by Brian Jackson, MD and Brian Shirts, MD, PhD

We’ve heard a lot of talk lately about personalized medicine (i.e., using advanced diagnostics to guide customized therapy).

A great deal of research is going into creating new molecular and genetic tests. But whether the health care system is prepared to actually generate value from these advanced diagnostics remains an open question. Our group’s research, presented in a new study published in the Journal of Pathology Informatics, finds that one relatively new test is widely misused in ways that drive up costs without benefiting patients.

Cervical cancer screening with annual Pap smears has been a bedrock component of women’s health care for decades. It’s so engrained in the medical culture that many women continue to receive annual Paps even after total hysterectomy (see JAMA article). The personalized medicine philosophy would suggest that screening frequency (and, potentially, modality) should be customized to a patient’s individual risk of cancer rather than following a cookbook formula. And the most important component of that risk turns out to be persistent infection with certain HPV genotypes.

The American Society for Colposcopy and Cervical Pathology (ASCCP) has developed a detailed set of recommendations for personalized cervical cancer screening using HPV testing together with Pap smears. Our study, which analyzed more than 450,000 HPV tests performed at ARUP Laboratories between 2003 and 2009, was designed to assess whether doctors are following those recommendations.

Briefly, the ASCCP recommendations state:

• HPV testing is contraindicated in women under 21.
• In women 21 to 29, HPV testing should not be used as a first-line test but may be used for stratifying patients with certain Pap smear findings (e.g., patients with atypical squamous cells of undetermined significance).
• For women 30 and older, HPV testing may be used either for primary screening or for stratifying patients with those Pap smear findings.
• In evaluation of HPV-positive, colonoscopy-negative cervical lesions, repeat HPV testing is recommended after one year; shorter intervals are not indicated given the natural history of HPV infections.
• In women older than 30, negative-screening HPV and cytology allow the follow-up interval to be safely extended to three years, and annual screening is not necessary.

Although we did find HPV-ordering patterns are starting to trend toward the testing guidelines, overall, we found that nearly a quarter of all HPV tests ordered were unnecessary. Here are our key findings in the study:

• The proportion of HPV tests performed on women under 21 declined over the six-year study period from 20 to 5 percent. Teenage girls and young women under 21 generally do not benefit from HPV testing. In some cases, testing these patients may lead to unnecessary follow-up care, including colposcopy and cervical biopsy.
• One-third of tests on women between ages 21 and 29 arrived at our laboratory five or fewer days after collection, suggesting that these tests were ordered before the Pap smear result was known.
• For women 30 and older who were HPV positive, the test was often repeated three to six months later, which is too short a time interval to provide useful information. According to the guidelines, decisions about follow-up actions, such as colposcopy, do not require a repeat HPV test. Thus, a more rational interval before a subsequent HPV test (in conjunction with a Pap test) would be 12 months.
• For women older than 30 with a negative HPV test result, the most common time interval before the next test was 12 months, suggesting that annual screening is predominant in this group. For low-risk women with negative Pap and HPV results, however, screening every three years is safe and appropriate. Only 6 percent of follow-up tests after a negative HPV results had an interval of three years or more.

These findings aren’t too surprising given the large body of previous research showing that medical practice often doesn’t follow published recommendations. But regardless, the findings show that our health care system has not sufficiently figured out how to optimize and customize treatment based on test results. To achieve the promise of personalized medicine, we need more than new high-tech tests. We need to fundamentally change how we deliver care.

Brian Jackson is Medical Director of Informatics at ARUP Laboratories and Brian Shirts is a Molecular Genetic Pathology Fellow at the University of Utah School of Medicine and Assistant Medical Director of Informatics at ARUP Laboratories.

Submit a guest post and be heard on social media’s leading physician voice.

