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AHCPR releases four new evidence reports/technology assessments

The Agency for Health Care Policy and Research recently released four new reports—drug therapy for alcohol dependence, testosterone suppression for prostatic cancer, evaluation of abnormal cervical cytology, and urinary complications in paralyzed people—from a new series of evidence reports/technology assessments sponsored by AHCPR to provide public- and private-sector organizations with comprehensive, science-based information on common, costly medical conditions and health care technologies. AHCPR awarded contracts to 12 Evidence-based Practice Centers (EPCs) in the United States and Canada to review all the relevant literature on designated topics related to prevention, diagnosis, treatment, and management of common diseases and clinical conditions and technology assessments of specific medical procedures or health care technologies.

Forthcoming AHCPR evidence reports/technology assessments examine treatment of depression with new drugs, treatment of attention deficit/hyperactivity disorder, diagnosis and treatment of acute sinusitis, and other topics. Recently assigned topics include management of acute chronic obstructive pulmonary disease, management of cancer pain, criteria for weaning from mechanical ventilation, and management of chronic hypertension during pregnancy.

Select to access online summaries of these evidence reports:

As well as summaries of two earlier reports:

Printed summaries of the reports are available from the AHCPR Publications Clearinghouse, and printed copies of the full reports are expected to be available in the near future.

Pharmacotherapies for Alcohol Dependence. Summary (AHCPR Publication No. 99-E003). Two relatively new medications, naltrexone and acamprosate, show promise for the treatment of patients with alcohol dependence, according to this evidence report, which was developed by the Research Triangle Institute (RTI) and the University of North Carolina (UNC) at Chapel Hill. The medications appear to reduce the urge to drink, decrease the frequency of a person's drinking, and, in some studies, improve abstinence. Naltrexone has been in use in the United States for the treatment of alcoholism only since 1994. Acamprosate is widely used in Europe and has been granted investigational drug status within this country by the Food and Drug Administration; clinical trials are currently underway.

Alcohol dependence or alcoholism is a chronic and progressive disorder that afflicts approximately 9.6 percent of men and 3.2 percent of women in the United States at some point in their lives. Alcoholism can develop as early as adolescence and continue in older age groups. Those at highest risk are men and women from 18 to 29 years of age.

About 100,000 Americans die each year from alcohol-related diseases such as cirrhosis of the liver and esophageal or stomach cancer, and from traumatic injuries such as overdose, suicide, homicide, and traffic accidents. Alcohol dependence costs the Nation an estimated $166 billion annually, mostly due to health effects, lost productivity, and treatment of alcohol-related diseases.

Naltrexone and acamprosate are used to treat the primary symptoms of alcohol dependence. Although they can diminish the frequency of drinking, enhance abstinence, and minimize relapse, the evidence indicates that these medications will not eliminate the problem of alcohol dependence. Many individuals continued to drink even while taking the medications.

The report suggests that future research address the effectiveness of long-term maintenance of patients on those medications proven to work alone, the effectiveness of combinations of medications, and the optimal combinations of drug and psychosocial therapies. Another suggested area of research is development of additional, more effective therapies for treating alcohol dependence.

The RTI-UNC researchers reviewed studies published from 1966 through 1997 in English, French, or German; on adults 18 years or older with alcohol dependence; with sample sizes of 10 or more subjects; and with a control group for comparison.

Testosterone Suppression for Advanced Prostate Cancer. Summary (AHCPR Publication No. 99-E011). Men with advanced prostate cancer who are given one of several different testosterone-suppressing drugs known as "luteinizing hormone-releasing hormone (LHRH) agonists" survive roughly the same length of time and experience roughly the same side effects, regardless of which drug they use, according to this technology assessment. It shows that despite the substantial differences in costs among the different LHRH agonists, they all produce equivalent health outcomes.

The report, which was prepared for AHCPR by the Blue Cross and Blue Shield Association (BCBSA) Technology Evaluation Center, also states that a more aggressive form of therapy called "combined androgen blockade" may be of little added clinical benefit, only marginally increases survival, and causes more severe side effects. Furthermore, while it has been hypothesized that subpopulations of patients who have a good prognosis may benefit more from such aggressive treatment, the evidence does not support this hypothesis.

