disease prevention and is important this winter season. Vaccinations can also help decrease the risk of severe disease.

Although many have stopped masking, as cases rise, it is time to consider masking particularly when community levels of any of these viruses are high. Masks help with preventing and spreading more than just COVID-19. Using them can be especially important for those going places such as stores and to large public gatherings and when riding on buses, planes, or trains.
 

In summary

Preventing exposure by masking can help keep individuals healthy prior to celebrating the holidays with others. With access to rapid testing, it makes sense to consider testing prior to gathering with friends and family. Most importantly, although we all are looking forward to spending time with our loved ones, it is important to stay home if not feeling well. Following these recommendations will allow us to have a safer and more joyful holiday season.

Dr. Wheat is a family physician at Erie Family Health Center and program director of Northwestern University’s McGaw Family Medicine residency program, both in Chicago. Dr. Wheat serves on the editorial advisory board of Family Practice News. You can contact her at [email protected].

References

1. Centers for Disease Control and Prevention. Influenza (flu). [Online] Dec. 1, 2022. [Cited: 2022 Dec 10.] https://www.cdc.gov/flu/index.htm.

2. Respiratory syncytial virus. Respiratory syncytial virus infection (RSV). [Online] Oct. 28, 2022. [Cited: 2022 Dec 10.] https://www.cdc.gov/rsv/index.html.

3. COVID-19. [Online] Dec. 7, 2022. [Cited: 2022 Dec 10.] https://www.cdc.gov/coronavirus/2019-ncov/index.html.

This holiday season, I am looking forward to spending some time with family, as I have in the past. As I have chatted with others, many friends are looking forward to events that are potentially larger and potentially returning to prepandemic type gatherings.

Gathering is important and can bring joy, sense of community, and love to the lives of many. Unfortunately, the risks associated with gathering are not over. We are currently facing what many are calling a “tripledemic” as our country faces many cases of respiratory syncytial virus (RSV), COVID-19, and influenza at the same time.

During the first week of December, cases of influenza were rising across the country¹ and were rising faster than in previous years. Although getting the vaccine is an important method of influenza prevention and is recommended for everyone over the age of 6 months with rare exception, many have not gotten their vaccine this year.
 

Influenza

Thus far, “nearly 50% of reported flu-associated hospitalizations in women of childbearing age have been in women who are pregnant.” We are seeing this at a time with lower-than-average uptake of influenza vaccine leaving both the pregnant persons and their babies unprotected. In addition to utilizing vaccines as prevention, isolating when ill, cleaning surfaces, and practicing good hand hygiene can all decrease transmission.

RSV

In addition to rises of influenza, there are currently high rates of RSV in various parts of the country. Prior to 2020, RSV typically started in the fall and peaked in the winter months. However, since the pandemic, the typical seasonal pattern has not returned, and it is unclear when it will. Although RSV hits the very young, the old, and the immunocompromised the most, RSV can infect anyone. Unfortunately, we do not currently have a vaccine for everyone against this virus. Prevention of transmission includes, as with flu, isolating when ill, cleaning surfaces, and washing hands.²

COVID-19

Of course, the effects of the COVID-19 pandemic are also still here as well. During the first week of December, the CDC reported rising cases of COVID across the country. Within the past few months, there have been several developments, though, for protection. There are now bivalent vaccines available as either third doses or booster doses approved for all persons over 6 months of age. As of the first week of December, only 13.5% of those aged 5 and over had received an updated booster.

There is currently wider access to rapid testing, including at-home testing, which can allow individuals to identify if COVID positive. Additionally, there is access to medication to decrease the likelihood of severe disease – though this does not take the place of vaccinations.

If anyone does test positive for COVID, they should follow the most recent quarantine guidelines including wearing a well-fitted mask when they do begin returning to activities.³

With rising cases of all three of these viruses, some may be asking how we can safely gather. There are several things to consider and do to enjoy our events. The first thing everyone can do is to receive updated vaccinations for both influenza and COVID-19 if eligible. Although it may take some time to be effective, vaccination is still one of our most effective methods of disease prevention and is important this winter season. Vaccinations can also help decrease the risk of severe disease.

Although many have stopped masking, as cases rise, it is time to consider masking particularly when community levels of any of these viruses are high. Masks help with preventing and spreading more than just COVID-19. Using them can be especially important for those going places such as stores and to large public gatherings and when riding on buses, planes, or trains.
 

In summary

Preventing exposure by masking can help keep individuals healthy prior to celebrating the holidays with others. With access to rapid testing, it makes sense to consider testing prior to gathering with friends and family. Most importantly, although we all are looking forward to spending time with our loved ones, it is important to stay home if not feeling well. Following these recommendations will allow us to have a safer and more joyful holiday season.

Dr. Wheat is a family physician at Erie Family Health Center and program director of Northwestern University’s McGaw Family Medicine residency program, both in Chicago. Dr. Wheat serves on the editorial advisory board of Family Practice News. You can contact her at [email protected].

References

1. Centers for Disease Control and Prevention. Influenza (flu). [Online] Dec. 1, 2022. [Cited: 2022 Dec 10.] https://www.cdc.gov/flu/index.htm.

2. Respiratory syncytial virus. Respiratory syncytial virus infection (RSV). [Online] Oct. 28, 2022. [Cited: 2022 Dec 10.] https://www.cdc.gov/rsv/index.html.

3. COVID-19. [Online] Dec. 7, 2022. [Cited: 2022 Dec 10.] https://www.cdc.gov/coronavirus/2019-ncov/index.html.

I have assumed that being a parent has always been an anxiety-producing experience. Even back when the neonatal mortality rate was orders of magnitude greater than we are experiencing now, I suspect that each birth was still accompanied by a period of angst. However, as families no longer felt the need to produce more children to replace those lost to illness, each surviving child fell under the glare of an ever brightening spotlight.

Raising a child no longer became just something that came naturally, learned from one’s parents. Philosophers and eventually physicians felt obligated to advise parents on the best practices. My parents turned to Dr. Benjamin Spock’s classic work when they had a question, but I never got the feeling that they took his words as gospel.

By the time I started in practice the condition of being a parent was morphing into a verb. Books on “parenting” were beginning to fill the shelves of libraries and bookstores. Frustrated by what I saw as poorly conceived instruction manuals I succumbed to the temptation to spread my “better” advice for anxiety-tormented parents by writing books on how to feed picky eaters, or how to get erratic sleepers to sleep, or how to get a misbehaving child to understand the simple concept of “No!”

Back in the pre-Internet days I was competing for the attention of anxiety-driven parents not just with other self-described experts sitting at word processors, but with grandmothers, aunts, and the ladies next door. The book publishing market has cooled but the demand for advice on how to be the best parent has heated up. Into the void, enabled by the Internet, has erupted the phenomenon of social-media mom groups.

The lady next door and the mothers with strollers meeting informally at the playground are a tiny blip on the radar screen compared with the abundance of other mothers eager to listen and comment on social media–based mom groups unlimited by either geographic or temporal time restraints.

Unfortunately, as a recent article in the Wall Street Journal suggests, these support groups can often have a dark side. Researchers from Pepperdine University found in a small survey of a homogenous population of women that stress, as measured by saliva cortisol levels, increased with increasing use of “mom-centric social media” sites.

Citing anecdotal observations by mothers who did not participate in the study, the WSJ article describes episodes of shaming over topics such as steroid use in eczema and vaccine hesitancy. One mother described how she found group discussions about breastfeeding “particularly anxiety-producing.”

I have limited experience with online support groups but I have been surprised by how rude and condescending some of the contributors can be to what I could consider to be emotionally neutral subjects such as outboard motor oil pressure. I can imagine that when it comes to subjects in which there is no one best answer, the relative anonymity of the Internet provides cover for language that can be hurtful and stress inducing for someone already feeling isolated and anxious about being a parent.

Although this Pepperdine study is small, I suspect that a larger study would support the authors’ observations. For us as providers, it suggests that we need to find where parents are getting their information when we are trying to help those who seem particularly distressed. We should caution them that, while sharing information with peers can be reassuring and helpful at times, mom groups can be toxic as well. It also means that we should be careful in recommending social media sites – even those for which we have had good feedback.

And, most importantly, we must continue to work hard to make ourselves available to provide sensible and sensitive answers to those questions that are anxiety-producing for new parents.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

I have assumed that being a parent has always been an anxiety-producing experience. Even back when the neonatal mortality rate was orders of magnitude greater than we are experiencing now, I suspect that each birth was still accompanied by a period of angst. However, as families no longer felt the need to produce more children to replace those lost to illness, each surviving child fell under the glare of an ever brightening spotlight.

Raising a child no longer became just something that came naturally, learned from one’s parents. Philosophers and eventually physicians felt obligated to advise parents on the best practices. My parents turned to Dr. Benjamin Spock’s classic work when they had a question, but I never got the feeling that they took his words as gospel.

By the time I started in practice the condition of being a parent was morphing into a verb. Books on “parenting” were beginning to fill the shelves of libraries and bookstores. Frustrated by what I saw as poorly conceived instruction manuals I succumbed to the temptation to spread my “better” advice for anxiety-tormented parents by writing books on how to feed picky eaters, or how to get erratic sleepers to sleep, or how to get a misbehaving child to understand the simple concept of “No!”