Link: http://www.reuters.com/article/2011/06/22/us-fda-implants-idUSTRE75L3NA20110622

Our 3^rd edition of Mountain Medicine Directory was published in January 2010 and has been very well received. We have been busy distributing the new publication to pharmacies, hospitals, medical offices and eateries in Garfield, Pitkin, Eagle and Mesa counties.

In the next few weeks, we will be taking the directory portion of our publication online. Mountain Medicine’s Online Directory will include information that you see in our print version plus offer expanded information to include business description, listing of practice physicians, website link, plus map and direction links.

One good thing about troubled economic times, is that it forces consumers to make smarter healthcare choices. Our mission at Mountain Medicine Directory is to help connect healthcare consumers with the best care available through licensed doctors, certified practioners, hospitals, clinics and wellness centers.

Healthcare consumers clearly make better decisions regarding their health when they are fully informed and know what their options are.

We invite you to look to Mountain Medicine Directory to provide informative articles plus comprehensive and detailed directory of healthcare providers in our area both in print and on the Internet.

Plastic surgery holds an interesting niche in medicine, one in which science and art become one.

A thorough knowledge of human anatomy blends with finely honed dexterity and a well developed sense of aesthetics. Dr. Daniel Thimsen has practiced plastic and reconstructive surgery for over 24 years, at the Mayo Clinic and for the past 11 years serving patients in the Glenwood Springs area.

Board certified by the American Board of Plastic Surgery, Dr. Thimsen keeps current with the latest developments in cosmetic surgery through his active involvement in The American Society of Plastic and Reconstructive Surgeons. His Rocky Mountain Plastic Surgery practice offers a full spectrum of surgery for both men and women.

Among the most popular procedures nationally is eyelid surgery (or blepharoplasty), which enhances the most notable aspect of a face - the eyes. It is given one of the highest satisfaction rates for patients post-surgically, according to national surveys, producing natural-looking improvement at a relatively low cost. The surgery removes fat, usually along with excess skin and muscle from the upper and lower eyelids. It can correct drooping upper lids and puffy bags below the eyes.

Dr. Thimsen performs many eyelid surgeries in his private surgical suite. The results are impressive. Blepharoplasty restores a youthful appearance in a very natural way, eliminating eyelid bags and puffiness.

One of Dr. Thimsen patients, an attractive woman in her fifties, had always been less than satisfied with her eyelids. "My eyes always had a lot of fatty skin over my eyelids. As a teenager, I cried the first time I tried to put on mascara and the fatty tisue touched my lashes. At this phase in my life, I was looking tired - much more tired than I actually felt. I did some investigation with Dr. Thimsen and decided on the eyelid surgery - I treated myself."

Her satisfaction with the procedure is palpable. "There are no perceptible scars and the recovery was precisely as Dr. Thimsen had predicted. And I don’t look tired or angry any more. I look how I really feel."

According to Dr. Thimsen, the best candidates for eyelid surgery are men and women who are physically healthy, psychologically stable, and realistic in their expectations. Most are 35 or older, but if droopy, baggy eyelids run in your family, you may decide to have eyelid surgery at a younger age.

His surgical services also include facelifts, browlifts, breast augmentation, laser skin resurfacing, rhinoplasty (nasal surgery), breast uplift, abdominoplasty (tummy tuck), liposuction, otoplasty (ear surgery), reconstructive breast surgery, mole and skin cancer removal, and hand surgery. Further information on these procedures is available on Dr. Thimsen’s website at www.rockymountainplasticsurgery.com.

In addition to Rocky Mountain Plastic Surgery’s state of the art facility, Dr. Thimsen also offers medical skin treatments and products at his Medispa at Glenwood Meadows. He also peforms injectable treatments such as botox, Restylane and Juvederm at the Medispa office. Free Medispa consultations are available by calling 970.945.8390.

Dr. Thimsen offers free cosmetic surgery consultations at his Glenwood office, as well as his offices in Eagle, Edwards, and Rifle. To make an appointment, call 970.945.1144.