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Orkaby AR et al. Association of statin use with all-cause and cardiovascular mortality in US veterans 75 years and older. JAMA 2020 Jul 7; 324:68. (https://doi.org/10.1001/jama.2020.7848)

retrospective cohort study of about 327,000 patients (age, ≥75; mean age, 81; mostly white men) without prior statin use, without a prior cardiovascular event;
in total 326K vets that were 75yr old and older and had never had a cardiovascular event those started on statin therapy did better!!!
all-cause mortality was 78.7 per 1000 person years in those started on a statin and 98.2 per 1000 person-years in those not a on a statin.
BUT devel in the details-- they say they looked at 7.2 million vets- then once you took out the people that had prior statin exposure, and removed the people with missing data, and then excluded those with a prior cardiovascular event, and threw out those individuals who died in the first 150 days -- you then get the 326K. and of those about 57k got a statin prescription and 269K never got a statin prescription. BUT those individuals who started a statin were more like to have the diagnoses codes of hyperlipidemia, diabetes, and hypertension AND less likely to have dementia.
so the patients that benefit from a statin are over the age of 75, have CV risk factors and dont have dementia.. well isnt it shocking that those individuals benefited from statin therapy!
out of the initial 7.2 million people you cut it down to the 7% or 57k that got a statin and you say “look they did better” than the people that had fewer risk factors and were demented that didnt get a statin. OR the statin had nothing to do with it -- we will never know cause you can match up the confounding variables in retrospective data, no matter how hard to yu try!! NEVER.
At this point statins are safe, we dont know if they work in the elderly because the data and studies often exclude them BUT we dont need any more observational studies, especially not ones that looks at 7.2 million charts then cuts it down to 326K. That is cherry picking the data and the cofounders will never be equal, at this point it is RCT or nothing, do the trial we all want or dont do the trial.




Family med- jack of all and master of many—because you can do so many things- I am bias-


Wallhed Finn S et al. Treatment of alcohol dependence in primary care compared with outpatient specialist treatment: Twelve-month follow-up of a randomized controlled trial, with trajectories of change. J Stud Alcohol Drugs 2020 May; 81:300. (https://doi.org/10.15288/jsad.2020.81.300)


moderate levels of alcohol dependence are more likely to seek care in primary care than a specialist
randomized controlled noninferiority trial
researchers in Sweden randomized 288 fulfilling ICD-10 criteria for alcohol dependence to comprehensive treatment by a team of experienced specialists at a single center or brief interventions provided by general practitioners who had received 8 hours of training.
primary outcome was change in weekly alcohol consumption measured in grams of alcohol before inclusion compared with 12 months after start of treatment
to give you and idea the averahe baseline alcohol consumption of these individuals was around 350G a week which equals about a 25 drinks a week
the results were that no matter which group you were in – at 12 months you were drinking less – you wer down to about 12.5 drinks a week if you went to a specialist and about 13.5 drinks a week
I guess this study fit my confirmation bias and specialist are not needed for anything ever-

I am kidding of course
BUt I am not kidding when I say I think screening for cancer is often a waste of time, at baseline people are healthy so it is very hard to screen for something when the person is healthy! conveying this message to patients can be very challenging.

It is hard to explain risk and benefits. When talking to my patients I try to lay the numbers out – make like dr. sues and say
“Today you are you! That is truer than true! There is no one alive who is you-er than you! And when it comes to screening it is not clear on what you should do”

but sadly not every screening website follows my advice-

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2763813

Assessment of Lung Cancer Screening Program Websites”
it looked at How do lung cancer screening program websites portray benefits and harms, and what next steps do they recommend for individuals considering screening?
looked at 162 lung cancer screening program websites

websites presented benefit far more than they presented harm (98% presented any benefit vs 48% presented any harm).
Apparently only 44% actually quantified benefit,= approximately 3 fewer deaths per 1000 people at high risk screened over 7 years).
about 1 in 5 reported the harms of false positives, radiation exposure, incidental findings, or the possibility of overdiagnosis.

This is consistnet to what we have seen in the past
people tend to overestimate benefit and underestimate harm.3

Shared decision-making can only be as good as the quality of the information being conveyed. At a minimum, any communication about lung cancer screening must cover some basic ground. google it!

Benefit (and harms) should be presented in absolute terms. For example, 18 in 1000 people died of lung cancer in the low-dose computed tomography group compared with 21 in 1000 people in the chest x-ray group, which represents 3 fewer lung cancer deaths per 1000 people screened (Figure
however in the 1000 people that are scanned there will be 350 false alarms and of thsoe about 20 people will get an invasive procedure or biopsy and have the risk for a collapse lung, infection, bleeding from the lung.
the evidence is not so clear cut as we wish and if they are against getting screening that is OK because thats wasnt the most important part of the visit---
Be clear that avoiding tobacco will have a larger and broader health effect (ie, reduce cardiovascular and lung disease risk as well as a variety of other cancers) than screening.


but while we are talking about screening the chest lets talk about my next favorite screening test in this paper titled-
Burton R and Stevenson C. Assessment of breast cancer mortality trends associated with mammographic screening and adjuvant therapy from 1986 to 2013 in the State of Victoria, Australia. JAMA Netw Open 2020 Jun 1; 3:e208249. (https://doi.org/10.1001/jamanetworkopen.2020.8249)

In the perfect world- breast cancer screening should identify women with early breast cancer (Stage I and II) while reducing incidence of advanced malignancies (Stage III and IV).


These Australian investigators analyzed associations between crude breast cancer mortality trends and uptake of adjuvant therapy and downstaging by mammographic screening.

Diagnosis of early breast cancer (EBC) in women by mammographic screening and postsurgical adjuvant endocrine therapy and chemotherapy (termed adjuvant therapy) began simultaneously in many countries in the 1990s.

So was it the screening that saved lives or was it the better treatment that saved lives- maybe the stage at which we caught it didn’t matter because the drugs were that much better?

Just as a reminder the argument for breast cancer is!
this is the argument- we catch cancer early so look at all the lives that we save!

In total from 1982 through 2013 there were 76,630 women with invasive breast cancer registered in Victoria Australia
When looking at death certificates the rates of mortality of women in the registry was 31.6 per 100 000 women in 1982 BUT IT FELL 23.9 per 100 000 women in 2013’

You might be saying well this make sense- in 1982 we don’t have much going on in the world of breast cancer, I would expect you to die more often than the same individual with the same diagnosis in 2013


PLUS in 1991 a program called breastscreeened was developed where women aged 50 to 69 years invited biennially for breast cancer screening. Prior to this program breast screening was 5-10% now it was around 55%.

So just maybe screening does save lives
Remember the death rate went from 31.6 per 100 000 women in 1982 BUT IT FELL 23.9 per 100 000 women in 2013’ and we have all this new screening

BUT BUT BUT from 1986 to 2013, incidence of advanced breast cancer rose from 12 per 100,000 women to 24 per 100,000.

Wait andrew are you telling me that from 1986 to 2013 the mortality with breast cancer decreased but despite a 1000 fold increase in mammogram screening during this time period we were actually were seeing double the rates of advance cancer?!?! Yes that is what I am saying and you are saying OMG how can that be-

TREATMENT
By 1999, 74% of women with early breast cancer were receiving adjuvant endocrine therapy (tamoxifen).
The treatment is better so we can find it later and its ok we still don’t have a problem.

I think the authors say it perfectly in their conclusion- “This study found that mammographic screening did not downstage breast cancer in Victoria from advanced to early, so population mortality benefit is lacking. Adjuvant therapy uptake was associated with all of the decline in Victorian breast cancer mortality since 1994.”