Back in the pre-Internet days I was competing for the attention of anxiety-driven parents not just with other self-described experts sitting at word processors, but with grandmothers, aunts, and the ladies next door. The book publishing market has cooled but the demand for advice on how to be the best parent has heated up. Into the void, enabled by the Internet, has erupted the phenomenon of social-media mom groups.

The lady next door and the mothers with strollers meeting informally at the playground are a tiny blip on the radar screen compared with the abundance of other mothers eager to listen and comment on social media–based mom groups unlimited by either geographic or temporal time restraints.

Unfortunately, as a recent article in the Wall Street Journal suggests, these support groups can often have a dark side. Researchers from Pepperdine University found in a small survey of a homogenous population of women that stress, as measured by saliva cortisol levels, increased with increasing use of “mom-centric social media” sites.

Citing anecdotal observations by mothers who did not participate in the study, the WSJ article describes episodes of shaming over topics such as steroid use in eczema and vaccine hesitancy. One mother described how she found group discussions about breastfeeding “particularly anxiety-producing.”

I have limited experience with online support groups but I have been surprised by how rude and condescending some of the contributors can be to what I could consider to be emotionally neutral subjects such as outboard motor oil pressure. I can imagine that when it comes to subjects in which there is no one best answer, the relative anonymity of the Internet provides cover for language that can be hurtful and stress inducing for someone already feeling isolated and anxious about being a parent.

Although this Pepperdine study is small, I suspect that a larger study would support the authors’ observations. For us as providers, it suggests that we need to find where parents are getting their information when we are trying to help those who seem particularly distressed. We should caution them that, while sharing information with peers can be reassuring and helpful at times, mom groups can be toxic as well. It also means that we should be careful in recommending social media sites – even those for which we have had good feedback.

And, most importantly, we must continue to work hard to make ourselves available to provide sensible and sensitive answers to those questions that are anxiety-producing for new parents.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

I have assumed that being a parent has always been an anxiety-producing experience. Even back when the neonatal mortality rate was orders of magnitude greater than we are experiencing now, I suspect that each birth was still accompanied by a period of angst. However, as families no longer felt the need to produce more children to replace those lost to illness, each surviving child fell under the glare of an ever brightening spotlight.

Raising a child no longer became just something that came naturally, learned from one’s parents. Philosophers and eventually physicians felt obligated to advise parents on the best practices. My parents turned to Dr. Benjamin Spock’s classic work when they had a question, but I never got the feeling that they took his words as gospel.

By the time I started in practice the condition of being a parent was morphing into a verb. Books on “parenting” were beginning to fill the shelves of libraries and bookstores. Frustrated by what I saw as poorly conceived instruction manuals I succumbed to the temptation to spread my “better” advice for anxiety-tormented parents by writing books on how to feed picky eaters, or how to get erratic sleepers to sleep, or how to get a misbehaving child to understand the simple concept of “No!”

Back in the pre-Internet days I was competing for the attention of anxiety-driven parents not just with other self-described experts sitting at word processors, but with grandmothers, aunts, and the ladies next door. The book publishing market has cooled but the demand for advice on how to be the best parent has heated up. Into the void, enabled by the Internet, has erupted the phenomenon of social-media mom groups.

The lady next door and the mothers with strollers meeting informally at the playground are a tiny blip on the radar screen compared with the abundance of other mothers eager to listen and comment on social media–based mom groups unlimited by either geographic or temporal time restraints.

Unfortunately, as a recent article in the Wall Street Journal suggests, these support groups can often have a dark side. Researchers from Pepperdine University found in a small survey of a homogenous population of women that stress, as measured by saliva cortisol levels, increased with increasing use of “mom-centric social media” sites.

Citing anecdotal observations by mothers who did not participate in the study, the WSJ article describes episodes of shaming over topics such as steroid use in eczema and vaccine hesitancy. One mother described how she found group discussions about breastfeeding “particularly anxiety-producing.”

I have limited experience with online support groups but I have been surprised by how rude and condescending some of the contributors can be to what I could consider to be emotionally neutral subjects such as outboard motor oil pressure. I can imagine that when it comes to subjects in which there is no one best answer, the relative anonymity of the Internet provides cover for language that can be hurtful and stress inducing for someone already feeling isolated and anxious about being a parent.

Although this Pepperdine study is small, I suspect that a larger study would support the authors’ observations. For us as providers, it suggests that we need to find where parents are getting their information when we are trying to help those who seem particularly distressed. We should caution them that, while sharing information with peers can be reassuring and helpful at times, mom groups can be toxic as well. It also means that we should be careful in recommending social media sites – even those for which we have had good feedback.

And, most importantly, we must continue to work hard to make ourselves available to provide sensible and sensitive answers to those questions that are anxiety-producing for new parents.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

This transcript has been edited for clarity.

F. Perry Wilson, MD, MSCE: Hello, and thank you for joining us today for what promises to be a lively discussion about screening for colon cancer.

My name is Perry Wilson. I’m an associate professor of medicine and director of the Clinical and Translational Research Accelerator at the Yale School of Medicine. My new book, “How Medicine Works and When It Doesn’t: Learning Who to Trust to Get and Stay Healthy,” is available for pre-order now anywhere that books are sold.

I’m joined by two wonderful experts. Dr. David Johnson is a professor of medicine and the chief of gastroenterology at the Eastern Virginia School of Medicine. He is the past president of the American College of Gastroenterology. And I’m very encouraged to see that he’s won a Distinguished Educator Award for his efforts in gastroenterology.

I’m also joined by Dr Kenny Lin. He’s a frequent contributor to Medscape and WebMD. He’s a family physician and public health consultant from Lancaster, Pa., and deputy editor of the American Family Physician journal. He’s also a teacher of residents and students at Lancaster General Health and the Penn Medicine Family Medicine Residency program.

So, we have two great educators with us today to hopefully help teach us something about colon cancer and colon cancer screening. Thank you for joining me today.

David A. Johnson, MD: Thanks for having us.

Kenneth W. Lin, MD, MPH: Good to be here.

Dr. Wilson: Colon cancer is the second leading cause of cancer mortality in the United States. A little over 50,000 people die every year in the United States due to colon cancer.

A month ago, I would have said that there was a pretty broad consensus, at least from my perspective, that people should be getting colonoscopies. That’s certainly what we tell our patients.

Then a paper came out in the New England Journal of Medicine, a very prestigious journal, that has caused a lot of consternation online and led to my receiving a lot questions from patients and their family members. Today, I’d like to talk about this randomized trial of screening colonoscopy for colon cancer, and why it has caused so much – perhaps – confusion, calls for change, and concern out there.

Dr Johnson, can you give us a brief overview of what this trial was about?

Dr. Johnson: This was a randomized trial looking at screening colonoscopy versus no screening test whatsoever. They looked at the outcomes of prevention of cancer and the prevention of colon cancer–related death.

The short answer was that it was disappointing as it relates to colonoscopy. The study looked at patients from four European countries, with data from three of them (Norway, Poland, and Sweden) ultimately analyzed in this report in NEJM. It got a lot of attention because it surprised a lot of people by saying maybe colonoscopy wasn’t quite as good as we thought it was.

They tried to correct that by only looking at the numbers of patients who got their colonoscopy screening, which still showed value, but it was less than that we’ve seen before. There’s lots of reasons for that, which we’ll discuss shortly.
 

An invitation to a screening

Dr. Wilson: This was a bit of an interesting trial design. I think I’m correct, Dr Lin, that this was the first randomized trial of screening colonoscopy. But they didn’t really randomize people to get a colonoscopy versus not get a colonoscopy. Can you tell us why this differed from that study design, which I’d have thought would be simpler way of assessing this?

Dr. Lin: It’s definitely an important point to highlight about the study. What investigators did was randomize patients to receive an invitation to get a screening colonoscopy. When the trial was set up, they randomized people before they were asked whether they wanted to participate in the study. If you did it the other way around, by first asking them whether they wanted to be in the study and then randomizing them, you would have been assured that more of them probably would have gotten the colonoscopy.

But in this case, they were more interested in figuring out the real-life results of having a national program that invited patients to receive screening colonoscopy. Because we know that everyone that you recommend to get a colonoscopy doesn’t necessarily want to do that, forgets to do it, or something happens that prevents their actually getting it.

When it comes to measuring the effectiveness of the colonoscopy, it perhaps wasn’t the greatest type of study to do that. But I think it did provide some information about what would happen if you invited people to get colonoscopy, in terms of how many would do it and the results overall for that population.
 

Lower participation numbers than expected

Dr. Wilson: Dr. Johnson, the data show that 42% of people who were in that invitation arm followed through and got their colonoscopy. You’re a gastroenterologist. Does that seem low or about right? Do about half of people who should get a colonoscopy end up getting one?

Dr. Johnson: No, it’s low. In the United States, those numbers are probably in the 70% range. Certainly, the test doesn’t work for people who don’t get the test performed. So, if 42% of those randomized to receive an invitation to get the colonoscopy got one, that really means the majority of patients never got the test.

