Public Health Clinical Preventive Medicine
by
Mark B. Johnson
  • LAST REVIEWED: 15 June 2015
  • LAST MODIFIED: 30 September 2013
  • DOI: 10.1093/obo/9780199756797-0117

Introduction

The clinical practice of preventive medicine has long been the dream of many who have believed that its promise is too great to ignore. But the actual history of clinical preventive medicine has been much more complex, and often much less rewarding, than these dreamers anticipated. Humanitarians have believed that its promise was in preventing, delaying, decreasing, or eliminating the pain and suffering that accompanies most morbid conditions, while government officials, insurance executives, and economists have more often focused on the potential cost savings it appears to promise. In the journey toward that promise, clinical preventive medicine has gone through several evolutionary changes as it rather unsuccessfully has attempted to define and promote itself in a more attractive and convincing manner to the practicing clinician. Three major complications have hampered its progress and acceptance in the medical community. First, the attractive insinuation that clinical preventive medicine would lead to cost savings has put it in the unenviable position of being measured and judged solely by its economic benefits, a disadvantage not shared with most other clinical modalities. When those savings have not been forthcoming, or when they have not been as great as expected, the medical community and health-care payers have been quick to discount its value. Second, unlike many bodies of medical knowledge that fall cleanly under the purview of a specific medical specialty, the practice of clinical preventive medicine intersects with the practice of almost all of the recognized medical specialties as well as with many other professional fields, both clinical and nonclinical, outside medicine. The knowledge, skills, and competencies required to practice clinical preventive medicine are oftentimes intensive, both in acquisition and provision (e.g., counseling and patient education), and they are either poorly remunerated or may be better provided by ancillary staff, such as nurses, dietitians, exercise physiologists, or behavioral scientists. Defining the unique and appropriate role of the physician in clinical prevention continues to be a point of deep debate and discussion in the medical community. A transformational change in this area may be occurring, however, as a growing number of physicians who claim to be practicing what is being called “lifestyle medicine” take on and greatly expand the scope of what has traditionally been called the practice of clinical preventive medicine. And finally, those who practice alternative and complementary medicine have been very successful in capturing and proclaiming the promise of clinical prevention to the media and lay public while often neglecting or bypassing the rigor required to ensure that their practices are based on scientific evidence.

Introductory Works

The sweep of clinical preventive medicine is well represented by the works given here. Stokes, et al. 1982 defines the terms that are used in the field and describes the general concepts on which the field has been built, defining clinical preventive medicine as “those personal health services, provided within the context of clinical medicine,” by which health is maintained and disease risk and untimely death are reduced. The extent of preventable disease and death in the United States is described in McGinnis and Foege 1993 in a novel and thought-provoking manner, and the seminal works Frame and Carlson 1975 and Breslow and Somers 1977 establish guidelines and schedules to formalize the periodic health examination, in a move away from the traditional annual physical examination. Canadian Task Force on the Periodic Health Examination 1979 took this field to new levels of scientific rigor by setting strict standards for the acceptability of various levels of evidence and utilizing a meticulous methodology in reviewing an increasing list of suggested and recommended screening tests. All subsequent activities of the US Preventive Services Task Force, the Canadian Task Force on Preventive Health Care, and the numerous specialty association guideline production committees truly stand on the shoulders of the original work of the Canadian Task Force on the Periodic Health Examination.

  • Breslow, Lester, and Anne R. Somers. 1977. The lifetime health-monitoring program: A practical approach to preventive medicine. New England Journal of Medicine 296.11: 601–608.

    DOI: 10.1056/NEJM197703172961104Save Citation »Export Citation »E-mail Citation »

    This article further refined recommendations for ethical periodic screening examinations, and added more economical insights into the evidence on which those recommendations were based.

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    • Canadian Task Force on the Periodic Health Examination. 1979. The periodic health examination. Canadian Medical Association Journal 121.9: 1193–1254.

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      This article exponentially expanded the scope of services reviewed and recommended, and it established the “most rigorous, detailed and comprehensive evaluation of the periodic health examination to date.” It also refined the definitions used in the field, and it set detailed criteria for the assessment of potentially preventable conditions that are the basis of all further work in this area.

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      • Canadian Task Force on Preventive Health Care.

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        The site of the reconstituted Canadian Task Force, with additional interventions reviewed and updates refining the work of the first group.

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        • Frame, Paul S., and Stephen J. Carlson. 1975. A critical review of periodic health screening using specific screening criteria. Part 1: Selected diseases of respiratory, cardiovascular, and central nervous systems. Journal of Family Practice 2.1: 29–36.

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          First of four articles that reviewed the literature on the periodic health screening up to this point, and that redefined it on a scientifically sound basis. Defined the criteria needed to justify screening programs, and formulated recommendations based on those criteria. Series continued in the Journal of Family Practice 2.2: 123–129 (Part 2: Selected Endocrine, Metabolic, and Gastrointestinal Diseases); 2.3: 189–194 (Part 3: Selected Diseases of the Genitourinary System); and 2.4: 283–289 (Part 4: Selected Miscellaneous Diseases).

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          • McGinnis, J. Michael, and William H. Foege. 1993. Actual causes of death in the United States. Journal of the American Medical Association 270.18: 2207–2212.

            DOI: 10.1001/jama.1993.03510180077038Save Citation »Export Citation »E-mail Citation »

            Creatively moved behind the leading cause of death indicators to focus on the true or “actual” causes of those deaths, thus opening a new vista on how such deaths might be prevented.

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            • Stokes, Joseph, III, Jay Noren, and Sidney Shindell. 1982. Definition of terms and concepts applicable to clinical preventive medicine. Journal of Community Health 8.1: 33–41.

              DOI: 10.1007/BF01324395Save Citation »Export Citation »E-mail Citation »

              This article by a committee of the American Teachers of Preventive Medicine Foundation helped set the stage for clinical preventive medicine by clarifying the definitions and terms that are used in the field.

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              • US Preventive Services Task Force.

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                This site continues the work of the original task force by updating recommendations based on new information and by increasing the number of interventions reviewed.

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                • US Preventive Services Task Force. 1989. Guide to clinical preventive services: An assessment of the effectiveness of 169 interventions. Baltimore: Williams & Wilkins.

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                  Working on the foundation set by the Canadian Task Force on the Periodic Health Examination, this guide expanded the number of interventions reviewed and formalized the evidence-based criteria needed for such a review.

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                  General Overviews

                  The concept of ethically bringing an asymptomatic individual into the health-care arena for examination, testing, and risk identification with the subsequent implementation of appropriate counseling or treatment modalities has gone through a number of stages in its evolution. Beginning in the mid-20th century, technological innovations and the expanding ability to analyze large databases of information led to two significant new modalities (Multiphasic Screening and Health Risk Appraisals) that could be combined with the traditional periodic health examination, as recommended by the American Medical Association (AMA) in Emerson 1923, to better define and estimate potential risk for the asymptomatic patient. The use of the periodic health examination was reexamined in American Medical Association Council on Scientific Affairs 1983, and was again endorsed, but with suggested changes in its implementation to enhance its efficacy. Wilson and Jungner 1968, a World Health Organization report, helped establish ethical principles of screening and had a significant impact on a worldwide audience. Breslow 1973 added “multiphasic screening” to the vocabulary and tested its efficacy in the Alameda Health Study. Collen 1971 moved this concept to the Kaiser Health System and helped establish guidelines for its use. The stage for the health risk appraisal and the computerized estimate of risk, with subsequent advice for prevention to decrease such risk, was set in Miller 1972, and its methods and implementation are discussed in Goetz, et al. 1980. Concerns about the lack of evidence supporting the use of the health risk appraisal, with suggested improvements, were raised in Schoenbach, et al. 1987.

                  • American Medical Association Council on Scientific Affairs. 1983. Medical evaluations of healthy persons. Journal of the American Medical Association 249.12: 1626–1633.

                    DOI: 10.1001/jama.1983.03330360066040Save Citation »Export Citation »E-mail Citation »

                    The AMA had strongly supported the annual checkup since at least 1923. This reevaluation of that position by the Council on Scientific Affairs supports their position, but adds several caveats in regard to the value of the periodic health examination and how it is best utilized by the practicing physician.