LHRH agonists are used to suppress the production of testosterone, the main androgen (male hormone). Produced primarily in the testicles, testosterone can promote the growth of prostate cancer cells. Combined androgen blockade uses either an LHRH agonist or surgical removal of the testicles, plus a second drug called a nonsteroidal anti-androgen, to block the action of testosterone. All LHRH agonists are as effective as surgical removal of the testicles, which was once considered the standard treatment for prostate cancer.

In preparing the technology assessment, the EPC also examined whether treating men early with testosterone suppression results in better outcomes than treating them later in the course of their disease. There was insufficient evidence to determine whether survival is improved by starting testosterone suppression as soon as advanced prostate cancer is detected. The alternative—waiting until symptoms develop—may spare the patient years of living with the serious side effects of treatment, one of which is impotence.

Prostate cancer, the second leading cause of cancer deaths in American men, is primarily a disease of older men. Approximately 185,000 new cases of prostate cancer are diagnosed annually, and 39,000 men die of the disease each year.

The cost of treating prostate cancer is substantial. The direct hospital charges alone for prostate cancer treatment cost Medicare more than $1.4 billion in 1994. Federal agencies that provide medical care to beneficiaries, such as the U.S. Department of Veterans Affairs and the U.S. Department of Health and Human Services' Indian Health Service, as well as private health insurers, also incur expenses for prostate cancer treatment.

Evaluation of Cervical Cytology. Summary (AHCPR Publication No. 99-E009). The conventional Pap test is still the most effective tool available for detecting cervical cancer in adult women with average risk, according to this evidence report, which was produced by Duke University in conjunction with Health Economics Research, Inc., a Waltham, Massachusetts firm. The Duke study compared three new technologies—ThinPrep®, AutoPap®, and Papnet®—to the conventional Pap test, examining their overall effectiveness and accuracy in screening performance. The study found that the Pap test remains the most reliable test available, but that the new technologies may help strengthen diagnostic accuracy in the detection of cervical cancer.

The researchers found that the new screening technologies for Pap testing appear to reduce significantly the likelihood that premalignant and malignant cells will be misdiagnosed as normal, that is, false negatives. However, little is known about the effect of these new technologies on diagnostic specificity, which is the likelihood of false positives.

Although the incidence of cervical cancer is decreasing, it is still one of the most common cancers in women. In 1998, an estimated 13,700 women developed invasive cervical cancer, and about 4,900 women died from the disease. More than 25 percent of invasive cervical cancer cases occur in women older than 65, and 40 to 50 percent of all women who die from cervical cancer are over 65 years of age. Highlights of the report include:

  • The Pap test, while key in decreasing cervical cancer in women, is not as accurate in diagnosing disease as previously believed. The evidence reveals that a single Pap test may miss abnormal cells in nearly half of the women who have abnormal cell growth.
  • Available data on the accuracy of the three technologies studied fail to describe reliable estimates for reducing false positives.
  • Evidence related to the accuracy of the newer technologies is incomplete.
  • When initial and rescreening intervals are lengthened to every 3 years or greater, the new technologies were more cost-effective than the traditional Pap test. These longer screening intervals result in lowering the costs per year of life saved.

Urinary Tract Infections in Paralyzed People. Summary (AHCPR Publication No. 99-E007). There is insufficient evidence to recommend the regular use of oral antibiotics to prevent urinary tract infections (UTIs) in adults and adolescents who have abnormal bladder function because of spinal cord damage, according to this Evidence reports/ technology assessments evidence report. Although research does indicate that prophylactic antibiotics reduce the amount of bacteria present, their use can double the development of bacteria that are resistant to the drugs. The report was prepared by the Southern California EPC/RAND in collaboration with the University of California, Los Angeles. The report discusses prevention and management of UTIs in the two populations most commonly affected—people with spinal cord injuries (SCIs) and people with multiple sclerosis (MS).

Diseases of the urinary system are the fifth most common cause of death for people with SCIs. Up to 90 percent of people with MS develop bladder dysfunction at some point, which increases their chance of urinary tract infection and other complications. Since the lifetime incidence of urinary tract infections among people with SCI and MS is very high, every person with bladder dysfunction caused by problems of the central or peripheral nervous system should be considered at high risk for infection.

The EPC based its report on 1,278 studies, involving patients aged 13 years and older and published after 1985. In studies of patients with SCIs, the analysis focused on nonacute patients (more than 90 days after injury). However, for the evaluation of antibiotic prophylaxis, additional studies of acute SCI patients were included.

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