Dr. Wilson: Certainly, we wouldn’t expect impressive results if they don’t get the test. But on the other hand, I imagine that people who choose to get the test when they’re invited are sort of a different breed. Perhaps they’re more health conscious or living in other healthy ways. Is that something we should worry about when we look at these results?

Dr. Johnson: I don’t think you can stratify based on this study. Factors like ethnicities and diet weren’t really explained. The key element that will hopefully have the major take-home impact is quality. It’s not just the test. It’s how the test is done.

The key results

Dr. Wilson: Let’s start with the big picture. This was a study looking at everyone invited; not the subgroup of people who got the colonoscopy, but the real randomized study population.

Dr. Lin, the study did show that the invited group had a lower risk of colon cancer over the next 10 years. That’s a good thing, I imagine.

Dr. Lin: I think that’s a significant benefit. Initially in the first few years, they had more colon cancers diagnosed. But that’s probably because those were cancers that were already existing and couldn’t be prevented by the test.

But then over the years the curves crossed, and by the end of the average follow-up of 10 years, there was a significantly lower rate of colon cancers being detected. That’s as you would expect, because you’re finding polyps and removing them before they became colon cancer.

Dr. Wilson: Dr. Johnson, is that the natural history of colon cancer? It starts out as a polyp that maybe can be easily removed and doesn’t require more therapy. Is that why screening colonoscopy is helpful?

Dr. Johnson: The ultimate goal of screening is prevention of cancer, rather than detection of cancer. That occurs by identification and complete removal of the polyps that we find that are precancerous. The key is, first, detection, and second, resection. Adequate resection comes down to some very significant issues of quality, which are questions that I’d raised about this study, and we can talk about momentarily.

Dr. Wilson: Absolutely. Let me first go through the two other big findings in this study.

The fact that there were fewer cases of colon cancer over 10 years seems good. But colon cancer mortality was not significantly different in the two groups. Now, of course, we know that not everyone got a colonoscopy. I would have expected though, if you had less colon cancer, you’d have less death from colon cancer.

Dr. Lin, what might explain this disconnect?

Dr. Lin: I think there are a couple of possible explanations.

One explanation is that they just didn’t follow the people long enough. Colon cancer takes a long time to go from an adenoma to cancer, and from cancer to something that would cause the patient’s death. You may need to follow them for longer than the 10 years that most of these patients were followed to see that benefit. I think there probably will be benefit after a while, because if you are removing colon cancers that otherwise would have progressed and metastasized, you often see a benefit.

We also have to consider the other possibility that not all the polyps removed necessarily were going to progress to advanced cancer. Therefore, you weren’t seeing the death benefit because not every polyp that was removed was necessarily going to cause health consequences.

In colonoscopy, quality is key to success

Dr. Wilson: You’re removing things and have no way of knowing in advance which are the bad ones and which aren’t.

Dr. Johnson, you’ve mentioned several times now that the quality of colonoscopy matters here. So, I’m intuiting that it’s not one-size-fits-all, that it’s not all the same. What do you mean by quality of colonoscopy, and what was it in the NEJM study?

Dr. Johnson: Quality colonoscopy is the quality of the whole process. It starts with the warm-up, if you will, and the clean out for the procedure. That allows the colonoscopist to be able to identify precancerous polyps, which we call adenomas (there are other precancerous polyps called sessile serrated lesions).

The identification of adenomas is extremely important. Even a small increase in the detection of those precancerous polyps has benefits. Well-performed studies looking at large databases show that a small, 1% increase in the adenoma detection leads to a 3% decrease in colon cancer and a 5% decrease in colon cancer–related death. There’s a huge array of effect when we talk about small increases in the adenoma detection rate.

Now, let’s go back to this study in NEJM.

If we base quality on the physician performing the colonoscopy, and say that the colonoscopy is achieving the act of getting all the way around the colon, but not all physicians in the study were able to do that, it starts to raise the question about quality, because adenoma detection is so important. Earlier reports from this group [Nordic-European Initiative on Colorectal Cancer Study Group] have shown that the adenoma detection rates have been way below the national thresholds. So, this raises the question of whether they found the polyp, and then whether they resected the polyp. They also don’t tell us where these cancers were. It is about the colonoscopy quality. It’s not the instrument. It’s the process.
 

An overview of other screening tools

Dr. Wilson: Dr. Lin, colonoscopy, which requires prep and anesthesia, is not the only colon cancer screening method we have. In fact, there are a bunch. I think we’re on board saying it’s probably better to detect colon cancer early than not detect it. But what are our other options aside from colonoscopy that can allow for early detection of colon cancer?

Dr. Lin: For most of my career, there were three options that I presented patients with. The first was the fecal test, which used to be in the form of initial hemoccult tests. These have been mostly replaced by fecal immunochemical testing. But they’re both just basically looking for the presence of blood in the stool. Anyone who has a positive test would be referred for a diagnostic colonoscopy.

The other test besides colonoscopy, which has been largely phased out in the United States, although it is still very much used in Canada and much of Europe, is flexible sigmoidoscopy. Until this study, the tests supported by randomized controlled trials were the fecal tests and flexible sigmoidoscopy.

Interestingly, there was a recent systematic review of flexible sigmoidoscopy looking at four trials and their effects over 15 years. They showed not only a reduction in colon cancer, but also a reduction in colon cancer mortality, and even a small reduction in all-cause mortality.

I believe three out of the four trials were done where the patients were consented and then randomized, so they had a higher uptake of the procedure.

But when you compare this with the colonoscopy trial, it really isn’t that impressive. You would expect a much larger benefit, because obviously you’re looking at the entire colon. But you really didn’t see that. It was, at best, maybe equivalent to sigmoidoscopy, but not a whole lot better.

Dr. Johnson: Perry, you mentioned sedation. It’s important to understand that this particular cohort of patients are from Norway, Sweden, and Poland, where it’s very much the norm to not get sedation for your colonoscopy. Any of the [audience] who have had colonoscopy will tell you that they are not ones to say, “Don’t give me sedation.” The rate of sedation is around 11% in Norway, maybe 23% in Sweden, and around 45% in Poland. So, the examiner and the patient were never really super comfortable.

I’ve done 50,000 colonoscopies in my career, and many nonsedated. We know that taking time increases the finding of polyps and the adequate identification and resection. So, that ability to perform at a high quality is very much impacted when the patients aren’t comfortable.

Dr. Wilson: Dr. Johnson, we brought up flexible sigmoidoscopy. For the patients watching whose doctors are talking to them about screening colonoscopy, what’s the difference?

Dr. Johnson: Flexible sigmoidoscopy is just a short scope examination, in which you see about one-third of the colon. I’ve been in the field for 45 years, and during that time we’ve seen that there’s a progressive increase in the development of cancers above that bottom third of the colon to the higher end, the two-thirds of the colon that you would miss without doing a full colonoscopy. Also, flexible sigmoidoscopy typically does not get covered for sedation.

Again, if you do the exam and find something, then you’re going to have to come back and do an adequate resection with a colonoscopy. So, one-stop-shopping colon cancer screening is not about detection of cancer, it’s about prevention of cancer, and that’s what colonoscopy does.

Patients want convenience, but at what cost?

Dr. Wilson: Dr. Lin, how are your patients in your family practice handling this study? Have conversations changed around colon cancer screening? What are people asking about these days?

Dr. Lin: I don’t think the conversations have changed in my practice that much. When patients ask about this study, we do discuss the limitations, that it wasn’t designed to assess the maximum benefit of getting a colonoscopy because the majority of people assigned to that group didn’t get colonoscopy.

But I think it is an opportunity in primary care to consider the way we present the options to patients. Because I would guess that a majority of primary care physicians, when they present the options, would say colonoscopy is the gold standard and recommend their patients get it. And they only offer fecal testing to patients who don’t want the colonoscopy or really refuse.

That hasn’t been my practice. I’m usually more agnostic, because there are both harms and benefits. If you get a fecal test, the chance of you having a complication from colonoscopy is automatically lower because most of those people will not get colonoscopy. Now obviously, the complications with colonoscopy are pretty rare and usually self-limited, but they do exist. If you’re doing lots and lots of these, eventually you’ll see them. Probably all primary care physicians have patients who’ve had a complication from colonoscopy and may or may not have regretted it depending on how information was presented.

But I feel like this study reinforces my feeling that we ought to be presenting these, and not saying one is superior or inferior to the other. Instead, I’d base it on what the patient’s priorities are. But I feel like this study reinforces my feeling that we ought to be presenting these, and not saying one is superior or inferior to the other. Instead, I’d base it on what the patient’s priorities are. Is your priority finding every single cancer? Do you want to know exactly what the benefit is? I think with colonoscopy, we’re still trying to figure out exactly what the benefit is. Whereas we can say it pretty confidently for fecal tests because we have those randomized trials.

Dr. Wilson: Dr. Johnson, I think patients who are watching need to know, first of all, that if they do the fecal test route, a positive fecal test does lead to colonoscopy. In some sense, all roads lead to colonoscopy once you have a positive screening test. So, I can certainly see the value of just sort of skipping to that point. But what about this risk-versus-benefit relationship? Colonoscopy, albeit a relatively safe procedure, is still a procedure. There is some risk associated with it. If we can get the same benefit from yearly fecal immunochemical testing, is that a better choice potentially, at least for patients at average risk?