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                    • Breslow, Lester. 1973. An historical review of multiphasic screening. Preventive Medicine 2.2: 177–196.

                      DOI: 10.1016/0091-7435(73)90063-7Save Citation »Export Citation »E-mail Citation »

                      Breslow coined the term “multiphasic screening” and applied the concept of multiple screening tests being utilized in the Alameda Health Study. The article discusses how the Kaiser Plan in San Francisco and the Health Insurance Plan of Greater New York took this concept and popularized it.

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                      • Collen, Morris F. 1971. Guidelines for multiphasic health checkups. Archives of Internal Medicine 127.1: 99–100.

                        DOI: 10.1001/archinte.1971.00310130103016Save Citation »Export Citation »E-mail Citation »

                        Building on the work from the Alameda Health Study, this author helped popularize the multiphasic health checkups and define the guidelines under which such screenings should be conducted. His role with Kaiser Health greatly magnified the influence of this work.

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                        • Emerson, Haven. 1923. Periodic medical examinations of apparently healthy persons. Journal of the American Medical Association 80.19: 1376–1381.

                          DOI: 10.1001/jama.1923.26430460003011Save Citation »Export Citation »E-mail Citation »

                          The groundbreaking report of the AMA’s Council on Health and Public Instruction that endorsed the use of periodic medical examinations, or the annual checkup, with suggested universal medical forms to be used, as well as recommendations as to what items needed to be included in the examination.

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                          • Goetz, Axel A., Jean F. Duff, and James E. Bernstein. 1980. Health risk appraisal: The estimation of risk. Public Health Reports 95.2: 119–126.

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                            An early report on the use of a formal health risk appraisal to identify areas of concern and risk in those being screened. Looks at the methodological and research issues involved in the development of a risk estimate.

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                            • Miller, Daniel G. 1972. Preventive medicine by risk factor analysis. Journal of the American Medical Association 222.3: 312–316.

                              DOI: 10.1001/jama.1972.03210030034008Save Citation »Export Citation »E-mail Citation »

                              Helped set the stage for health risk appraisals and interventions tailored to their findings.

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                              • Schoenbach, Victor J., Edward H. Wagner, and William L. Beery. 1987. Health risk appraisal: Review of evidence for effectiveness. Health Services Research 22.4: 553–579.

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                                A lengthy review of the lack of evidence that the quantitative estimate of risk that is produced by the health risk appraisals of that time had any positive impact on the population being tested. Discusses suggested changes to help improve the product.

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                                • Wilson, J. M. G., and G. Jungner. 1968. Principles and practice of screening for disease. Public Health Papers 34. Geneva, Switzerland: World Health Organization.

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                                  Very influential report from the World Health Organization that influenced all subsequent work on health screening and periodic health examination task forces.

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                                  Reference Works

                                  The ultimate reference works on evidence-based clinical preventive services are the updated recommendations of the US Preventive Services Task Force and those of its predecessor, the Canadian Task Force on Preventive Health Care (previously known as Canadian Task Force on the Periodic Health Examination). Created in 1984, the US Preventive Services Task Force (USPSTF) is an independent group of national experts in prevention and evidence-based medicine that works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services. It is provided staff support by the Agency for Healthcare Research and Quality (AHRQ), one of twelve agencies within the US Department of Health and Human Services. AHRQ’s mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans, and it helps the USPSTF with day-to-day operations, coordinates the production of evidence reports, ensures consistent use of its methods, and helps disseminate its materials and recommendations. The American Academy of Family Physicians has adopted the USPSTF recommendations for clinical preventive services for the most part, but it occasionally adapts them to better suit the needs and practices of its members (see American Academy of Family Physicians 2012). The World Health Organization’s Global Health Observatory website combines links to the basic data on health risks and health needs around the world with programs for health education, screening, and implementation of clinical preventive services. Heymann 2008 is the public health authority on infectious disease control, including the clinical preventive practices that are recommended for the treatment and prevention of communicable disease. Woolf, et al. 2008 provides a broad view of clinical preventive guidelines and recommendations, with practical suggestions for the practicing clinician on how best to implement the recommendations and assist individuals with necessary lifestyle modifications for health. Rippe 2012 is a monumental work on clinical preventive medicine under the new and growing designation of “lifestyle medicine.” The work includes a comprehensive listing and review of recommendations and modalities that are currently being used to assess lifestyle habits, their risks, and their impact on the health of individuals.

                                  • American Academy of Family Physicians. 2012. Summary of recommendations for clinical preventive services. Leawood, KS: American Academy of Family Physicians.

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                                    Recommendations for clinical preventive services from the AAFP’s Commission on Health of the Public and Science as approved by the AAFP Board of Directors. Based largely on the US Preventive Services Task Force recommendations, with some differences deemed important by the AAFP.

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                                    • Canadian Task Force on Preventive Health Care.

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                                      Website of the Canadian Task on Preventive Health Care, with links to its recommendations, updates, methods, and history. Also links to resources on implementation of the recommendations for primary care clinicians and resources for patients.

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                                      • Global Health Observatory (GHO). World Health Organization.

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                                        Resource for global information and statistics on health risks and the global burden of disease for national health indicators comparisons. Links to reports and information on implementation of prevention programs and WHO goals.

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                                        • Heymann, David L., ed. 2008. Control of communicable diseases manual. Washington, DC: American Public Health Association.

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                                          The authoritative handbook for the control of communicable diseases, including information on immunizations and other steps in the prevention of communicable disease at both the individual and community level.

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                                          • Rippe, James M. 2012. Encyclopedia of lifestyle medicine and health. 2 vols. Thousand Oaks, CA: SAGE.

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                                            A comprehensive reference on relevant lifestyle medicine topics, with evidence-based recommendations and information on lifestyle habits, their risks, and their impact on health. Updated information on nutrition, physical activity, behavioral health, and clinical practices that can be implemented to prevent and treat mortality and morbidity relating to lifestyle practices.

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                                            • US Preventive Services Task Force.

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                                              Home site of the US Preventive Services Task Force, with information on the task force, its work, its methods, and its history. Lists updates to recommendations since the last full report was published, and has a site for submitting suggested new topics for recommendations.

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                                              • US Preventive Services Task Force (USPSTF): An introduction.

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                                                Links to the last published US Preventive Services Task Force list of recommendations, as well as PowerPoint presentations from AHRQ conferences on the USPSTF and its recommendations.

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                                                • Woolf, Stephen H., Steven Jonas, and Evonne Kaplan-Liss, eds. 2008. Health promotion and disease prevention in clinical practice. 2d ed. Philadelphia: Williams & Wilkins.

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                                                  This book reviews updated guidelines from major credible recommending authorities, including the US Preventive Services Task Force. It also has numerous suggestions for practicing physicians as to how they might better implement the recommended lifestyle changes needed in their patients’ lives.

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                                                  Textbooks

                                                  Very few textbooks have been produced that focus uniquely and specifically on clinical preventive medicine. Lang and Hensrud 2004 is a continuation of a series of several editions of a textbook dedicated to the practice of clinical preventive medicine in primary care settings, with which Lang has been associated from the first. Most textbooks, however, that deal with the subject of clinical preventive medicine deal with it as only a part of their overall subjects. Textbooks written primarily for the primary care specialties almost uniformly have clinical prevention as a section in their work, or have clinical preventive services scattered throughout the book. Such examples include Rakel and Rakel 2011; Kliegman, et al. 2011; and Goldman and Schafer 2012. Rose 2008 presents the new concept of clinical preventive medicine within a population by viewing disease as a continuum, and paradoxically advising that the greatest good may be done by focusing on the prevention and treatment on those of lower risk on the continuum. In addition to this, some of the primary care subspecialty areas have also expanded their focus to include the clinical preventive medical aspects of their practices. This is highlighted in textbooks for the fields of preventive cardiology (Blumenthal, et al. 2011) and preventive oncology (Colditz and Hunter 2002). Finally, Egger, et al. 2010 moves many of the clinical preventive medicine modalities into the newly named field of lifestyle medicine in this international text on the practice of prevention in a primary care setting.

                                                  • Blumenthal, Roger, JoAnne Foody, and Nathan D. Wong, eds. 2011. Preventive cardiology: A companion to Braunwald’s Heart Disease. Philadelphia: Elsevier Saunders.

