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AHRQ publishes evidence report summaries on breast disease and three other topics

The Agency for Healthcare Research and Quality recently released four new evidence report summaries: management of specific breast abnormalities, Ayurvedic interventions for diabetes, surgical treatment of coexisting cataract and glaucoma, and treatment of pulmonary disease following cervical spinal cord injury. These evidence report summaries are now available from AHRQ, both online and in print from the AHRQ Publications Clearinghouse. Copies of the full evidence reports will be available in the near future.

AHRQ's evidence reports and summaries provide organizations with comprehensive, science-based information on common, costly medical conditions and new health care technologies. There are 12 AHRQ-supported EPCs; they systematically review the relevant scientific literature on topics assigned to them by AHRQ and conduct additional analyses when appropriate prior to developing their reports and assessments. The goal is to inform health plans, providers, purchasers, and the health care system as a whole by providing essential information to improve health care quality.

Management of Specific Breast Abnormalities. Evidence Report/Technology Assessment No. 33.

EPC researchers at MetaWorks, Inc., of Medford, MA, (contract 290-97-0016) found strong evidence for performing an excisional biopsy following a stereotactic core needle biopsy for diagnosis of atypical ductal hyperplasia (ADH), as the excisional biopsy results often lead to a change in diagnosis. ADH, a condition where the cells lining the milk ducts of the breast grow abnormally, can only be diagnosed by examining a sample of breast tissue under a microscope. Although ADH is a noncancerous condition, cancer tissue also can be found with ADH. Stereotactic core needle biopsy removes only small fragments of breast tissue through a hollow needle and may fail to capture cancerous tissue in its sampling. An excisional biopsy removes breast tissue through a surgical procedure and allows for a larger volume of tissue to be tested.

Both ADH and lobular carcinoma in situ (LCIS), a noncancerous abnormality of the cells contained in the milk-producing lobules of the breast, place women at greater risk for developing breast cancer in the future. Although data are limited, the evidence suggests that tamoxifen therapy markedly decreases the incidence of breast cancer following a diagnosis of ADH or LCIS, but it is associated with an increased risk of endometrial cancer, thromboembolic disease, and other complications.

According to the results of this extensive review of the literature, studies to date suggest sentinel lymph node biopsy is successful in determining whether breast cancer has spread throughout the regional lymph nodes in most patients. However, the MetaWorks researchers caution that long-term cancer outcomes and survival data are required before sentinel lymph node biopsy can be considered a standard of care. They also suggest that future research should examine breast disease risk factors and breast symptoms and how these relate to cancer diagnoses. Further research also is needed to identify new and additional risk factors.

This topic was nominated for review by Kaiser Permanente of Northern California. Copies of the summary (AHRQ Publication No. 01-E045) are available from the AHRQ Publications Clearinghouse. Copies of the full report (AHRQ Publication No. 01-E046) will be available in late fall 2001.

Ayurvedic Interventions for Diabetes Mellitus: A Systematic Review. Evidence Report/Technology Assessment No. 41.

Ayurveda is the traditional Hindu system of medicine, based largely on homeopathy and naturopathy. The Southern California/RAND EPC (contract 290-97-0001) conducted a broad search of the published literature and found sufficient research to support a systematic review of the use of Ayurvedic therapies for the treatment of diabetes. They identified 54 articles presenting the results of 62 studies; because of the heterogeneity of the studies, a meta-analysis was not possible.

More than 45 single herbs or combination herbal therapies were tested. The most common single herbs studied were Gymnema sylvestre, Coccinia indica, fenugreek (Trigonella foenum-graecum), and Eugenia jambolana. They concluded that there is evidence to suggest that the single herbs Coccinia indica, holy basil, fenugreek, and Gymnema sylvestre and the herbal formulas Ayush-82 and D-400 have a glucose-lowering effect and deserve further, more rigorous study.

A summary of the report (AHRQ Publication No. 01-E039) is now available from the AHRQ Publications Clearinghouse. The full report (AHRQ Publication No. 01-E040) is expected to be available in late fall 2001.

Surgical Treatment of Coexisting Cataract and Glaucoma. Evidence Report/Technology Assessment No. 38.

Performing surgery for coexisting glaucoma and cataract at the same time results in lower intraocular pressure (IOP) than cataract surgery alone, according to this evidence report. Increased IOP is a hallmark feature of glaucoma and results from fluid buildup in the eye. Unless the pressure is controlled, the optic nerve may be damaged, resulting in vision loss.

The research was undertaken by the Johns Hopkins EPC (contract 290-97-0006) to identify the most important questions regarding surgical treatment of the coexisting conditions, review the quality and content of existing evidence on surgical treatment, and identify future areas of promising research. The EPC concluded that because the progression of glaucoma is slow, long-term studies (5 years or longer) are needed to assess the effects of surgery on quality of life. Also, few of the studies included significant numbers of blacks, a population that has a high prevalence of glaucoma. Blacks may respond differently to glaucoma surgery and should be included in larger numbers in future studies.

The report identifies four topics for future research: development of cataract after a patient undergoes glaucoma surgery; control of IOP after cataract surgery in glaucoma patients; long-term control of IOP after cataract surgery in glaucoma patients; and determination of the optimal surgical technique, including a comparison of the benefits of staged vs. combined procedures.

A summary of the report (AHRQ Publication No. 01-E049) is now available from the AHRQ Publications Clearinghouse. The full report (AHRQ Publication No. 01-E050) is expected to be available in late fall 2001.

Treatment of Pulmonary Disease Following Cervical Spinal Cord Injury. Evidence Report/Technology Assessment No. 27.

The incidence of spinal cord injury (SCI) in the United States is approximately 10,000 new cases each year or 32 to 35 people per million population. Because people with SCI are surviving longer, the prevalence has been increasing and there are now more than 200,000 people with SCI in the United States. Injuries at the cervical level of the spinal cord, depending on the completeness of the lesion, can lead to quadriplegia, loss of sensory function, and paralysis of the respiratory muscles. Respiratory failure is the most common cause of death for patients with cervical injuries during the acute phase of hospitalization.

Researchers at the Duke EPC (contract 290-97-0014) assessed the evidence currently available on the prevention and treatment of pulmonary disease following traumatic cervical SCI. They found that patients with cervical SCI are at significant risk for ventilatory failure, and this risk differs by the level and completeness of injury. Ventilatory support is needed for a majority of patients with C5 and higher injuries and virtually all patients with C3 and higher injuries in the acute phase. In the report, the EPC researchers assess the available evidence on a variety of therapeutic and clinical assessment strategies, including active respiratory muscle exercise, deflating cuffed tracheostomies, electrophrenic respiration, manual assisted cough, rotating beds, and many other approaches.

A summary of the report (AHRQ Publication No. 01-E013) is available now from the AHRQ Publications Clearinghouse. Copies of the full report (AHRQ Publication No. 01-E014) are expected to be available in late fall 2001.

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