What are the hot topics and clinical trends in internal medicine that clinicians are talking about? Two expert internists took some time recently to discuss their thoughts on these issues.
Donald L. Deye, MD, FACP, is a general internist who has practiced for over 30 years at Cambridge Medical Center in Cambridge, MN. He is also Chief Medical Officer for Oakstone, and host of the acclaimed MKSAP Audio Companion. Timothy Leigh Rodgers, MD, is an internal medicine specialist practicing in Santa Barbara, CA.
Timing and Use of Pap Smear
Dr. Deye: There’s new data on Pap smears which may radically change our practice, as well. This study not only looked at timing of Pap smears, it also suggested the primary use of Pap smears for cervical cancer screening may no longer be necessary. We currently do Pap smears every three years in the screening setting and every five years if high risk HPV testing is done at the same time. Because of limited resources, some third-world clinicians have been doing just the HPV testing alone, without a Pap smear.
Dr. Rodgers: This is a really interesting situation where limited access to Pap smears may have shown the way to a more optimal way to do screening. When outcomes were analyzed, they found that doing the actual Pap smear did not have any value. Doing just the HPV testing alone was as effective as doing both this and the Pap smear at the same time. No difference. So it appears that we can do HPV testing alone and go for five years before the next test if normal.
Dr. Deye: Watch for guideline changes in the future.
Dr. Rodgers: When you tell women in their 50s about this, they often get a little anxious because they’ve been programmed to get a Pap smear every year. We have to reassure them by going over the evidence using layperson language. That’s where the art of medicine and interpersonal skills come into play.
Dr. Deye: Timothy, there has been an evolving story on PSA testing and prostate cancer diagnosis. What’s the latest?
Dr. Rodgers: Well Don, routine PSA testing is still controversial, but new approaches to diagnosis appear to show promise. We are seeing more specific imaging approaches to prostate biopsy in patients with elevated PSA, especially if they have a low percentage of free PSA, less than 20 percent. Instead of just doing an ultrasound and biopsy, a fusion targeted biopsy is being done, using a combination of MRI and ultrasound. It appears that this can improve finding the best location for biopsy. This may reduce false negative biopsies and better target the locations with higher grade or higher scored prostate cancer cells.
Dr. Deye: We are also finding that watchful waiting works when you have low-grade Gleason score. Twenty years ago we operated on most patients with prostate cancer including indolent cases. We saw a lot of incontinence and impotence that probably could have been avoided. This more accurate and cautious approach to treatment looks like a great improvement.