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                                                    A companion textbook to one of the leading textbooks on cardiology, focusing on the clinical preventive aspects of the practice of cardiology.

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                                                    • Colditz, Graham A., and David Hunter, eds. 2002. Cancer prevention: The causes and prevention of cancer. Cancer Prevention—Cancer Causes 1. Dordrecht, The Netherlands: Kluwer Academic.

                                                      DOI: 10.1007/0-306-47523-5Save Citation »Export Citation »E-mail Citation »

                                                      General review of cancer, its causes, and what preventive measures may be taken at both the individual and community level.

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                                                      • Egger, Garry, Andrew Binns, and Stephan Rossner. 2010. Lifestyle medicine: Managing diseases of lifestyle in the 21st century. 2d ed. North Ryde, Australia: McGraw-Hill.

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                                                        Clinical preventive medicine and lifestyle medicine with a more international focus. Practical advice for putting clinical preventive services into a primary care physician’s practice.

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                                                        • Goldman, Lee, and Andrew I. Schafer, eds. 2012. Goldman’s Cecil medicine. 24th ed. Philadelphia: Elsevier Saunders.

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                                                          A leading textbook on the practice of internal medicine, with inclusion of sections on clinical preventive medicine in both infectious and chronic disease.

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                                                          • Kliegman, Robert M., Bonita F. Stanton, Joseph St. Geme, Nina F. Schor, and Richard E. Behrman, eds. 2011. Nelson textbook of pediatrics. 19th ed. Philadelphia: Elsevier Saunders.

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                                                            A leading textbook on the practice of pediatrics, with sections on clinical preventive medicine in both infectious and chronic disease.

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                                                            • Lang, Richard S., and Donald D. Hensrud. 2004. Clinical preventive medicine. 2d ed. Chicago: American Medical Association.

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                                                              Background and practice of clinical preventive medicine in primary care settings, with a focus on the rationale and current preventive practices and the delivery of primary clinical preventive services and screening.

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                                                              • Rakel, Robert E., and David P. Rakel, eds. 2011. Textbook of family practice. 8th ed. Philadelphia: Elsevier Saunders.

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                                                                A leading textbook on the practice of family medicine, with sections on clinical preventive medicine in both infectious and chronic disease.

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                                                                • Rose, Geoffery. 2008. Rose’s strategy of preventive medicine. With commentary by Kay-Tee Khaw and M. G. Marmot. Oxford: Oxford Univ. Press.

                                                                  DOI: 10.1093/acprof:oso/9780192630971.001.0001Save Citation »Export Citation »E-mail Citation »

                                                                  A seminal work on the relationship between individual risk factors for disease and the population distribution of those risk factors, and how this relates to the overall burden of disease. Presents a conceptual shift in how disease is perceived as a continuum within a population, and describes strategies for approaching the prevention and treatment of diseases by prioritizing prevention in low-risk individuals as opposed to treatment of very high-risk individuals.

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                                                                  Journals

                                                                  Listed here are some major US and international journals specifically interested in clinical preventive medicine, as well as general medical journals with ongoing articles and sections devoted to lifestyle and its impact on health risk and overall health. While the American Journal of Lifestyle Medicine is dedicated to articles and research that would all be classified as clinical preventive medicine, most journals that publish articles on the clinical aspects of prevention are general medical journals or include a nonclinical public health focus in addition to clinical preventive medicine. The following journals have been the leaders in the publication of articles that have been important to clinical preventive medicine for the past half-century. American Family Physician is the specialty journal for family physicians in the United States, and it includes articles that update primary care physicians on expert clinical preventive guidelines as well as articles specifically targeting the preventive aspects of a primary care practice. The specialty of preventive medicine includes diplomates who focus on research, academics, and clinical practice. The American Journal of Preventive Medicine includes articles of interest for all of these areas of focus, and it has published many that deal with research studies in clinical preventive medicine as well as guidelines for the practice of clinical preventive medicine. As the journal of one of the defined primary care specialties, the Annals of Internal Medicine presents studies and guidelines on clinical prevention that are of particular interest and relevance to the practicing internist. The British Medical Journal, the Journal of the American Medical Association, and the Lancet are international peer-reviewed general medical journals whose objectives include the improvement of health and health care internationally by elevating the quality of disease prevention. In their attempts to fulfill this objective, each journal frequently publishes articles of general medical interest describing research and evidence-based practices in clinical preventive medicine. Preventive Medicine is an international journal dedicated to providing information on applied research into all aspects of preventive medicine, including special features and articles focusing on clinical preventive medicine and lifestyle-related diseases.

                                                                  History

                                                                  The evolution of clinical preventive medicine as it is viewed today really began in the late 18th century with the discovery of the vaccination for smallpox, and it was greatly expanded in the late 19th and early 20th centuries as immunizations were developed for many more infectious diseases. It is not possible to include all of these discoveries in this listing, but the current recommendations and guidelines from the authoritative bodies are included in the section on Immunizations. Most of what is considered clinical preventive medicine currently focuses on the recommended practices dealing with chronic disease conditions in adults. Modern clinical preventive medicine was really founded with the initiation of the annual medical checkup, or the periodic health examination. Gould 1900 was one of the first works to suggest that a system of “personal biologic examinations” would both establish an ongoing record of health for individuals and provide general practitioners with patients and income, as more and more of the procedures they had provided were being “taken away from them” by medical specialists. The American Medical Association Preventive Medicine Section 1911 is included here, even though it deals with children, because this committee’s recommendations helped to further the idea of the periodic health examination in the United States. Emerson 1923 solidified the AMA’s endorsement of the annual periodic health examination. This report of the Council on Health and Public Instruction recommended an annual physical checkup and provided a form to be used by its members, as well as a list of recommended examinations that should be included. Fitz 1939 reported favorably on the periodic health examination as a method of clinical investigation that helps discover asymptomatic signs of disease as well as helping to establish normal findings in a population and building trusting relationships between patients and physicians. Long 1947 reacted with alarm that medical curricula around the country were deemphasizing the importance of clinical preventive medicine, and it made a strong argument for why clinical preventive medicine needed to be included, as well as why it needed to be clearly differentiated from the practice of public health. Smillie 1947 also differentiated public health from clinical preventive medicine, and it predicted that the future primary care physician would spend most of his or her time practicing clinical preventive medicine and seeing patients with chronic, not infectious, conditions. Collen 1971 addressed the addition of automated multiphasic screening to the periodic health examination to provide a more complete assessment of an individual’s current health status, and Rose 1985 compared two distinct approaches to prevention, one dealing with the “high-risk” approach of individual disease determinants, and the other dealing with those determinants that impact the incidence of disease in a population. Although it may seem counterintuitive, Rose advocated for the discovery and control of the causes of incidence in preference to the control of “high-risk” disease determinants.

                                                                  • American Medical Association Preventive Medicine Section. 1911. Report of the Committee on Administration Methods of Physical Examination of School Children. Journal of the American Medical Association 57.22: 1750–1751.

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                                                                    Recommends that each school child have a thorough examination by a physician every year to determine variations from normal. Recommends standardization of the examinations by physicians and claims that examinations by nurses and untrained medical inspectors are often inadequate and of little use to teachers in the education of children.

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                                                                    • Collen, Morris F. 1971. Guidelines for multiphasic health checkups. Archives of Internal Medicine 127.1: 99–100.

                                                                      DOI: 10.1001/archinte.1971.00310130103016Save Citation »Export Citation »E-mail Citation »

                                                                      Delineates the lessons learned from twenty years of multiphasic health checkups, and claims that such programs are successful only when they are of high quality, provide good service to both the individual and their physician, and are economical.

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                                                                      • Emerson, Haven. 1923. Periodic medical examinations of apparently healthy persons. Journal of the American Medical Association 80.19: 1376–1381.

                                                                        DOI: 10.1001/jama.1923.26430460003011Save Citation »Export Citation »E-mail Citation »

                                                                        The groundbreaking report of the AMA’s Council on Health and Public Instruction that endorsed the use of periodic medical examinations, or the annual checkup, with suggested universal medical forms to be used, as well as recommendations as to what items needed to be included in the examination.

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                                                                        • Fitz, Reginald. 1939. The periodic health examination as a method of clinical investigation. Journal of the American Medical Association 112.12: 1115–1120.