Dr. Johnson: The stool-based testing is really more effective for detection of cancer. That’s not screening, where the entire goal is the prevention of cancer. The fecal-based testing, including the stool-based DNA testing, misses the majority of precancerous polyps. And the fecal immunochemical tests, which Dr. Lin just mentioned, misses virtually all of them. We really want to get to the prevention of cancer, meaning identification and removal of polyps, not just screening for cancer.

Dr. Wilson: Do you see anything on the horizon that could unseat colonoscopy as, to quote Dr. Lin, the potential gold standard for screening for colon cancer?

Dr. Johnson: I think not on the horizon for identification and removal of polyps. That’s really the gold standard. Technology continues to advance. We’ll see what happens. But on the short and intermediate horizon, colonoscopy is going to be needed.

We are finding that some patients are starting to acquiesce to stool-based testing because they can do it at home. Maybe they don’t have to do a prep. We’re talking about screening only here, not about the follow-up of patients who have a family history, patients who have colitis, patients who have had colon polyps, or other reasons. Stool-based testing is not an option for the follow-up of those patients.

Convenience testing, in the face of COVID, also has thrown a wrench into things. Patients may have wanted to stay home and do these tests. Again, we need to be proactive, not reactive. We want to prevent cancer, not detect it.
 

Changing advice in the face of younger screening thresholds

Dr. Wilson: Dr. Lin, I’m 42 years old. I don’t believe I’m at any increased risk of colon cancer based on my family history or other risk factors. I’m 3 years away from when the U.S. Preventive Services Task Force tells me I should potentially consider starting to screen for colon cancer. That recommendation has recently been moved down from 50 years old to 45 years old. So, it’s on my mind as I approach that age. What do you advise younger patients approaching 45 right now in terms of screening for colon cancer?

Dr. Lin: For patients with the risk factors that Dr. Johnson mentioned, I would recommend screening colonoscopy as the initial test.

Assuming you don’t have those risk factors, I present it as we have a couple of different fecal tests. There’s the traditional one that just looks for blood. Then there’s the newer one that also adds DNA, which is more sensitive for colorectal cancer, but a little less specific, which is a problem just because there are more false positives.

But you need to compare that with colonoscopy, which you only need to get done ideally every 10 years if there are no findings. That is more complete. And theoretically, as we’ve been talking about, it would also prevent as well as detect early cancers.

So, I think it’s really down to your preference in terms of how the various factors that come into play, such as convenience of the test and your level of concern about cancer. I do tell patients that family history of cancer is not terribly predictive of whether you get it or not. A lot of people unfortunately who develop colorectal cancer have no previous family history. Diet will come into play to some extent. There are some things that point to increased risk for colorectal cancer if you have a diet high in red meat and things like that. But ultimately, it really is up to the patient. I lay out the options, and whatever they choose, I’m happy to pursue.

But the most important thing is that they do some test, because doing no test is not going to help anyone. I do agree with the notion that the best test is the test that gets done.

Dr. Wilson: Absolutely. I think the NEJM study supports that, even when we’re talking about colonoscopy.

Dr. Johnson, you’ve had some criticisms about the NEJM study, and I think they make sense. At the same time, as this is the first randomized trial of colonoscopy, it’s kind of the only data we have. Are we going to get better data? Are there other studies going on out there that might help shed some light on what’s turning out to be a complicated issue?

Dr. Johnson: Yes, there are ongoing studies. They’re not taking place within the United States, because you couldn’t get through a no-screening option trial. There are comparative studies that are probably still 5 years away looking at stool-based testing.

But again, we have to recognize that if you do these alternative tests that were eloquently discussed by Dr. Lin, and not the colonoscopy, which would be every 10 years with high-quality performance, that you have to annualize or do them in sequence. It’s important that you follow up on those with regularity. It’s not just a one-time test every 10 years for these individual tests.

And any of the time that those tests are ordered, the patient should be instructed that if it’s positive you need a colonoscopy. We’re seeing a lot of slippage on that front for the stool-based testing. Convenience is not the answer. It’s getting the job done.

Dr. Wilson: Would you agree, Dr. Johnson, that for patients that really don’t want to do the colonoscopy for one reason or another, and you’ve done your best in explaining what you think the risks and benefits are, that you’d rather have them get something than nothing?

Dr. Johnson: Absolutely. It comes down to what I recommend and then what you decide. But I still make the point explicit: If we’ve gone through those checkpoints and it’s positive, we agree that you understand that colonoscopy is the next step.

Final take-home messages

Dr. Wilson: Dr. Lin, I’ll turn the last word over to you, as the person who is probably discussing the choice of screening modalities more than any of us, before someone would get referred to someone like Dr. Johnson. What’s your final take-home message about the NEJM study and the state of colon cancer screening in the United States?

Dr. Lin: My take-home points about the study are that there were some limitations, but it is good to finally have a randomized trial of colonoscopy screening 2 decades after we really started doing that in the United States. It won’t immediately change – nor do I think it should – the way we practice and discuss different options. I think that some of Dr. Johnson’s points about making sure that whoever’s doing the colonoscopies for your practices is doing it in a high-quality way are really important. Just as it’s important, if you’re doing the fecal tests, to make sure that all patients who have positives get expeditiously referred for colonoscopy.

Dr. Johnson: Perry, I’d like to make one concluding comment as the gastroenterology expert in this discussion. I’ve had countless questions about this study from my patients and my peers. I tell them the following: Don’t let the headlines mislead you.

When you look at this study, the instrument is not so much the question. We know that getting the test is the first step in colon cancer screening. But we also know that getting the test done, with the highest-quality providers and the best-quality performance, is really the key to optimizing the true value of colonoscopy for colon cancer prevention.

So please don’t lose sight of this when reading the headlines in the media around this study. We really need to analyze the true characteristics of what we call a quality performance, because that’s what drives success and that’s what prevents colon cancer.

Dr. Wilson: Dr. Johnson and Dr. Lin, thank you very much. I appreciate you spending time with me here today and wish you all the best.

I guess I’ll sum up by saying that if you’re getting a colonoscopy, make sure it’s a good one. But do get screened.

This video originally appeared on WebMD. A transcript appeared on Medscape.com.

This transcript has been edited for clarity.

F. Perry Wilson, MD, MSCE: Hello, and thank you for joining us today for what promises to be a lively discussion about screening for colon cancer.

My name is Perry Wilson. I’m an associate professor of medicine and director of the Clinical and Translational Research Accelerator at the Yale School of Medicine. My new book, “How Medicine Works and When It Doesn’t: Learning Who to Trust to Get and Stay Healthy,” is available for pre-order now anywhere that books are sold.

I’m joined by two wonderful experts. Dr. David Johnson is a professor of medicine and the chief of gastroenterology at the Eastern Virginia School of Medicine. He is the past president of the American College of Gastroenterology. And I’m very encouraged to see that he’s won a Distinguished Educator Award for his efforts in gastroenterology.

I’m also joined by Dr Kenny Lin. He’s a frequent contributor to Medscape and WebMD. He’s a family physician and public health consultant from Lancaster, Pa., and deputy editor of the American Family Physician journal. He’s also a teacher of residents and students at Lancaster General Health and the Penn Medicine Family Medicine Residency program.

So, we have two great educators with us today to hopefully help teach us something about colon cancer and colon cancer screening. Thank you for joining me today.

David A. Johnson, MD: Thanks for having us.

Kenneth W. Lin, MD, MPH: Good to be here.

Dr. Wilson: Colon cancer is the second leading cause of cancer mortality in the United States. A little over 50,000 people die every year in the United States due to colon cancer.

A month ago, I would have said that there was a pretty broad consensus, at least from my perspective, that people should be getting colonoscopies. That’s certainly what we tell our patients.

Then a paper came out in the New England Journal of Medicine, a very prestigious journal, that has caused a lot of consternation online and led to my receiving a lot questions from patients and their family members. Today, I’d like to talk about this randomized trial of screening colonoscopy for colon cancer, and why it has caused so much – perhaps – confusion, calls for change, and concern out there.

Dr Johnson, can you give us a brief overview of what this trial was about?

Dr. Johnson: This was a randomized trial looking at screening colonoscopy versus no screening test whatsoever. They looked at the outcomes of prevention of cancer and the prevention of colon cancer–related death.

The short answer was that it was disappointing as it relates to colonoscopy. The study looked at patients from four European countries, with data from three of them (Norway, Poland, and Sweden) ultimately analyzed in this report in NEJM. It got a lot of attention because it surprised a lot of people by saying maybe colonoscopy wasn’t quite as good as we thought it was.

They tried to correct that by only looking at the numbers of patients who got their colonoscopy screening, which still showed value, but it was less than that we’ve seen before. There’s lots of reasons for that, which we’ll discuss shortly.
 

An invitation to a screening

Dr. Wilson: This was a bit of an interesting trial design. I think I’m correct, Dr Lin, that this was the first randomized trial of screening colonoscopy. But they didn’t really randomize people to get a colonoscopy versus not get a colonoscopy. Can you tell us why this differed from that study design, which I’d have thought would be simpler way of assessing this?

