Screening for bowel cancer

Screening for colorectal cancer halves the number of emergency admissions to hospital and postoperative mortality associated with the condition, the five year results from a pilot study in England show.

The pilot tested the feasibility of using faecal occult blood testing by post every two years to screen for bowel cancer in people aged 50-69 years.

The study compared validated data on admissions to hospital for bowel cancer in the year before screening was introduced (1999) with those for the five years of the screening programme (2000-4) The results showed that 1236 new cases of bowel cancer were managed during the study period, equivalent to 200 cases a year. The percentage of all admissions for bowel cancer that were emergency admissions fell from 29.4% in 1999 to 15.8% in 2004. The number of emergency procedures for bowel cancer fell over the same period, as did the rate of stoma formation.

In the pre-screening year almost half of patients (48%) who underwent emergency surgery died within 30 days of the operation. By 2004, five years into the programme, mortality at 30 days after the operation had fallen to 13%.

The number of relatively advanced, bowel cancers halved from 38 in 1999 to 16 in 2004. However, no significant change was shown over the duration of the programme in the proportion of advanced cancers in emergency presentations.

The size of the improvement over a short time period seemed to be the result of better detection of asymptomatic malignancies through the screening programme, greater awareness among the public of the symptoms of colorectal cancer, and quicker referrals by GPs in the area. The authors concluded that screening for bowel cancer is effective, but they noted that take-up of the test fell from 59% in the first round of the pilot to 52% in the second.

The government has decided to limit the target age group in the NHS bowel cancer screening programme, which started this year, to people aged 60 to 69 years, rather than 50 to 69, which may reduce the overall effectiveness of the programme, the Coventry group warned.

However, in its new cancer reform strategy the government has announced that it will extend the upper threshold to include those aged 70 to 75 years by 2012

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Prevention of falls and fractures in older people

This study was set up to evaluate the effectiveness of multifactorial assessment and intervention programmes to prevent falls and injuries among older adults recruited to trials in primary care, community, or emergency care settings. It was a systematic review of randomised and quasi-randomised controlled trials, and meta-analysis.

Eligible studies were randomised or quasi-randomised trials that evaluated interventions to prevent falls that were based in emergency departments, primary care, or the community that assessed multiple risk factors for falling and provided or arranged for treatments to address these risk factors. Outcomes were number of fallers, fall related injuries, fall rate, death, admission to hospital, contacts with health services, move to institutional care, physical activity, and quality of life. Methodological quality assessment included allocation concealment, blinding, losses and exclusions, intention to treat analysis, and reliability of outcome measurement.

Nineteen studies, of variable methodological quality, were included. The combined risk ratio for the number of fallers during follow-up among 18 trials was 0.91 and for fall related injuries (eight trials) was 0.90 .

No differences were found in admissions to hospital, emergency department attendance, death, or move to institutional care. Subgroup analyses found no evidence of different effects between interventions in different locations, populations selected for high risk of falls or unselected, and multidisciplinary teams including a doctor, but interventions that actively provide treatments may be more effective than those that provide only knowledge and referral.

Overall, then, evidence that multifactorial fall prevention programmes in primary care, community, or emergency care settings are effective in reducing the number of fallers or fall related injuries is limited. Data were insufficient to assess fall and injury rates.

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Anti-obesity drugs

This study was set up to summarise the long term efficacy of anti-obesity drugs in reducing weight and improving health status. It was and updated meta-analysis of randomised trials.  The studies reviewed were double blind randomised placebo controlled trials of approved anti-obesity dugs used in adults (age over 18) for one year or longer.

Thirty trials of one to four years’ duration met the inclusion criteria: 16 orlistat (n=10 631 participants), 10 sibutramine (n=2623), and four rimonabant (n=6365). Of these, 14 trials were new and 16 had previously been identified. Attrition rates averaged 30-40%. Compared with placebo, orlistat reduced weight by 2.9 kg (95% confidence interval 2.5 kg to 3.2 kg), sibutramine by 4.2 kg (3.6 kg to 4.7 kg), and rimonabant by 4.7 kg (4.1 kg to 5.3 kg). Patients receiving active drug treatment were significantly more likely to achieve 5% and 10% weight loss thresholds.

Orlistat reduced the incidence of diabetes and improved concentrations of total cholesterol and low density lipoprotein cholesterol, blood pressure, and glycaemic control in patients with diabetes but increased rates of gastrointestinal side effects and slightly lowered concentrations of high density lipoprotein.

Sibutramine lowered concentrations of high density lipoprotein cholesterol and triglycerides but raised blood pressure and pulse rate.

Rimonabant improved concentrations of high density lipoprotein cholesterol and triglycerides, blood pressure, and glycaemic control in patients with diabetes but increased the risk of mood disorders.

The authors conclude that orlistat, sibutramine, and rimonabant modestly reduce weight, have differing effects on cardiovascular risk profiles, and have specific adverse effects.

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