                                                                          DOI: 10.1001/jama.1939.02800120001001Save Citation »Export Citation »E-mail Citation »

                                                                          Using examples from a history of fifteen years of periodic health examinations, the author states that such examinations add to the information that medicine has regarding what is normal and how disease begins and progresses.

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                                                                          • Gould, George M. 1900. A system of personal biologic examinations the condition of adequate medical and scientific conduct of life. Journal of the American Medical Association 35.3: 134–138.

                                                                            DOI: 10.1001/jama.1900.24620290004002Save Citation »Export Citation »E-mail Citation »

                                                                            Acknowledged as the first to recommend the periodic health examination. Presented to the Section on the Practice of Medicine at the 1900 annual meeting of the AMA. Alleges that most of what a general practitioner does has been taken away by specialists, and that this is an important area that can be claimed by the primary care practitioner.

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                                                                            • Long, Perrin H. 1947. Clinical approach to preventive medicine. The Lancet 249.6449: 435–438.

                                                                              DOI: 10.1016/S0140-6736(47)91938-7Save Citation »Export Citation »E-mail Citation »

                                                                              An appeal to keep preventive medicine as part of the clinical curricula in medical schools. Discusses differences between public health and preventive medicine. Describes clinical prevention as part of every medical specialty and not a unique field by itself.

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                                                                              • Rose, Geoffrey. 1985. Sick individuals and sick populations. International Journal of Epidemiology 14.1: 32–38.

                                                                                DOI: 10.1093/ije/14.1.32Save Citation »Export Citation »E-mail Citation »

                                                                                Describes and defines the “paradox of prevention,” which shows that by addressing the incidence of disease in a population in preference to addressing the needs of those at “high risk,” more overall health will accrue to the population. Rose concludes that, fortunately, the two approaches are not often mutually exclusive, but that the discovery and control of the causes of incidence should always be of primary concern.

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                                                                                • Smillie, Wilson G. 1947. The role of preventive medicine in clinical practice. Annals of Internal Medicine 28.4: 826–832.

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                                                                                  Predicts the continuing decrease of infectious diseases and an increase in chronic (“degenerative”) diseases as the population ages. Differentiates public health from preventive medicine. Foresees that the “internist of the future must become a practitioner of preventive medicine, working primarily with people who are not ill.”

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                                                                                  Immunizations

                                                                                  Immunization is the process through which an individual’s immune system, which helps protect the individual from agents that are foreign to it, is fortified by the controlled exposure to potentially infectious agents in a manner that causes the individual to produce elements (antibodies) that will reject or destroy the foreign infectious agent when subsequently reexposed to it. This process is controlled by limiting the initial exposure, or attenuating the infectious agent, in such a way as to lead to the desired immune response while not directly causing an infection. Numerous immunizations have now been produced, and to optimize the body’s response to them, the timing of their administration has been carefully studied. The Advisory Committee on Immunization Practices (ACIP) is a group of experts in medicine and public health that develops recommendations on which immunizations to use and how their administration should be scheduled to control diseases in the United States. Members of the ACIP are voluntarily appointed by the secretary of the US Department of Health and Human Services, and their activities are staffed by the Centers for Disease Control and Prevention (CDC). The CDC’s “Recommended Immunization Schedules for Persons Aged 0 through 18 Years—United States, 2012” (Centers for Disease Control and Prevention 2012) reflects the ACIP’s current immunization recommendations for infants, children, and youth. Bridges, et al. 2013 (“Advisory Committee on Immunization Practices: Recommended Immunization Schedule for Adults Aged 19 Years and Older—United States, 2013”) incorporates the current ACIP guidelines for the immunization of adults, and the CDC’s “General Recommendations on Immunization” (Kroger, et al. 2011) delineates the current understanding of the immunization process, the effectiveness and efficacy of immunizations, their optimal scheduling and administration, and common adverse reactions and their treatment. In addition to these general guidelines for the use and scheduling of immunizations, the ACIP promulgates recommendations for certain high-risk groups, including its “Immunization of Health-Care Personnel” (Shefer, et al. 2011). Other organizations may adopt the recommendations of the ACIP for distribution to their members. This is what the American Academy of Pediatrics has done in its “Recommended Childhood and Adolescent Immunization Schedules—United States, 2012” (American Academy of Pediatrics 2012).

                                                                                  Periodic Health Examinations

                                                                                  Much of clinical preventive medicine has been focused on the implementation of evidence-based recommendations for the screening, testing, and examination of apparently healthy individuals. This has usually been accomplished in what has become known as the “annual physical examination,” or the “periodic health examination.” Although the periodic health examination eventually became an expected aspect of the physician-patient interaction, questions about the cost-effectiveness of annual physical examinations, the use of evidence-based versus unproven screening tests, the acceptance of guidelines from alleged expert sources, and competence in the performance of the examinations by practicing physicians have continued to be raised by many researchers and participants in health care. Romm, et al. 1981 concluded that periodic health examinations were worthwhile but did not need to be performed annually. Coffield, et al. 2001 found that preventive services were not provided indiscriminately to all classes of patients, and concluded that the value and cost-effectiveness of the services recommended by the US Preventive Services Task Force depended on population factors. Prochazka, et al. 2005 found that many practicing primary care physicians continued to use unproven screening tests and believed in the effectiveness of the annual examinations in spite of contrary research findings. National Opinion Research Center 2007 and Shires, et al. 2012 evaluate the factors involved in the adoption, integration, and delivery of clinical preventive services, based on types of health plans and physician and patient attributes. Maciosek, et al. 2006 reviews the recommendations of the US Preventive Services Task Force and the Advisory Committee on Immunization Practices and prioritizes them based on their relative health impact and cost-effectiveness. Cohen and Neumann 2007 compare three reviews of the cost-effectiveness and cost savings of implementing clinical preventive services, and Woolf and Harris 2012 highlights the potential harms of periodic health examinations and screening modalities, and also addresses recent controversies that have arisen due to significant differences between US Preventive Services Task Force recommendations and those of some specialty societies.

                                                                                  • Coffield, Ashley B., Michael V. Maciosek, J. Michael McGinnis, et al. 2001. Priorities among recommended clinical preventive services. American Journal of Preventive Medicine 21.1: 1–9.

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                                                                                    A systematic assessment of the value of clinical preventive services recommended by the US Preventive Services Task Force based on burden of disease and cost-effectiveness. Concludes that the value of services will vary depending on population factors. Finds that recommended preventive services are provided at lower rates to populations with disparities.

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                                                                                    • Cohen, Joshua T., and Peter J. Neumann. 2007. The cost savings and cost-effectiveness of clinical preventive care. Research Synthesis Report 18. Princeton, NJ: The Synthesis Project, Robert Wood Johnson Foundation.

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                                                                                      Reviews the claims that clinical preventive services are cost-effective and produce cost savings. Compares the results of three reviews that evaluate intervention costs and health benefits, quantify benefits in terms of a general measure, and are not limited to a particular intervention or particular interventions for a particular subpopulation.

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                                                                                      • Maciosek, Michael V., Ashley B. Coffield, Nichol M. Edwards, Thomas J. Flottemesch, Michael J. Goodman, and Leif I. Solberg. 2006. Priorities among effective clinical preventive services: Results of a systematic review and analysis. American Journal of Preventive Medicine 31.1: 52–61.

                                                                                        DOI: 10.1016/j.amepre.2006.03.012Save Citation »Export Citation »E-mail Citation »

                                                                                        Updates previous ranking of relative health impact and cost-effectiveness for clinical preventive services recommended by the US Preventive Services Task Force and the Advisory Committee on Immunization Practices.

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                                                                                        • National Opinion Research Center. 2007. Evaluation of the U.S. Preventive Services Task Force recommendations for clinical preventive services. AHRQ Publication 08-M011-EF. Washington, DC: Agency for Health Care Research and Quality.

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                                                                                          Reports on the adoption, integration, and delivery of the US Preventive Services Task Force recommendations in four different types of health plans. Finds that the health plan structure affects the integration and delivery of the services but that all four health plans place a high priority on the “A” and “B” recommendations. Common challenges to the delivery of the services are time constraints, patient resistance, and staff availability.