Dr. Lin: It’s definitely an important point to highlight about the study. What investigators did was randomize patients to receive an invitation to get a screening colonoscopy. When the trial was set up, they randomized people before they were asked whether they wanted to participate in the study. If you did it the other way around, by first asking them whether they wanted to be in the study and then randomizing them, you would have been assured that more of them probably would have gotten the colonoscopy.

But in this case, they were more interested in figuring out the real-life results of having a national program that invited patients to receive screening colonoscopy. Because we know that everyone that you recommend to get a colonoscopy doesn’t necessarily want to do that, forgets to do it, or something happens that prevents their actually getting it.

When it comes to measuring the effectiveness of the colonoscopy, it perhaps wasn’t the greatest type of study to do that. But I think it did provide some information about what would happen if you invited people to get colonoscopy, in terms of how many would do it and the results overall for that population.
 

Lower participation numbers than expected

Dr. Wilson: Dr. Johnson, the data show that 42% of people who were in that invitation arm followed through and got their colonoscopy. You’re a gastroenterologist. Does that seem low or about right? Do about half of people who should get a colonoscopy end up getting one?

Dr. Johnson: No, it’s low. In the United States, those numbers are probably in the 70% range. Certainly, the test doesn’t work for people who don’t get the test performed. So, if 42% of those randomized to receive an invitation to get the colonoscopy got one, that really means the majority of patients never got the test.

Dr. Wilson: Certainly, we wouldn’t expect impressive results if they don’t get the test. But on the other hand, I imagine that people who choose to get the test when they’re invited are sort of a different breed. Perhaps they’re more health conscious or living in other healthy ways. Is that something we should worry about when we look at these results?

Dr. Johnson: I don’t think you can stratify based on this study. Factors like ethnicities and diet weren’t really explained. The key element that will hopefully have the major take-home impact is quality. It’s not just the test. It’s how the test is done.

The key results

Dr. Wilson: Let’s start with the big picture. This was a study looking at everyone invited; not the subgroup of people who got the colonoscopy, but the real randomized study population.

Dr. Lin, the study did show that the invited group had a lower risk of colon cancer over the next 10 years. That’s a good thing, I imagine.

Dr. Lin: I think that’s a significant benefit. Initially in the first few years, they had more colon cancers diagnosed. But that’s probably because those were cancers that were already existing and couldn’t be prevented by the test.

But then over the years the curves crossed, and by the end of the average follow-up of 10 years, there was a significantly lower rate of colon cancers being detected. That’s as you would expect, because you’re finding polyps and removing them before they became colon cancer.

Dr. Wilson: Dr. Johnson, is that the natural history of colon cancer? It starts out as a polyp that maybe can be easily removed and doesn’t require more therapy. Is that why screening colonoscopy is helpful?

Dr. Johnson: The ultimate goal of screening is prevention of cancer, rather than detection of cancer. That occurs by identification and complete removal of the polyps that we find that are precancerous. The key is, first, detection, and second, resection. Adequate resection comes down to some very significant issues of quality, which are questions that I’d raised about this study, and we can talk about momentarily.

Dr. Wilson: Absolutely. Let me first go through the two other big findings in this study.

The fact that there were fewer cases of colon cancer over 10 years seems good. But colon cancer mortality was not significantly different in the two groups. Now, of course, we know that not everyone got a colonoscopy. I would have expected though, if you had less colon cancer, you’d have less death from colon cancer.

Dr. Lin, what might explain this disconnect?

Dr. Lin: I think there are a couple of possible explanations.

One explanation is that they just didn’t follow the people long enough. Colon cancer takes a long time to go from an adenoma to cancer, and from cancer to something that would cause the patient’s death. You may need to follow them for longer than the 10 years that most of these patients were followed to see that benefit. I think there probably will be benefit after a while, because if you are removing colon cancers that otherwise would have progressed and metastasized, you often see a benefit.

We also have to consider the other possibility that not all the polyps removed necessarily were going to progress to advanced cancer. Therefore, you weren’t seeing the death benefit because not every polyp that was removed was necessarily going to cause health consequences.

In colonoscopy, quality is key to success

Dr. Wilson: You’re removing things and have no way of knowing in advance which are the bad ones and which aren’t.

Dr. Johnson, you’ve mentioned several times now that the quality of colonoscopy matters here. So, I’m intuiting that it’s not one-size-fits-all, that it’s not all the same. What do you mean by quality of colonoscopy, and what was it in the NEJM study?

Dr. Johnson: Quality colonoscopy is the quality of the whole process. It starts with the warm-up, if you will, and the clean out for the procedure. That allows the colonoscopist to be able to identify precancerous polyps, which we call adenomas (there are other precancerous polyps called sessile serrated lesions).

The identification of adenomas is extremely important. Even a small increase in the detection of those precancerous polyps has benefits. Well-performed studies looking at large databases show that a small, 1% increase in the adenoma detection leads to a 3% decrease in colon cancer and a 5% decrease in colon cancer–related death. There’s a huge array of effect when we talk about small increases in the adenoma detection rate.

Now, let’s go back to this study in NEJM.

If we base quality on the physician performing the colonoscopy, and say that the colonoscopy is achieving the act of getting all the way around the colon, but not all physicians in the study were able to do that, it starts to raise the question about quality, because adenoma detection is so important. Earlier reports from this group [Nordic-European Initiative on Colorectal Cancer Study Group] have shown that the adenoma detection rates have been way below the national thresholds. So, this raises the question of whether they found the polyp, and then whether they resected the polyp. They also don’t tell us where these cancers were. It is about the colonoscopy quality. It’s not the instrument. It’s the process.
 

An overview of other screening tools

Dr. Wilson: Dr. Lin, colonoscopy, which requires prep and anesthesia, is not the only colon cancer screening method we have. In fact, there are a bunch. I think we’re on board saying it’s probably better to detect colon cancer early than not detect it. But what are our other options aside from colonoscopy that can allow for early detection of colon cancer?

Dr. Lin: For most of my career, there were three options that I presented patients with. The first was the fecal test, which used to be in the form of initial hemoccult tests. These have been mostly replaced by fecal immunochemical testing. But they’re both just basically looking for the presence of blood in the stool. Anyone who has a positive test would be referred for a diagnostic colonoscopy.

The other test besides colonoscopy, which has been largely phased out in the United States, although it is still very much used in Canada and much of Europe, is flexible sigmoidoscopy. Until this study, the tests supported by randomized controlled trials were the fecal tests and flexible sigmoidoscopy.

Interestingly, there was a recent systematic review of flexible sigmoidoscopy looking at four trials and their effects over 15 years. They showed not only a reduction in colon cancer, but also a reduction in colon cancer mortality, and even a small reduction in all-cause mortality.

I believe three out of the four trials were done where the patients were consented and then randomized, so they had a higher uptake of the procedure.

But when you compare this with the colonoscopy trial, it really isn’t that impressive. You would expect a much larger benefit, because obviously you’re looking at the entire colon. But you really didn’t see that. It was, at best, maybe equivalent to sigmoidoscopy, but not a whole lot better.

Dr. Johnson: Perry, you mentioned sedation. It’s important to understand that this particular cohort of patients are from Norway, Sweden, and Poland, where it’s very much the norm to not get sedation for your colonoscopy. Any of the [audience] who have had colonoscopy will tell you that they are not ones to say, “Don’t give me sedation.” The rate of sedation is around 11% in Norway, maybe 23% in Sweden, and around 45% in Poland. So, the examiner and the patient were never really super comfortable.

I’ve done 50,000 colonoscopies in my career, and many nonsedated. We know that taking time increases the finding of polyps and the adequate identification and resection. So, that ability to perform at a high quality is very much impacted when the patients aren’t comfortable.

Dr. Wilson: Dr. Johnson, we brought up flexible sigmoidoscopy. For the patients watching whose doctors are talking to them about screening colonoscopy, what’s the difference?

Dr. Johnson: Flexible sigmoidoscopy is just a short scope examination, in which you see about one-third of the colon. I’ve been in the field for 45 years, and during that time we’ve seen that there’s a progressive increase in the development of cancers above that bottom third of the colon to the higher end, the two-thirds of the colon that you would miss without doing a full colonoscopy. Also, flexible sigmoidoscopy typically does not get covered for sedation.

Again, if you do the exam and find something, then you’re going to have to come back and do an adequate resection with a colonoscopy. So, one-stop-shopping colon cancer screening is not about detection of cancer, it’s about prevention of cancer, and that’s what colonoscopy does.

Patients want convenience, but at what cost?

Dr. Wilson: Dr. Lin, how are your patients in your family practice handling this study? Have conversations changed around colon cancer screening? What are people asking about these days?

Dr. Lin: I don’t think the conversations have changed in my practice that much. When patients ask about this study, we do discuss the limitations, that it wasn’t designed to assess the maximum benefit of getting a colonoscopy because the majority of people assigned to that group didn’t get colonoscopy.

But I think it is an opportunity in primary care to consider the way we present the options to patients. Because I would guess that a majority of primary care physicians, when they present the options, would say colonoscopy is the gold standard and recommend their patients get it. And they only offer fecal testing to patients who don’t want the colonoscopy or really refuse.

