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Electronic letters published:
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U.S. Preventive Services Task Force Recommendation on Screening for COPD
COPD and the role of Spirometry
Screening Spirometry In Asymptomatic Copd
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Ned Calonge, MD, MPH U.S. Preventive Services Task Force, Diana B. Petitti, MD, MPH, and Kenneth Lin, MD
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ned.calonge{at}state.co.us Ned Calonge, et al.
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June 18, 2008 Editor Annals of Internal Medicine Dear Editor: We appreciate the letter from Drs. Petty and Mannino regarding the U.S. Preventive Service Task Force’s (USPSTF) recent recommendation against screening for COPD using spirometry (1). Their comments provide us the opportunity to emphasize some important issues that the USPSTF considered in making this recommendation. Identifying a disease earlier in its natural course does not automatically improve health outcomes. Clinicians should screen patients only if 1) effective interventions are more beneficial during the asymptomatic disease stage than at clinical diagnosis, and 2) when the harms of screening or treatment do not outweigh the benefits. The USPSTF’s review of the evidence (2) found that for more than 90 percent of individuals without respiratory symptoms who would have airflow obstruction on spirometry, the sole effective therapy was tobacco cessation interventions, which the USPSTF already recommends for all adult smokers (3). Even accounting for the few individuals who might gain symptomatic relief from medications, several hundred patients would need to be screened with spirometry to defer a single COPD exacerbation. The USPSTF judged that the harms of such screening – false-positive tests leading to adverse effects from treatment (e.g., tachycardia, urinary retention), coupled with the significant time and effort required by patients and the health care system – were at least equal to this small potential benefit. Although Drs. Petty and Mannino argue that providing smokers with spirometry results may motivate them to quit smoking, none of the studies they cite were designed to appropriately test this hypothesis. For example, since all of the participants in the randomized trial by Parkes et al. (4) had spirometry, the only definite conclusion that can be drawn is that communicating spirometry results to smokers in understandable terms (lung age) was more effective than providing the underlying clinical data. The USPSTF does not discourage clinicians from utilizing spirometry to diagnose patients with unexplained respiratory symptoms or to monitor patients with a previously established pulmonary diagnosis. We are puzzled by the assertion that recommending against the inappropriate overuse of spirometry (screening) will lead to underuse of the test in appropriate (diagnostic or monitoring) clinical situations. Although the American College of Physicians’ COPD practice guideline (5) came to the same conclusion about screening as did the USPSTF, the USPSTF includes a broad representation of primary care clinicians and generalists and has an independent guideline development process. The difference in the composition of and processes used by these two groups provides evidence that evidence-based guidelines are highly reliable. Ned Calonge, MD, MPH Diana B. Petitti, MD, MPH Kenneth Lin, MD References 1. U.S. Preventive Services Task Force. Screening for chronic obstructive pulmonary disease using spirometry: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008;148:529-534. 2. Lin K, Watkins B, Johnson T, Rodriguez JA, Barton MB. Screening for chronic obstructive pulmonary disease using spirometry: summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2008;148: 535-543. 3. U.S. Preventive Services Task Force. Counseling to prevent tobacco use and tobacco-caused disease. Rockville, Maryland: Agency for Healthcare Research and Quality, 2003. Available at: http://www.ahrq.gov/clinic/uspstf/uspstbac.htm. Accessed June 11, 2008. 4. Parkes G, Greehalgh T, Griffin M, Dent R. Effect on smoking quit rate of telling patients their lung age: the Step2quit randomised controlled trial. BMJ 2008;336:598-600. 5. Qaseem A, Snow V, Shekelle P, Sherif K, Wilt TJ, Weinberger S et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2007;147:633-638. Conflict of Interest:None declared |
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David M. Mannino, MD University of Kentucky, Thomas L. Petty
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Dmannino{at}uky.edu David M. Mannino, et al.