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                                                                                          • Prochazka, Allan V., Kristy Lundahl, Wesley Pearson, Sylvia K. Oboler, and Robert J. Anderson. 2005. Support of evidence-based guidelines for the annual physical examination: A survey of primary care providers. Archives of Internal Medicine 165.12: 1347–1352.

                                                                                            DOI: 10.1001/archinte.165.12.1347Save Citation »Export Citation »E-mail Citation »

                                                                                            Reports on a survey of primary care providers and their use and attitudes toward the annual screening physical examination for asymptomatic adults. Finds that most primary care providers use many unproven screening tests and believe the annual physical examination detects subclinical illness in spite of research findings to the contrary.

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                                                                                            • Romm, Fredric J., Suzanne W. Fletcher, and Barbara S. Hulka. 1981. The periodic health examination: Comparison of recommendations and internists’ performance. Southern Medical Journal 74.3: 265–271.

                                                                                              DOI: 10.1097/00007611-198103000-00004Save Citation »Export Citation »E-mail Citation »

                                                                                              A review of practicing internists’ performances and perceptions of three expert sources of recommendations for preventive care in periodic health examinations. Concludes that periodic health examinations serve a worthwhile purpose but need not be performed annually, practitioners need better awareness of their beneficial purposes, and a better consensus of recommendations must be developed.

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                                                                                              • Shires, Deirdre A., Kurt C. Stange, George Divine, et al. 2012. Prioritization of evidence-based preventive health services during periodic health examinations. American Journal of Preventive Medicine 42.2: 164–173.

                                                                                                DOI: 10.1016/j.amepre.2011.10.008Save Citation »Export Citation »E-mail Citation »

                                                                                                Evaluates factors associated with the delivery of clinical preventive services during periodic health examinations. Likelihood of service provision increased with increasing patient BMI, time after scheduled appointment that physician presented, and patient-physician gender concordance. It decreased with patient age, number of concerns raised by the patient, use of electronic medical record in the exam room, and if the patient had been seen within the past year.

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                                                                                                • Woolf, Steven H., and Russell Harris. 2012. The harms of screening: New attention to an old concern. Journal of the American Medical Association 307.6: 565–566.

                                                                                                  DOI: 10.1001/jama.2012.100Save Citation »Export Citation »E-mail Citation »

                                                                                                  Addresses recent controversies in which the US Preventive Services Task Force recommendations have conflicted with specialty society recommendations for screening modalities or frequencies. Highlights the potential harms of screening and how they relate to the ethical nature of screening recommendations.

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                                                                                                  Multiphasic Screening

                                                                                                  The term “multiphasic screening” was used in Breslow 1973 (cited under General Overviews) to describe the multiple screening tests that were used in the Alameda Health Study, and it has subsequently been used to describe programs with automated laboratory testing, Health Risk Appraisals and Periodic Health Examinations, either individually or combined. Technological advances in the latter half of the 20th century made automated laboratory testing on large groups of individuals both feasible and economically viable, and also introduced the ability to rapidly produce Health Risk Appraisals for large populations. Thorner 1969 describes some of these technological advances and raises the question as to what the potential benefit of multiphasic screening might be. Wilson 1963 provides a good overview of the purposes of multiple screening programs, and also discusses the indications and contraindications of their use. Bates and Yellin 1972 identifies physicians as the limiting step in the value of multiphasic screening, due to their response to positive findings. Shapiro 1973 evaluates the efficacy of different methods of providing multiple screening modalities. Fletcher, et al. 1977 shows the value of multiphasic screening as a case-finding tool in a teaching hospital, and Berwick 1985 discusses the limited value of multiphasic screening in community health fairs due to the lack of follow-up. South-East London Screening Study Group 2001 finds no difference in outcome at five and nine years between a group receiving medical care as usual and one receiving multiphasic screening. Goroll and Julley 2009 reviews the role of multiphasic screening in a broader health maintenance program.

                                                                                                  • Bates, Barbara, and Joel A. Yellin. 1972. The yield of multiphasic screening. Journal of the American Medical Association 222.1: 74–78.

                                                                                                    DOI: 10.1001/jama.1972.03210010054012Save Citation »Export Citation »E-mail Citation »

                                                                                                    The evaluation of one multiphasic screening program that showed the limiting step in the value of the program was physician response to positive findings. This finding, if generalizable, raises questions about the long-term benefits from multiphasic screening.

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                                                                                                    • Berwick, Donald M. 1985. Screening at health fairs: A critical review of benefits, risks, and costs. Journal of the American Medical Association 254.11: 1492–1498.

                                                                                                      DOI: 10.1001/jama.1985.03360110082029Save Citation »Export Citation »E-mail Citation »

                                                                                                      Critically analyzes the rapid expansion of community health fairs in the United States, with an emphasis on the potential benefits, risks, and costs of such events. Discusses the difference between health fairs “discovering” conditions, and actually impacting the health of individuals in which such discoveries are made.

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                                                                                                      • Fletcher, Suzanne W., Myra Sourkes, Martina Rabzel, and Robert H. Fletcher. 1977. Multiphasic screening: Case-finding tool in a teaching hospital medical clinic. Journal of the American Medical Association 237.9: 887–891.

                                                                                                        DOI: 10.1001/jama.1977.03270360049018Save Citation »Export Citation »E-mail Citation »

                                                                                                        Reports on a randomized trial measuring case finding, as opposed to mass screening, among patients in a teaching hospital. The multiphasic screening group in the study had a significant increase in newly identified medical problems, “important” medical problems identified, medical problems acted upon, and impact on medical care.

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                                                                                                        • Goroll, Allan H., and Albert G. Julley. 2009. Health maintenance and the role of screening. In Primary care medicine: Office evaluation and management of the adult patient. 6th ed. Edited by Allan H. Goroll and Albert G. Julley, 16–19. Philadelphia: Lippincott Williams & Wilkins.

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                                                                                                          A general presentation of the role of screening in health maintenance, including tables on criteria for screening, conditions that warrant screening in all patients of appropriate age and gender, and conditions that warrant screening in selected patients only.

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                                                                                                          • Shapiro, Sam. 1973. Evaluation of two contrasting types of screening programs. Preventive Medicine 2.2: 266–277.

                                                                                                            DOI: 10.1016/0091-7435(73)90070-4Save Citation »Export Citation »E-mail Citation »

                                                                                                            Compares, contrasts, and evaluates two different types of screening programs, one with a well-defined, straightforward hypothesis and methodology with a highly specific end result; and one with a multiple array of services, automated multiphasic screening, and tied to a periodic health examination program.

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                                                                                                            • South-East London Screening Study Group. 2001. A controlled trial of multiphasic screening in middle-age: Results of the South-East London Screening Study. International Journal of Epidemiology 30.5: 935–940.

                                                                                                              DOI: 10.1093/ije/30.5.935Save Citation »Export Citation »E-mail Citation »

                                                                                                              This study reports no significant differences at five-years’ and nine-years’ follow-up between two randomized groups, one receiving multiphasic screening and one receiving medical care as usual. The estimated cost of adding multiphasic screening on a national basis in the United Kingdom is discussed.

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                                                                                                              • Thorner, Robert M. 1969. Whither multiphasic screening? New England Journal of Medicine 280.19: 1037–1042.

                                                                                                                DOI: 10.1056/NEJM196905082801904Save Citation »Export Citation »E-mail Citation »

                                                                                                                Questions the place of multiphasic screening in the health-care system and discusses the technological improvements that have occurred since the earlier screening tests, including automated multiphasic screening available for laboratory testing and the addition of health risk appraisals to screening programs.

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                                                                                                                • Wilson, J. M. G. 1963. Multiple screening. The Lancet 282.7298: 51–54.

                                                                                                                  DOI: 10.1016/S0140-6736(63)90059-XSave Citation »Export Citation »E-mail Citation »

                                                                                                                  An early review by a British physician of multiple screening programs being implemented in the United States. A good overview of the differences between screening for infectious and chronic diseases and the indications and contraindications related to mass screening.