That hasn’t been my practice. I’m usually more agnostic, because there are both harms and benefits. If you get a fecal test, the chance of you having a complication from colonoscopy is automatically lower because most of those people will not get colonoscopy. Now obviously, the complications with colonoscopy are pretty rare and usually self-limited, but they do exist. If you’re doing lots and lots of these, eventually you’ll see them. Probably all primary care physicians have patients who’ve had a complication from colonoscopy and may or may not have regretted it depending on how information was presented.

But I feel like this study reinforces my feeling that we ought to be presenting these, and not saying one is superior or inferior to the other. Instead, I’d base it on what the patient’s priorities are. But I feel like this study reinforces my feeling that we ought to be presenting these, and not saying one is superior or inferior to the other. Instead, I’d base it on what the patient’s priorities are. Is your priority finding every single cancer? Do you want to know exactly what the benefit is? I think with colonoscopy, we’re still trying to figure out exactly what the benefit is. Whereas we can say it pretty confidently for fecal tests because we have those randomized trials.

Dr. Wilson: Dr. Johnson, I think patients who are watching need to know, first of all, that if they do the fecal test route, a positive fecal test does lead to colonoscopy. In some sense, all roads lead to colonoscopy once you have a positive screening test. So, I can certainly see the value of just sort of skipping to that point. But what about this risk-versus-benefit relationship? Colonoscopy, albeit a relatively safe procedure, is still a procedure. There is some risk associated with it. If we can get the same benefit from yearly fecal immunochemical testing, is that a better choice potentially, at least for patients at average risk?

Dr. Johnson: The stool-based testing is really more effective for detection of cancer. That’s not screening, where the entire goal is the prevention of cancer. The fecal-based testing, including the stool-based DNA testing, misses the majority of precancerous polyps. And the fecal immunochemical tests, which Dr. Lin just mentioned, misses virtually all of them. We really want to get to the prevention of cancer, meaning identification and removal of polyps, not just screening for cancer.

Dr. Wilson: Do you see anything on the horizon that could unseat colonoscopy as, to quote Dr. Lin, the potential gold standard for screening for colon cancer?

Dr. Johnson: I think not on the horizon for identification and removal of polyps. That’s really the gold standard. Technology continues to advance. We’ll see what happens. But on the short and intermediate horizon, colonoscopy is going to be needed.

We are finding that some patients are starting to acquiesce to stool-based testing because they can do it at home. Maybe they don’t have to do a prep. We’re talking about screening only here, not about the follow-up of patients who have a family history, patients who have colitis, patients who have had colon polyps, or other reasons. Stool-based testing is not an option for the follow-up of those patients.

Convenience testing, in the face of COVID, also has thrown a wrench into things. Patients may have wanted to stay home and do these tests. Again, we need to be proactive, not reactive. We want to prevent cancer, not detect it.
 

Changing advice in the face of younger screening thresholds

Dr. Wilson: Dr. Lin, I’m 42 years old. I don’t believe I’m at any increased risk of colon cancer based on my family history or other risk factors. I’m 3 years away from when the U.S. Preventive Services Task Force tells me I should potentially consider starting to screen for colon cancer. That recommendation has recently been moved down from 50 years old to 45 years old. So, it’s on my mind as I approach that age. What do you advise younger patients approaching 45 right now in terms of screening for colon cancer?

Dr. Lin: For patients with the risk factors that Dr. Johnson mentioned, I would recommend screening colonoscopy as the initial test.

Assuming you don’t have those risk factors, I present it as we have a couple of different fecal tests. There’s the traditional one that just looks for blood. Then there’s the newer one that also adds DNA, which is more sensitive for colorectal cancer, but a little less specific, which is a problem just because there are more false positives.

But you need to compare that with colonoscopy, which you only need to get done ideally every 10 years if there are no findings. That is more complete. And theoretically, as we’ve been talking about, it would also prevent as well as detect early cancers.

So, I think it’s really down to your preference in terms of how the various factors that come into play, such as convenience of the test and your level of concern about cancer. I do tell patients that family history of cancer is not terribly predictive of whether you get it or not. A lot of people unfortunately who develop colorectal cancer have no previous family history. Diet will come into play to some extent. There are some things that point to increased risk for colorectal cancer if you have a diet high in red meat and things like that. But ultimately, it really is up to the patient. I lay out the options, and whatever they choose, I’m happy to pursue.

But the most important thing is that they do some test, because doing no test is not going to help anyone. I do agree with the notion that the best test is the test that gets done.

Dr. Wilson: Absolutely. I think the NEJM study supports that, even when we’re talking about colonoscopy.

Dr. Johnson, you’ve had some criticisms about the NEJM study, and I think they make sense. At the same time, as this is the first randomized trial of colonoscopy, it’s kind of the only data we have. Are we going to get better data? Are there other studies going on out there that might help shed some light on what’s turning out to be a complicated issue?

Dr. Johnson: Yes, there are ongoing studies. They’re not taking place within the United States, because you couldn’t get through a no-screening option trial. There are comparative studies that are probably still 5 years away looking at stool-based testing.

But again, we have to recognize that if you do these alternative tests that were eloquently discussed by Dr. Lin, and not the colonoscopy, which would be every 10 years with high-quality performance, that you have to annualize or do them in sequence. It’s important that you follow up on those with regularity. It’s not just a one-time test every 10 years for these individual tests.

And any of the time that those tests are ordered, the patient should be instructed that if it’s positive you need a colonoscopy. We’re seeing a lot of slippage on that front for the stool-based testing. Convenience is not the answer. It’s getting the job done.

Dr. Wilson: Would you agree, Dr. Johnson, that for patients that really don’t want to do the colonoscopy for one reason or another, and you’ve done your best in explaining what you think the risks and benefits are, that you’d rather have them get something than nothing?

Dr. Johnson: Absolutely. It comes down to what I recommend and then what you decide. But I still make the point explicit: If we’ve gone through those checkpoints and it’s positive, we agree that you understand that colonoscopy is the next step.

Final take-home messages

Dr. Wilson: Dr. Lin, I’ll turn the last word over to you, as the person who is probably discussing the choice of screening modalities more than any of us, before someone would get referred to someone like Dr. Johnson. What’s your final take-home message about the NEJM study and the state of colon cancer screening in the United States?

Dr. Lin: My take-home points about the study are that there were some limitations, but it is good to finally have a randomized trial of colonoscopy screening 2 decades after we really started doing that in the United States. It won’t immediately change – nor do I think it should – the way we practice and discuss different options. I think that some of Dr. Johnson’s points about making sure that whoever’s doing the colonoscopies for your practices is doing it in a high-quality way are really important. Just as it’s important, if you’re doing the fecal tests, to make sure that all patients who have positives get expeditiously referred for colonoscopy.

Dr. Johnson: Perry, I’d like to make one concluding comment as the gastroenterology expert in this discussion. I’ve had countless questions about this study from my patients and my peers. I tell them the following: Don’t let the headlines mislead you.

When you look at this study, the instrument is not so much the question. We know that getting the test is the first step in colon cancer screening. But we also know that getting the test done, with the highest-quality providers and the best-quality performance, is really the key to optimizing the true value of colonoscopy for colon cancer prevention.

So please don’t lose sight of this when reading the headlines in the media around this study. We really need to analyze the true characteristics of what we call a quality performance, because that’s what drives success and that’s what prevents colon cancer.

Dr. Wilson: Dr. Johnson and Dr. Lin, thank you very much. I appreciate you spending time with me here today and wish you all the best.

I guess I’ll sum up by saying that if you’re getting a colonoscopy, make sure it’s a good one. But do get screened.

This video originally appeared on WebMD. A transcript appeared on Medscape.com.

This transcript has been edited for clarity.

F. Perry Wilson, MD, MSCE: Hello, and thank you for joining us today for what promises to be a lively discussion about screening for colon cancer.

My name is Perry Wilson. I’m an associate professor of medicine and director of the Clinical and Translational Research Accelerator at the Yale School of Medicine. My new book, “How Medicine Works and When It Doesn’t: Learning Who to Trust to Get and Stay Healthy,” is available for pre-order now anywhere that books are sold.

I’m joined by two wonderful experts. Dr. David Johnson is a professor of medicine and the chief of gastroenterology at the Eastern Virginia School of Medicine. He is the past president of the American College of Gastroenterology. And I’m very encouraged to see that he’s won a Distinguished Educator Award for his efforts in gastroenterology.

I’m also joined by Dr Kenny Lin. He’s a frequent contributor to Medscape and WebMD. He’s a family physician and public health consultant from Lancaster, Pa., and deputy editor of the American Family Physician journal. He’s also a teacher of residents and students at Lancaster General Health and the Penn Medicine Family Medicine Residency program.

So, we have two great educators with us today to hopefully help teach us something about colon cancer and colon cancer screening. Thank you for joining me today.

David A. Johnson, MD: Thanks for having us.

Kenneth W. Lin, MD, MPH: Good to be here.

Dr. Wilson: Colon cancer is the second leading cause of cancer mortality in the United States. A little over 50,000 people die every year in the United States due to colon cancer.