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The recent series of task force reports published in the Annals of Internal Medicine which appear to advise primary care physicians not to do spirometry concerns us (1-3). This could detract from a nationwide effort to diagnose and treat COPD early(4;5). COPD is the only disease among the top 5 lethal diseases in the U.S. that is rising in morbidity and mortality(6). Separating the diseases that are decreasing (heart disease, stroke, cancer and accidents) from COPD are effective early detection and prevention strategies for the former. The recommendation in the Guidelines figure, in large bold letters, states “Do not screen for chronic obstructive pulmonary disease using spirometry”(2). In the fine print below, however, caveats appear: this recommendation applies to healthy adults who do not recognize or report symptoms to a clinician and it does not apply to individuals with a family history of á1-antitrypsin deficiency. Thus, the flip side of the argument against screening is that unhealthy people (particularly those with a diagnosed respiratory disease), people with respiratory symptoms, and people with a family history of á1-antitrypsin deficiency should have spirometry done. We would add to this list people that the guidelines acknowledge as being at increased risk for COPD (adults over 40 with current or former tobacco use or exposure to occupational or environmental pollutants). This, of course, is not screening but appropriate clinical care. How are we doing in this regard as clinicians? Not very well. National data from the US and other countries demonstrate that a high proportion of adults with documented impaired lung function have never been diagnosed with ANY respiratory disease (7-9). Furthermore, among people with a clinical diagnosis of COPD, where spirometry is mandatory, a minority of patients have had testing done(10;11). If spirometry use in this group with a clear cut indication is so low, one can imagine that use in patients with chronic respiratory symptoms but no diagnosis is even lower. The task force argued that spirometry does not influence smoking cessation. Several new studies challenge this conclusion (12-15). The most recent by Parkes et al., in which all patients (smokers 35 and older) had spirometry and equal exposure to cessation resources, but the intervention group was told their lung age, validated cessation rates were more than doubled in the intervention group (6.4 percent vs 13.6% percent) (14). So what’s the bottom line? At a minimum, good clinical practice mandates that adults with a diagnosis of COPD or other chronic respiratory disease (asthma, sarcoidosis, pulmonary fibrosis) should have spirometry done. In addition, patients with respiratory symptoms or a family history of á1-antitrypsin deficiency should have spirometry done. This, of course, is not screening but case-finding and appropriate treatment of our patients. Finally, it is our hope that the task force will expeditiously reevaluate the evidence for spirometry as an adjunct in encouraging smoking cessation. Reference List (1) Qaseem A, Snow V, Shekelle P, Sherif K, Wilt TJ, Weinberger S et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2007;147:633-38. (2) Screening for chronic obstructive pulmonary disease using spirometry: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008;148:529-34. (3) Lin K, Watkins B, Johnson T, Rodriguez JA, Barton MB. Screening for chronic obstructive pulmonary disease using spirometry: summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2008;148:535-43. (4) Petty TL, Weinmann GG. Building a national strategy for the prevention and management of and research in chronic obstructive pulmonary disease. National Heart, Lung, and Blood Institute Workshop Summary. Bethesda, Maryland, August 29-31, 1995 [see comments]. JAMA. 1997;277:246- 53. (5) Ferguson GT, Enright PL, Buist AS, Higgins MW. Office spirometry for lung health assessment in adults: A consensus statement from the National Lung Health Education Program. Chest. 2000;117:1146-61. (6) Jemal A, Ward E, Hao Y, Thun M. Trends in the leading causes of death in the United States, 1970-2002. JAMA. 2005;294:1255-59. (7) Mannino DM, Gagnon RC, Petty TL, Lydick E. Obstructive lung disease and low lung function in adults in the United States: data from the National Health and Nutrition Examination Survey, 1988-1994. Arch Intern Med. 2000;160:1683-89. (8) Shahab L, Jarvis MJ, Britton J, West R. Chronic obstructive pulmonary disease prevalence, diagnosis and relation to tobacco dependance in a nationally representative population sample. Thorax. 2006;61:1043-47. (9) Menezes AM, Perez-Padilla R, Jardim JR, Muino A, Lopez MV, Valdivia G et al. Chronic obstructive pulmonary disease in five Latin American cities (the PLATINO study): a prevalence study. Lancet. 