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                                                                                                                  Health Risk Appraisals

                                                                                                                  Health risk appraisals are health questionnaires that capture information relating to demographic characteristics; lifestyle choices and habits; personal and family medical histories; physiological data, including weight, height, blood pressure, blood cholesterol, and fasting blood sugar; and psychological attitudes toward health and a willingness to change health behaviors. This information is then used to assess an individual’s health status and health risks, estimate an appraised “health age” and potential length of life, and provide health promotional feedback. Health risk appraisals became popular in the 1980s when computer availability and database power allowed them to be used by many governmental entities and worksites. Sacks, et al. 1980 reviewed the reliability of the health risk appraisal (health hazard appraisal) as an instrument and found that improvements were needed, while Smith, et al. 1987 reviewed the validity of over forty health risk appraisal instruments. DeFriese and Fielding 1990 assessed the use and value of health risk appraisals and predicted they would become an important tool in the future of clinical preventive medicine. Wagner, et al. 1982 also reviewed the instrument and questioned the assumptions behind some of the techniques and methodologies used. Foxman and Edington 1987 compared predicted mortality from health risk appraisal with actual mortality data in the Tecumseh Community Health Study and found the instrument performed quite well. Smith, et al. 1989 reassessed the reliability and validity of health risk appraisal instruments and found that the instruments’ usefulness in health promotion activities was limited by patient unreliability. Law and Wald 2002 questioned the utility of using thresholds in the measurement of risk in health risk appraisals, and it argued that disease risk was reduced by a constant proportion regardless of where the beginning level of risk was found to be. Stuck, et al. 2007 examined an international randomized controlled study of health risk appraisal use in older persons and found them to be well accepted, helpful in identifying health risks and problems, and helpful in providing insight into willingness to change health behaviors.

                                                                                                                  • DeFriese, Gordon H., and Jonathan E. Fielding. 1990. Health risk appraisal in the 1990s: Opportunities, challenges, and expectations. Annual Review of Public Health 11:401–418.

                                                                                                                    DOI: 10.1146/annurev.pu.11.050190.002153Save Citation »Export Citation »E-mail Citation »

                                                                                                                    A wide-ranging review of the use and history of health risk appraisal instruments, including problems and concerns raised and addressed in the methodologies used. An optimistic prediction that health risk appraisal instruments will continue to improve and become an important modality in clinical preventive medicine in the future.

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                                                                                                                    • Foxman, Betsy, and Dee W. Edington. 1987. The accuracy of health risk appraisal in predicting mortality. American Journal of Public Health 77.8: 971–974.

                                                                                                                      DOI: 10.2105/AJPH.77.8.971Save Citation »Export Citation »E-mail Citation »

                                                                                                                      This study assessed the accuracy of the Centers for Disease Control/Health Risk Appraisal (CDC/HRA) program results with the actual deaths that occurred during the Tecumseh Community Health Study. In contrast to studies of health risk appraisal instruments tested against other models, the comparison of actual to predicted mortality of this instrument showed that it performed quite well.

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                                                                                                                      • Law, M. R., and N. J. Wald. 2002. Risk factor thresholds: Their existence under scrutiny. British Medical Journal 324.7353: 1570–1576.

                                                                                                                        DOI: 10.1136/bmj.324.7353.1570Save Citation »Export Citation »E-mail Citation »

                                                                                                                        The authors take the position that viewing thresholds for risk factors is counterproductive, and that a given reduction in physiological variables that are known to cause diseases reduces the risk of disease by a constant proportion irrespective of the starting level of the variable or the level of existing risk.

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                                                                                                                        • Sacks, Jeffrey J., W. Mark Krushat, and Jeffrey Newman. 1980. Reliability of the health hazard appraisal. American Journal of Public Health 70.7: 730–732.

                                                                                                                          DOI: 10.2105/AJPH.70.7.730Save Citation »Export Citation »E-mail Citation »

                                                                                                                          The reliability of health hazard appraisal is questioned in this study, which shows a high level of change in baseline data on subsequent appraisals. These can have a significant impact on appraised age and call for improvements in the reliability of the instruments before the tool is adopted for widespread practice.

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                                                                                                                          • Smith, Kevin W., Sonja M. McKinlay, and John B. McKinlay. 1989. The reliability of health risk appraisals: A field trial of four instruments. American Journal of Public Health 79.12: 1603–1607.

                                                                                                                            DOI: 10.2105/AJPH.79.12.1603Save Citation »Export Citation »E-mail Citation »

                                                                                                                            Reports on a field trial of four health risk appraisal instruments to determine their reliability and validity. Respondents generally gave consistent reports for family history, cigarette smoking, and relative weight, but they were much less consistent on physiological status and lifestyle items. The use of health risk appraisals to evaluate the effectiveness of interventions may over- or underestimate effect due to the lack of reliability of the instrument.

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                                                                                                                            • Smith, Kevin W., Sonja M. McKinlay, and Bruce D. Thorington. 1987. The validity of health risk appraisal instruments for assessing coronary heart disease risk. American Journal of Public Health 77.4: 419–424.

                                                                                                                              DOI: 10.2105/AJPH.77.4.419Save Citation »Export Citation »E-mail Citation »

                                                                                                                              Over forty health risk appraisal instruments are assessed as to the ten-year risk of death estimates given due to coronary heart disease. The most important characteristic for the validity of the instruments was the sophistication of the estimation method, followed by the range of risk estimates an instrument is capable of producing and the degree to which the instrument considers the person’s age.

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                                                                                                                              • Stuck, Andreas E., Kalpa Kharicha, Ulrike Dapp, et al. 2007. Development, feasibility and performance of a health risk appraisal questionnaire for older persons. BMC Medical Research Methodology 7:1–14.

                                                                                                                                DOI: 10.1186/1471-2288-7-1Save Citation »Export Citation »E-mail Citation »

                                                                                                                                The authors report on the modification of a health risk appraisal developed for the elderly in the United States to an updated and regionally adapted multilingual health risk appraisal for use in Europe. The modified appraisal was well accepted by nondisabled community-dwelling older persons in three different European countries, identified a high number of health risks and problems, and provided information on participants’ intention to change high-risk behaviors.

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                                                                                                                                • Wagner, Edward H., William L. Beery, Victor J. Schoenbach, and Robin M. Graham. 1982. An assessment of health hazard/health risk appraisal. American Journal of Public Health 72.4: 347–352.

                                                                                                                                  DOI: 10.2105/AJPH.72.4.347Save Citation »Export Citation »E-mail Citation »

                                                                                                                                  A thorough review of the techniques and methodologies used in health risk appraisal instruments raises questions in regard to assumptions behind the principles used in the instruments and their ability to motivate behavioral change in individuals. The claim is made that the importance of this technique appears to have been exaggerated.

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                                                                                                                                  Evidence-Based Guidelines

                                                                                                                                  There are a number of articles on the methodology behind evidence-based guidelines and recommendations, and on website access to the major bodies that make recommendations for clinical preventive medicine modalities and practice guidelines. Guidelines for the use of clinical preventive services all trace their origins back to Canadian Task Force on the Periodic Health Examination 1979 (cited under Introductory Works). Most of the current work, however, in broad-based clinical guidelines is being done by the US Preventive Services Task Force. The Canadian Task Force on Preventive Health Care and the US Preventive Services Task Force remain the two most credible sources of recommendations for general health screening and the provision of clinical preventive services. Some specialty societies have adapted and adopted the evidence-based guidelines from either of these two task forces, with minor, but sometimes important, variations, and some have additionally promulgated recommendations of their own in their specialty areas. Other groups have compiled and published evidence-based guidelines for specific groups by age or gender. Lichtenstein, et al. 2006) and American Cancer Society 2012 are representative examples of evidence-based clinical guidelines recommended by national specialty societies, while Centers for Disease Control and Prevention, et al. 2011 and Institute of Medicine Committee on Preventive Services for Women 2011 are representative examples of such guidelines recommended for a specific age group or gender. American Academy of Family Physicians 2012 delineates the evidence-based guidelines that this specialty society has adapted and adopted, mostly from the US Preventive Services Task Force recommendations, for recommendation to their membership. The National Guideline Clearinghouse contains a repository of over 15,000 clinical practice guidelines for the diagnosis, treatment, and prevention of disease conditions. This website provides structured, standardized summaries containing information derived from guidelines using a specific template for guideline attributes that it developed to make guidelines uniform and comparable.