A month ago, I would have said that there was a pretty broad consensus, at least from my perspective, that people should be getting colonoscopies. That’s certainly what we tell our patients.

Then a paper came out in the New England Journal of Medicine, a very prestigious journal, that has caused a lot of consternation online and led to my receiving a lot questions from patients and their family members. Today, I’d like to talk about this randomized trial of screening colonoscopy for colon cancer, and why it has caused so much – perhaps – confusion, calls for change, and concern out there.

Dr Johnson, can you give us a brief overview of what this trial was about?

Dr. Johnson: This was a randomized trial looking at screening colonoscopy versus no screening test whatsoever. They looked at the outcomes of prevention of cancer and the prevention of colon cancer–related death.

The short answer was that it was disappointing as it relates to colonoscopy. The study looked at patients from four European countries, with data from three of them (Norway, Poland, and Sweden) ultimately analyzed in this report in NEJM. It got a lot of attention because it surprised a lot of people by saying maybe colonoscopy wasn’t quite as good as we thought it was.

They tried to correct that by only looking at the numbers of patients who got their colonoscopy screening, which still showed value, but it was less than that we’ve seen before. There’s lots of reasons for that, which we’ll discuss shortly.
 

An invitation to a screening

Dr. Wilson: This was a bit of an interesting trial design. I think I’m correct, Dr Lin, that this was the first randomized trial of screening colonoscopy. But they didn’t really randomize people to get a colonoscopy versus not get a colonoscopy. Can you tell us why this differed from that study design, which I’d have thought would be simpler way of assessing this?

Dr. Lin: It’s definitely an important point to highlight about the study. What investigators did was randomize patients to receive an invitation to get a screening colonoscopy. When the trial was set up, they randomized people before they were asked whether they wanted to participate in the study. If you did it the other way around, by first asking them whether they wanted to be in the study and then randomizing them, you would have been assured that more of them probably would have gotten the colonoscopy.

But in this case, they were more interested in figuring out the real-life results of having a national program that invited patients to receive screening colonoscopy. Because we know that everyone that you recommend to get a colonoscopy doesn’t necessarily want to do that, forgets to do it, or something happens that prevents their actually getting it.

When it comes to measuring the effectiveness of the colonoscopy, it perhaps wasn’t the greatest type of study to do that. But I think it did provide some information about what would happen if you invited people to get colonoscopy, in terms of how many would do it and the results overall for that population.
 

Lower participation numbers than expected

Dr. Wilson: Dr. Johnson, the data show that 42% of people who were in that invitation arm followed through and got their colonoscopy. You’re a gastroenterologist. Does that seem low or about right? Do about half of people who should get a colonoscopy end up getting one?

Dr. Johnson: No, it’s low. In the United States, those numbers are probably in the 70% range. Certainly, the test doesn’t work for people who don’t get the test performed. So, if 42% of those randomized to receive an invitation to get the colonoscopy got one, that really means the majority of patients never got the test.

Dr. Wilson: Certainly, we wouldn’t expect impressive results if they don’t get the test. But on the other hand, I imagine that people who choose to get the test when they’re invited are sort of a different breed. Perhaps they’re more health conscious or living in other healthy ways. Is that something we should worry about when we look at these results?

Dr. Johnson: I don’t think you can stratify based on this study. Factors like ethnicities and diet weren’t really explained. The key element that will hopefully have the major take-home impact is quality. It’s not just the test. It’s how the test is done.

The key results

Dr. Wilson: Let’s start with the big picture. This was a study looking at everyone invited; not the subgroup of people who got the colonoscopy, but the real randomized study population.

Dr. Lin, the study did show that the invited group had a lower risk of colon cancer over the next 10 years. That’s a good thing, I imagine.

Dr. Lin: I think that’s a significant benefit. Initially in the first few years, they had more colon cancers diagnosed. But that’s probably because those were cancers that were already existing and couldn’t be prevented by the test.

But then over the years the curves crossed, and by the end of the average follow-up of 10 years, there was a significantly lower rate of colon cancers being detected. That’s as you would expect, because you’re finding polyps and removing them before they became colon cancer.

Dr. Wilson: Dr. Johnson, is that the natural history of colon cancer? It starts out as a polyp that maybe can be easily removed and doesn’t require more therapy. Is that why screening colonoscopy is helpful?

Dr. Johnson: The ultimate goal of screening is prevention of cancer, rather than detection of cancer. That occurs by identification and complete removal of the polyps that we find that are precancerous. The key is, first, detection, and second, resection. Adequate resection comes down to some very significant issues of quality, which are questions that I’d raised about this study, and we can talk about momentarily.

Dr. Wilson: Absolutely. Let me first go through the two other big findings in this study.

The fact that there were fewer cases of colon cancer over 10 years seems good. But colon cancer mortality was not significantly different in the two groups. Now, of course, we know that not everyone got a colonoscopy. I would have expected though, if you had less colon cancer, you’d have less death from colon cancer.

Dr. Lin, what might explain this disconnect?

Dr. Lin: I think there are a couple of possible explanations.

One explanation is that they just didn’t follow the people long enough. Colon cancer takes a long time to go from an adenoma to cancer, and from cancer to something that would cause the patient’s death. You may need to follow them for longer than the 10 years that most of these patients were followed to see that benefit. I think there probably will be benefit after a while, because if you are removing colon cancers that otherwise would have progressed and metastasized, you often see a benefit.

We also have to consider the other possibility that not all the polyps removed necessarily were going to progress to advanced cancer. Therefore, you weren’t seeing the death benefit because not every polyp that was removed was necessarily going to cause health consequences.

In colonoscopy, quality is key to success

Dr. Wilson: You’re removing things and have no way of knowing in advance which are the bad ones and which aren’t.

Dr. Johnson, you’ve mentioned several times now that the quality of colonoscopy matters here. So, I’m intuiting that it’s not one-size-fits-all, that it’s not all the same. What do you mean by quality of colonoscopy, and what was it in the NEJM study?

Dr. Johnson: Quality colonoscopy is the quality of the whole process. It starts with the warm-up, if you will, and the clean out for the procedure. That allows the colonoscopist to be able to identify precancerous polyps, which we call adenomas (there are other precancerous polyps called sessile serrated lesions).

The identification of adenomas is extremely important. Even a small increase in the detection of those precancerous polyps has benefits. Well-performed studies looking at large databases show that a small, 1% increase in the adenoma detection leads to a 3% decrease in colon cancer and a 5% decrease in colon cancer–related death. There’s a huge array of effect when we talk about small increases in the adenoma detection rate.

Now, let’s go back to this study in NEJM.

If we base quality on the physician performing the colonoscopy, and say that the colonoscopy is achieving the act of getting all the way around the colon, but not all physicians in the study were able to do that, it starts to raise the question about quality, because adenoma detection is so important. Earlier reports from this group [Nordic-European Initiative on Colorectal Cancer Study Group] have shown that the adenoma detection rates have been way below the national thresholds. So, this raises the question of whether they found the polyp, and then whether they resected the polyp. They also don’t tell us where these cancers were. It is about the colonoscopy quality. It’s not the instrument. It’s the process.
 

An overview of other screening tools

Dr. Wilson: Dr. Lin, colonoscopy, which requires prep and anesthesia, is not the only colon cancer screening method we have. In fact, there are a bunch. I think we’re on board saying it’s probably better to detect colon cancer early than not detect it. But what are our other options aside from colonoscopy that can allow for early detection of colon cancer?

Dr. Lin: For most of my career, there were three options that I presented patients with. The first was the fecal test, which used to be in the form of initial hemoccult tests. These have been mostly replaced by fecal immunochemical testing. But they’re both just basically looking for the presence of blood in the stool. Anyone who has a positive test would be referred for a diagnostic colonoscopy.

The other test besides colonoscopy, which has been largely phased out in the United States, although it is still very much used in Canada and much of Europe, is flexible sigmoidoscopy. Until this study, the tests supported by randomized controlled trials were the fecal tests and flexible sigmoidoscopy.

Interestingly, there was a recent systematic review of flexible sigmoidoscopy looking at four trials and their effects over 15 years. They showed not only a reduction in colon cancer, but also a reduction in colon cancer mortality, and even a small reduction in all-cause mortality.

I believe three out of the four trials were done where the patients were consented and then randomized, so they had a higher uptake of the procedure.

But when you compare this with the colonoscopy trial, it really isn’t that impressive. You would expect a much larger benefit, because obviously you’re looking at the entire colon. But you really didn’t see that. It was, at best, maybe equivalent to sigmoidoscopy, but not a whole lot better.

Dr. Johnson: Perry, you mentioned sedation. It’s important to understand that this particular cohort of patients are from Norway, Sweden, and Poland, where it’s very much the norm to not get sedation for your colonoscopy. Any of the [audience] who have had colonoscopy will tell you that they are not ones to say, “Don’t give me sedation.” The rate of sedation is around 11% in Norway, maybe 23% in Sweden, and around 45% in Poland. So, the examiner and the patient were never really super comfortable.

I’ve done 50,000 colonoscopies in my career, and many nonsedated. We know that taking time increases the finding of polyps and the adequate identification and resection. So, that ability to perform at a high quality is very much impacted when the patients aren’t comfortable.