2005;366:1875-81. (10) Damarla M, Celli BR, Mullerova H, Pinto-Plata VM. Discrepancy in the Use of Confirmatory Tests in Patients Hospitalized with the Diagnosis of Chronic Obstructive Pulmonary Disease or Congestive Heart Failure. Respir Care. 2006. (11) Joo MJ, Lee TA, Weiss KB. Geographic Variation of Spirometry Use in Newly Diagnosed COPD. Chest. 2008. (12) Bednarek M, Gorecka D, Wielgomas J, Czajkowska-Malinowska M, Regula J, Mieszko-Filipczyk G et al. Smokers with airway obstruction are more likely to quit smoking. Thorax. 2006;61:869-73. (13) van Schayck CP, Loozen JM, Wagena E, Akkermans RP, Wesseling GJ. Detecting patients at a high risk of developing chronic obstructive pulmonary disease in general practice: cross sectional case finding study. BMJ. 2002;324:1370. (14) Parkes G, Greenhalgh T, Griffin M, Dent R. Effect on smoking quit rate of telling patients their lung age: the Step2quit randomised controlled trial. BMJ. 2008;336:598-600. (15) Stratelis G, Molstad S, Jakobsson P, Zetterstrom O. The impact of repeated spirometry and smoking cessation advice on smokers with mild COPD. Scand J Prim Health Care. 2006;24:133-39. Conflict of Interest:DMM serves on advisory boards for GlaxoSmithKline, Pfizer, AstraZeneca, Boerhinger-Ingelheim, and Novartis and has received research funding from Pfizer, Novartis and GlaxoSmithKline. |
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Lawrence W. Raymond, MD, ScM Carolinas Medical Center, Mary C. Townsend, Dr PH
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Larry.Raymond{at}carolinashealthcare.org Lawrence W. Raymond, et al.
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While not disagreeing with the U.S. Preventive Services Task Force recommendation against the use of spirometry for screening asymptomatic persons for COPD (1), we would like to remind readers that spirometry has many valid applications, including screening workers with occupational exposures that may cause respiratory impairment or disease. In addition, though the USPSTF has used the common COPD-screening criterion of an FEV1/FVC < 0.70 to define airways obstruction, there has been significant discussion of the false positives that occur, especially among older subjects when this blanket definition of airways obstruction is applied (2,3). Perhaps spirometry would fare better as a screening test for COPD if the definition for airways obstruction followed the ATS/ERS 2005 guidelines, and identified subjects as obstructed only when their FEV1/FVC falls below the LLN (4). In addition, we note that Lin et al (5) reviewed evidence to support the use of spirometry as a motivational tool for smoking cessation, apart from the use of pharmacologic agents. They found it inconclusive (5, Table 2), and suggested that further studies may be needed. Two such studies provide evidence that spirometry, in concert with the Fletcher-Peto diagram, may indeed improve smoking cessation rates (6,7). In view of the unique potential of smoking cessation to improve health outcomes, we wish to call attention to these studies. 1. U.S. Preventive Services Task Force. Screening for chronic obstructive pulmonary disease using spirometry: U.S. Preventive services Task Force Recommendation Statement. Ann Inter Med 2008;148:529-34. 2. Hansen JE, Sun XG, Wasserman K. Spirometric criteria for airway obstruction: Use percentage of FEV1/FVC ratio below the fifth percentile, not < 70%. Chest. 2007 Feb;131(2):349-55. 3. Townsend MC. Conflicting definitions of airways obstruction - Drawing the line between normal and abnormal (Editorial). Chest 2007; 131(2):335-336. 4. American Thoracic Society – European Respiratory Society: Interpretative Strategies for Lung Function Tests. Eur Respir J 2005; 26:948-968. 5. Lin K, Watkins B, Johnson T, Rodriuguez JA, Barton MB. Screening for chronic obstructive pulmonary disease using spirometry: Summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2008;148:535-543. 6. Bednarek M, Gorecka D, Wielgomas J, Czajkowska-Malinowska M, Regula J, Mieszko-Filipczyk G et al. Smokers with airway obstruction are more likely to quit smoking. Thorax 2006;61:869-873. 7. Parkes G, Greenhalgh T, Griffin M, Dent R. Effect of smoking on quit rate of telling patients their lung age: The Step2quit randomized controlled trial. BMJ 2008;336:598-600. The authors are Chair and Member, respectively, of the Occupational and Environmental Lung Disorders Committee, American College of Occupational and Environmental Medicine. Lawrence W. Raymond, MD, ScM Director, Occupational and Environmental Medicine Carolinas HealthCare System PO Box 32861 Charlotte, NC 28232 Mary C. Townsend, Dr PH M.C. Townsend Associates, LLC 289 Park Entrance Drive Pittsburgh, PA 15228 Conflict of Interest:None declared |
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