                                                                                                                                  Lifestyle Medicine

                                                                                                                                  Lifestyle medicine encourages the use of lifestyle, or behavioral, interventions as the basic modalities in the treatment and management of disease. A growing body of scientific evidence shows that lifestyle interventions can be effective and essential components in the treatment and prevention of chronic disease, and they may at times be as effective as pharmaceutical interventions, but without the level of risks and side effects that often accompany medications. Quite often the lifestyle intervention works synergistically with the medical treatment. Belloc and Breslow 1972 shows a correlation between lifestyle health practices and physical and mental health. Wiley and Camacho 1980 shows that five health practices are predictive of good health in the future. Ornish, et al. 1990, a landmark study, shows that lifestyle changes can induce regression in arterial plaque. Haskell, et al. 1994 compares usual medical care with medications plus lifestyle changes and shows the intervention decreased arterial stenosis progression and hospitalizations. Pan, et al. 1997 reports on the prevention of diabetes mellitus in a prediabetic population by using diet and exercise, while van Dam 2003 shows that a comprehensive lifestyle behavior change can prevent type 2 diabetes. Joshipura, et al. 2001 shows significant decreases in the development of coronary heart disease through healthy dietary changes, and Danaei, et al. 2009 analyzes the effects on mortality of major dietary, lifestyle, and metabolic risk-factor changes, showing a significant increase in the prevention of mortality.

                                                                                                                                  • Belloc, Nedra B., and Lester Breslow. 1972. Relationship of physical health status and health practices. Preventive Medicine 1.3: 409–421.

                                                                                                                                    DOI: 10.1016/0091-7435(72)90014-XSave Citation »Export Citation »E-mail Citation »

                                                                                                                                    Based on the Alameda County, California, health study, this article shows the correlation between the physical and mental health of the general population and individuals’ adherence to seven common health practices. At five years of follow-up, good practices were associated with positive health, were cumulative, and were independent of age, sex, or economic status.

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                                                                                                                                    • Danaei, G., Eric L. Ding, Dariush Mozaffarian, et al. 2009. The preventable causes of death in the United States: Comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Medicine 6: e1000058.

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                                                                                                                                      Analysis of mortality effects of major dietary, lifestyle, and metabolic risk factors in the United States shows that tobacco smoking is responsible for nearly one in five deaths, high blood pressure is responsible for nearly one in six deaths, and overweight/obesity, physical inactivity, and high blood glucose are each responsible for nearly one in ten deaths.

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                                                                                                                                      • Haskell, W. L., E. L. Alderman, J. M. Fair, et al. 1994. Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease: The Stanford Coronary Risk Intervention Project (SCRIP). Circulation 89:975–990.

                                                                                                                                        DOI: 10.1161/01.CIR.89.3.975Save Citation »Export Citation »E-mail Citation »

                                                                                                                                        Four-year study of coronary atherosclerosis response to care as usual or with a comprehensive program of risk reduction involving the use of appropriate medications and lifestyle changes. The group with medication plus lifestyle changes had significantly less progression of atherosclerosis and decreased hospitalizations. Deaths were equal in both groups.

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                                                                                                                                        • Joshipura, Kaumudi J., Frank B. Hu, JoAnn E. Manson, et al. 2001. The effect of fruit and vegetable intake on risk for coronary heart disease. Annals of Internal Medicine 134.12: 1106–1114.

                                                                                                                                          DOI: 10.7326/0003-4819-134-12-200106190-00010Save Citation »Export Citation »E-mail Citation »

                                                                                                                                          Analysis of data from the Nurses’ Health Study and the Health Professionals’ Follow-Up Study showed significant decreases in the development of coronary heart disease in those in the highest quintile of fruit and vegetable intake. Each serving per day of fruits or vegetables showed a 4 percent lower risk for coronary heart disease. Green leafy vegetables and vitamin-C-rich fruits and vegetables had the highest apparent protective effect.

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                                                                                                                                          • Ornish, Dean, Shirley E. Brown, Larry W. Scherwitz, et al. 1990. Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. The Lancet 336.8708: 129–133.

                                                                                                                                            DOI: 10.1016/0140-6736(90)91656-USave Citation »Export Citation »E-mail Citation »

                                                                                                                                            Landmark study showing that lifestyle changes, including a low-fat vegetarian diet, moderate aerobic exercise, stress management training, smoking cessation, and group support, can reverse coronary artery disease. Arterial stenosis showed increased regression in women and in those who most actively adopted the lifestyle changes.

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                                                                                                                                            • Pan, Xiao-Ren, Guang-Wei Li, Ying-Hua Hu, et al. 1997. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance: The Da Qing IGT and Diabetes Study. Diabetes Care 20.4: 537–544.

                                                                                                                                              DOI: 10.2337/diacare.20.4.537Save Citation »Export Citation »E-mail Citation »

                                                                                                                                              Six-year Chinese study of progression to non-insulin-dependent diabetes mellitus (NIDDM) in individuals with impaired glucose tolerance randomized to one of four groups: control group, dietary changes only group, exercise only group, or dietary changes plus exercise group. All three intervention groups showed significant reductions in developing diabetes mellitus.

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                                                                                                                                              • van Dam, Rob M. 2003. The epidemiology of lifestyle and risk for type 2 diabetes. European Journal of Epidemiology 18.12: 1115–1125.

                                                                                                                                                DOI: 10.1023/B:EJEP.0000006612.70245.24Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                Review of ecological and migration studies and lifestyle interventions on the reduction of risk for type 2 diabetes. Lifestyle programs effecting dietary changes, increased physical activity, weight loss, increased consumption of whole-grain products, exchanging unsaturated fat for saturated fat in the diet, and possibly regular light to moderate alcohol consumption can lower the risk for type 2 diabetes.

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                                                                                                                                                • Wiley, James A., and Terry C. Camacho. 1980. Life-style and future health: Evidence from the Alameda County study. Preventive Medicine 9.1: 1–21.

                                                                                                                                                  DOI: 10.1016/0091-7435(80)90056-0Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                  Nine-year follow-up of the Alameda County, California, health study confirms that five of the seven health practices (not smoking cigarettes, alcohol consumption, physical exercise, hours of sleep per night, and weight in relation to height) continued to be associated with positive health, and were predictive of future health status.

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                                                                                                                                                  Chemoprevention

                                                                                                                                                  The ability to effectively approach clinical prevention from the pharmacological route has long been the hope and dream of many preventionists. Research attempting to find a preventive chemical, whether naturally residing in a food source or being manufactured in a chemical laboratory, has consumed the careers of many. Wattenberg 1985 compiles and describes a large number of compounds that are known to have certain activities that can inhibit the initiation of steps that lead to cancer in experimental animals. The challenge remains, however, in how to effectively produce these protective agents in forms that can be used in humans. Hennekens, et al. 1996 and Omenn, et al. 1996 report on the disappointing research results of the use of beta-carotene and vitamin A in humans, both of which had promising cancer prevention activities in animal models. Sporn and Suh 2000 defines chemoprevention as “a pharmacological approach to intervention in order to arrest or reverse the process of carcinogenesis,” and the authors describe newly discovered compounds that have great promise in this field. Sporn is also the individual who coined the term “chemoprevention.” Sharma, et al. 2001 calls for physicians to be better educated to the potential chemoprevention activities of several medications that are commonly used for other indications, and to learn about the potential risks and benefits of each. Kakizoe 2003 and Tsao, et al. 2004 review the clinical trials that have shown great promise in chemoprevention and discuss the competing advantageous and toxic effects that many of the chemical agents exhibit. Lippman and Lee 2006 reviews the results of two large chemoprevention trials that exhibited the potential of the approach as well as the side effects that limit the ability to use most of the promising agents in a low- to moderate-risk population. They call for better methods of identifying high-risk populations, and for the development of more accurate pharmacoecogenetic models to reduce the risk of chemoprevention.

                                                                                                                                                  • Hennekens, Charles H., Julie E. Buring, JoAnn E. Manson, et al. 1996. Lack of effect of long-term supplementation with beta carotene on the incidence of malignant neoplasms and cardiovascular disease. New England Journal of Medicine 334.18: 1145–1149.

