News briefs

Experts advise against routine testing for prostate cancer

Routine testing for prostate cancer is not recommended for most men because the benefit is small and uncertain, and there are clear harms, according to a panel of international experts in The BMJ. But they acknowledge that some men, such as those with a family history of prostate cancer, may be more likely to consider screening, and for this group, discussing possible harms and benefits with their doctor is essential. An international panel including clinicians, men at risk of prostate cancer, and research methodologists undertook a detailed analysis of the latest evidence, applying the GRADE system for assessing its quality. A review including more than 700 000 men in clinical trials found that the benefit of screening for reducing prostate cancer-related deaths is at best very small. Accordingly, the panel advised against offering routine prostate-specific antigen (PSA) screening, noting that most men decline screening because the benefits are small and uncertain and the harms are clear. Clinicians need not feel obliged to systematically raise the question with all their patients, and should engage in shared decision-making for those considering screening. A linked editorial pointed to recent advances in active surveillance, “which have the potential to reduce the harms of testing”. In the meantime, the experts suggest that conversations with patients requesting a PSA test “should explore their reasons for requesting a test, and include evidence-based discussions about possible harms and benefits of PSA testing, informed by the patient’s ethnicity and family history”.

https://www.bmj.com/content/362/bmj.k3519

https://www.bmj.com/content/362/bmj.k3702

Diclofenac associated with increased risk of major cardiovascular events

The commonly used painkiller diclofenac is associated with an increased risk of major cardiovascular events, such as heart attack and stroke, compared with using paracetamol, other traditional painkillers, or no drug at all, according to a study published by The BMJ. The findings prompted the researchers to suggest that diclofenac should not be available over the counter, and, when prescribed, it should be accompanied by an appropriate front package warning about its potential risks. Diclofenac is a traditional non-steroidal anti-inflammatory drug (NSAID) for treating pain and inflammation and is widely used around the world. But its cardiovascular risks have not previously been compared with those of other traditional NSAIDs in large randomised controlled trials, and concerns about these risks mean that such trials would no longer be unethical. Researchers at Aarhus University Hospital in Denmark examined the cardiovascular risks of starting diclofenac therapy compared those associated with starting other traditional NSAIDs (ibuprofen or naproxen), starting paracetamol, or not starting anything. The results are based on national registry data (for the period 1996–2016) for more than 6.3 million adults in Denmark with at least one year of continuous prescription records before January 1996. Participants were divided into groups at low, moderate and high baseline cardiovascular risk. The median age of participants starting NSAIDs was 46–49 years and 56 years for those starting paracetamol. After adjusting for potentially confounding factors, starting diclofenac was associated with a higher rate of major adverse cardiovascular events within 30 days than starting other traditional NSAIDs or paracetamol. Events included irregular heartbeat or flutter, ischaemic stroke, heart failure, and heart attack. The increased risks applied to men and women of all ages, and also at low doses of diclofenac. Starting diclofenac was also associated with a higher rate of cardiac disease-related death than taking no NSAIDs, and with an increased risk of upper gastrointestinal bleeding compared with no NSAIDs, ibuprofen or paracetamol, but not with naproxen. When the results were analysed by baseline cardiovascular risk, the absolute number of events per 1000 diclofenac starters per year was consistently higher than for the other groups. As this was an observational study, no firm conclusions can be drawn about cause and effect. However, the sample size was larger than for most relevant analyses of observational and randomised studies taken together.

https://www.bmj.com/content/362/bmj.k3426