Dr. Wilson: Dr. Johnson, we brought up flexible sigmoidoscopy. For the patients watching whose doctors are talking to them about screening colonoscopy, what’s the difference?

Dr. Johnson: Flexible sigmoidoscopy is just a short scope examination, in which you see about one-third of the colon. I’ve been in the field for 45 years, and during that time we’ve seen that there’s a progressive increase in the development of cancers above that bottom third of the colon to the higher end, the two-thirds of the colon that you would miss without doing a full colonoscopy. Also, flexible sigmoidoscopy typically does not get covered for sedation.

Again, if you do the exam and find something, then you’re going to have to come back and do an adequate resection with a colonoscopy. So, one-stop-shopping colon cancer screening is not about detection of cancer, it’s about prevention of cancer, and that’s what colonoscopy does.

Patients want convenience, but at what cost?

Dr. Wilson: Dr. Lin, how are your patients in your family practice handling this study? Have conversations changed around colon cancer screening? What are people asking about these days?

Dr. Lin: I don’t think the conversations have changed in my practice that much. When patients ask about this study, we do discuss the limitations, that it wasn’t designed to assess the maximum benefit of getting a colonoscopy because the majority of people assigned to that group didn’t get colonoscopy.

But I think it is an opportunity in primary care to consider the way we present the options to patients. Because I would guess that a majority of primary care physicians, when they present the options, would say colonoscopy is the gold standard and recommend their patients get it. And they only offer fecal testing to patients who don’t want the colonoscopy or really refuse.

That hasn’t been my practice. I’m usually more agnostic, because there are both harms and benefits. If you get a fecal test, the chance of you having a complication from colonoscopy is automatically lower because most of those people will not get colonoscopy. Now obviously, the complications with colonoscopy are pretty rare and usually self-limited, but they do exist. If you’re doing lots and lots of these, eventually you’ll see them. Probably all primary care physicians have patients who’ve had a complication from colonoscopy and may or may not have regretted it depending on how information was presented.

But I feel like this study reinforces my feeling that we ought to be presenting these, and not saying one is superior or inferior to the other. Instead, I’d base it on what the patient’s priorities are. But I feel like this study reinforces my feeling that we ought to be presenting these, and not saying one is superior or inferior to the other. Instead, I’d base it on what the patient’s priorities are. Is your priority finding every single cancer? Do you want to know exactly what the benefit is? I think with colonoscopy, we’re still trying to figure out exactly what the benefit is. Whereas we can say it pretty confidently for fecal tests because we have those randomized trials.

Dr. Wilson: Dr. Johnson, I think patients who are watching need to know, first of all, that if they do the fecal test route, a positive fecal test does lead to colonoscopy. In some sense, all roads lead to colonoscopy once you have a positive screening test. So, I can certainly see the value of just sort of skipping to that point. But what about this risk-versus-benefit relationship? Colonoscopy, albeit a relatively safe procedure, is still a procedure. There is some risk associated with it. If we can get the same benefit from yearly fecal immunochemical testing, is that a better choice potentially, at least for patients at average risk?

Dr. Johnson: The stool-based testing is really more effective for detection of cancer. That’s not screening, where the entire goal is the prevention of cancer. The fecal-based testing, including the stool-based DNA testing, misses the majority of precancerous polyps. And the fecal immunochemical tests, which Dr. Lin just mentioned, misses virtually all of them. We really want to get to the prevention of cancer, meaning identification and removal of polyps, not just screening for cancer.

Dr. Wilson: Do you see anything on the horizon that could unseat colonoscopy as, to quote Dr. Lin, the potential gold standard for screening for colon cancer?

Dr. Johnson: I think not on the horizon for identification and removal of polyps. That’s really the gold standard. Technology continues to advance. We’ll see what happens. But on the short and intermediate horizon, colonoscopy is going to be needed.

We are finding that some patients are starting to acquiesce to stool-based testing because they can do it at home. Maybe they don’t have to do a prep. We’re talking about screening only here, not about the follow-up of patients who have a family history, patients who have colitis, patients who have had colon polyps, or other reasons. Stool-based testing is not an option for the follow-up of those patients.

Convenience testing, in the face of COVID, also has thrown a wrench into things. Patients may have wanted to stay home and do these tests. Again, we need to be proactive, not reactive. We want to prevent cancer, not detect it.
 

Changing advice in the face of younger screening thresholds

Dr. Wilson: Dr. Lin, I’m 42 years old. I don’t believe I’m at any increased risk of colon cancer based on my family history or other risk factors. I’m 3 years away from when the U.S. Preventive Services Task Force tells me I should potentially consider starting to screen for colon cancer. That recommendation has recently been moved down from 50 years old to 45 years old. So, it’s on my mind as I approach that age. What do you advise younger patients approaching 45 right now in terms of screening for colon cancer?

Dr. Lin: For patients with the risk factors that Dr. Johnson mentioned, I would recommend screening colonoscopy as the initial test.

Assuming you don’t have those risk factors, I present it as we have a couple of different fecal tests. There’s the traditional one that just looks for blood. Then there’s the newer one that also adds DNA, which is more sensitive for colorectal cancer, but a little less specific, which is a problem just because there are more false positives.

But you need to compare that with colonoscopy, which you only need to get done ideally every 10 years if there are no findings. That is more complete. And theoretically, as we’ve been talking about, it would also prevent as well as detect early cancers.

So, I think it’s really down to your preference in terms of how the various factors that come into play, such as convenience of the test and your level of concern about cancer. I do tell patients that family history of cancer is not terribly predictive of whether you get it or not. A lot of people unfortunately who develop colorectal cancer have no previous family history. Diet will come into play to some extent. There are some things that point to increased risk for colorectal cancer if you have a diet high in red meat and things like that. But ultimately, it really is up to the patient. I lay out the options, and whatever they choose, I’m happy to pursue.

But the most important thing is that they do some test, because doing no test is not going to help anyone. I do agree with the notion that the best test is the test that gets done.

Dr. Wilson: Absolutely. I think the NEJM study supports that, even when we’re talking about colonoscopy.

Dr. Johnson, you’ve had some criticisms about the NEJM study, and I think they make sense. At the same time, as this is the first randomized trial of colonoscopy, it’s kind of the only data we have. Are we going to get better data? Are there other studies going on out there that might help shed some light on what’s turning out to be a complicated issue?

Dr. Johnson: Yes, there are ongoing studies. They’re not taking place within the United States, because you couldn’t get through a no-screening option trial. There are comparative studies that are probably still 5 years away looking at stool-based testing.

But again, we have to recognize that if you do these alternative tests that were eloquently discussed by Dr. Lin, and not the colonoscopy, which would be every 10 years with high-quality performance, that you have to annualize or do them in sequence. It’s important that you follow up on those with regularity. It’s not just a one-time test every 10 years for these individual tests.

And any of the time that those tests are ordered, the patient should be instructed that if it’s positive you need a colonoscopy. We’re seeing a lot of slippage on that front for the stool-based testing. Convenience is not the answer. It’s getting the job done.

Dr. Wilson: Would you agree, Dr. Johnson, that for patients that really don’t want to do the colonoscopy for one reason or another, and you’ve done your best in explaining what you think the risks and benefits are, that you’d rather have them get something than nothing?

Dr. Johnson: Absolutely. It comes down to what I recommend and then what you decide. But I still make the point explicit: If we’ve gone through those checkpoints and it’s positive, we agree that you understand that colonoscopy is the next step.

Final take-home messages

Dr. Wilson: Dr. Lin, I’ll turn the last word over to you, as the person who is probably discussing the choice of screening modalities more than any of us, before someone would get referred to someone like Dr. Johnson. What’s your final take-home message about the NEJM study and the state of colon cancer screening in the United States?

Dr. Lin: My take-home points about the study are that there were some limitations, but it is good to finally have a randomized trial of colonoscopy screening 2 decades after we really started doing that in the United States. It won’t immediately change – nor do I think it should – the way we practice and discuss different options. I think that some of Dr. Johnson’s points about making sure that whoever’s doing the colonoscopies for your practices is doing it in a high-quality way are really important. Just as it’s important, if you’re doing the fecal tests, to make sure that all patients who have positives get expeditiously referred for colonoscopy.

Dr. Johnson: Perry, I’d like to make one concluding comment as the gastroenterology expert in this discussion. I’ve had countless questions about this study from my patients and my peers. I tell them the following: Don’t let the headlines mislead you.

When you look at this study, the instrument is not so much the question. We know that getting the test is the first step in colon cancer screening. But we also know that getting the test done, with the highest-quality providers and the best-quality performance, is really the key to optimizing the true value of colonoscopy for colon cancer prevention.

So please don’t lose sight of this when reading the headlines in the media around this study. We really need to analyze the true characteristics of what we call a quality performance, because that’s what drives success and that’s what prevents colon cancer.

Dr. Wilson: Dr. Johnson and Dr. Lin, thank you very much. I appreciate you spending time with me here today and wish you all the best.

I guess I’ll sum up by saying that if you’re getting a colonoscopy, make sure it’s a good one. But do get screened.

This video originally appeared on WebMD. A transcript appeared on Medscape.com.