                                                                                                                                                    DOI: 10.1056/NEJM199605023341801Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                    Reports on a twelve-year randomized, double-blind, placebo-controlled trial of beta-carotene in a healthy male population with moderate to high risks for cancer. The trial results showed neither benefit nor harm in the incidence of malignant neoplasms, cardiovascular disease, or death from all causes.

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                                                                                                                                                    • Kakizoe, Tadao. 2003. Chemoprevention of cancer: Focusing on clinical trials. Japanese Journal of Clinical Oncology 33.9: 421–442.

                                                                                                                                                      DOI: 10.1093/jjco/hyg090Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                      Reviews the emerging field of chemoprevention and those drugs that have shown promise as agents in the field, focusing on the completed and ongoing clinical trials, and notes that funding for such trials is limited.

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                                                                                                                                                      • Lippman, Scott M., and J. Jack Lee. 2006. Reducing the “risk” of chemoprevention: Defining and targeting high risk: 2005 AACR Cancer Research and Prevention Foundation Award Lecture. Cancer Research 66:2893–2903.

                                                                                                                                                        DOI: 10.1158/0008-5472.CAN-05-4573Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                        Two large-scale cancer prevention trials using chemoprevention are reviewed and reveal both the promise and pitfalls that had been theoretically predicted: a reduction in cancer but major adverse findings. In the Breast Cancer Prevention Trial (BCPT), tamoxifen reduced breast cancer but increased the risk for endometrial cancer, and in the Prostate Cancer Prevention Trial, finasteride reduced prostate cancer but increased the risk of high-grade prostatic cancer.

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                                                                                                                                                        • Omenn, Gilbert S., Gary E. Goodman, Mark D. Thornquist, et al. 1996. Effects of a combination of beta carotene and vitamin A on lung cancer and cardiovascular disease. New England Journal of Medicine 334.18: 1150–1155.

                                                                                                                                                          DOI: 10.1056/NEJM199605023341802Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                          No benefit was found in a four-year multicenter, randomized, double-blind, placebo-controlled primary prevention trial of beta-carotene and vitamin A on the incidence of lung cancer, but the results show there may actually have been an increase in the risk of death from lung cancer, cardiovascular disease, and any cause in smokers exposed to asbestos and the agents used in the study.

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                                                                                                                                                          • Sharma, R. A., A. J. Gescher, K. J. O’Byrne, and W. P. Steward. 2001. Familiar drugs may prevent cancer. Postgraduate Medical Journal 77.910: 492–497.

                                                                                                                                                            DOI: 10.1136/pmj.77.910.492Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                            Appeals to physicians to study and learn to better understand the use and potential use of known, common medications as chemopreventive drugs. Describes some of the studies in chemoprevention that have been shown to be promising with such drugs as aspirin, nonsteroidal anti-inflammatory drugs, and angiotensin-converting enzyme (ACE) inhibitors.

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                                                                                                                                                            • Sporn, Michael B., and Nanjoo Suh. 2000. Chemoprevention of cancer. Carcinogenesis 21.3: 525–530.

                                                                                                                                                              DOI: 10.1093/carcin/21.3.525Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                              Discusses four new classes of promising chemopreventive agents and the importance of continuing the development of totally new classes of potentially useful chemicals for the prevention of cancer.

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                                                                                                                                                              • Tsao, Anne S., Edward S. Kim, and Waun Ki Hong. 2004. Chemoprevention of cancer. CA: A Cancer Journal for Clinicians 54.3: 150–180.

                                                                                                                                                                DOI: 10.3322/canjclin.54.3.150Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                A comprehensive review of chemoprevention, focusing on the multistep process of carcinogenesis and the chemical aspects of the agents and the genotypical and phenotypical aspects of the individuals that are exposed to them.

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                                                                                                                                                                • Wattenberg, Lee W. 1985. Chemoprevention of cancer. Cancer Research 45.1: 1–8.

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                                                                                                                                                                  Describes the mechanisms by which numerous compounds are known to inhibit carcinogenesis in animal studies, and classifies such compounds as those that are known to have effect against carcinogens themselves and those that work against tumor promoters. Discusses the problems inherent in using toxic substances in groups of varying risk for disease.

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                                                                                                                                                                  Breast Cancer

                                                                                                                                                                  The studies cited here support the hypothesis that selective estrogen receptor modulators (tamoxifen and raloxifene) and selective tissue estrogenic activity regulators (tibolone) are effective in decreasing the risk for invasive breast cancer in women without preexisting cancer. Unfortunately, these agents also have adverse side effects, some of them very serious. Fisher, et al. 1998; Powles, et al. 1998; and Veronesi, et al. 1998 examined early trials of tamoxifen and show that it demonstrated the ability to prevent invasive breast cancer in women at increased risk for breast cancer, but not in healthy women, and that it did not prevent breast cancer in women who had been hysterectomized. A beneficial side effect was seen in a decrease in fractures, but endometrial cancer was increased in the women receiving the intervention who still had their uterus. Following up on the apparent but limited success of tamoxifen, Cummings, et al. 1999 studied raloxifene, another selective estrogen modulator with antiestrogenic effects on the breast and uterus, as well as estrogenic effects on bone, lipids, and blood-clotting mechanisms. Once again, the risk of invasive breast cancer decreased, but there was an increase in thromboembolic events. IBIS Investigators 2002 reported results similar to the earlier studies with tamoxifen in a multinational five-year trial. The lack of a strong benefit-to-harm ratio for these agents led the US Preventive Services Task Force to recommend that tamoxifen and raloxifene not be used for the primary prevention of breast cancer in women with average risk (see US Preventive Services Task Force 2002). Nelson, et al. 2009 is a systematic review of eight clinical trials, finding that while all of these agents have the ability to decrease the risk of invasive breast cancer, each of them has adverse side effects that limit their effectiveness.

                                                                                                                                                                  • Cummings, Steven R., Stephen Eckert, Kathryn A. Krueger, et al. 1999. The effect of raloxifene on risk of breast cancer in postmenopausal women: Results from the MORE randomized trial. Journal of the American Medical Association 281.23: 2189–2197.

                                                                                                                                                                    DOI: 10.1001/jama.281.23.2189Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                    Reports on the results of a three-year multinational, multicenter, randomized, double-blind trial of raloxifene, a selective estrogen receptor modulator with antiestrogenic effects on breast and endometrial tissue and estrogenic effects on bone, lipids, and blood clotting, on postmenopausal women with osteoporosis. Risk of invasive breast cancer was decreased, risk of venous thromboembolic disease increased, and risk of endometrial cancer did not change.

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                                                                                                                                                                    • Fisher, Bernard, Joseph P. Costantino, C. Lawrence Wickerham, et al. 1998. Tamoxifen for prevention of breast cancer: Report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study. Journal of the National Cancer Institute 90.18: 1371–1388.

                                                                                                                                                                      DOI: 10.1093/jnci/90.18.1371Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                      Results of one of the earlier studies on tamoxifen’s ability to prevent invasive breast cancer in women at increased risk. Tamoxifen decreased the incidence of both invasive and noninvasive breast cancer, but it did have increased adverse side effects, especially in women over fifty years of age.

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                                                                                                                                                                      • IBIS Investigators. 2002. First results from the International Breast Cancer Intervention Study (IBIS-I): A randomised prevention trial. The Lancet 360.9336: 817–824.

                                                                                                                                                                        DOI: 10.1016/S0140-6736(02)09962-2Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                        Reports on a five-year, multinational, randomized, double-blind, placebo-controlled trial of tamoxifen to decrease the frequency of breast cancer. Risk of breast cancer was reduced by about a third. Thromboembolic disease and deaths were increased. The overall risk to benefit for the use of tamoxifen to prevent breast cancer is unclear.

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                                                                                                                                                                        • Nelson, Heidi D., Rongwei Fu, Jessica C. Griffin, Peggy Nygren, Beth Smith, and Linda Humphrey. 2009. Systematic review: Comparative effectiveness of medications to reduce risk for primary breast cancer. Annals of Internal Medicine 151.10: 703–715.

                                                                                                                                                                          DOI: 10.7326/0000605-200911170-00147Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                          Review of eight clinical trials studying tamoxifen, raloxifene, and tibolone and their ability to reduce risk of invasive breast cancer. All of the medications reduced risk of invasive breast cancer and reduced fractures, but tamoxifen and raloxifene increased thromboembolic events, tamoxifen increased endometrial cancer and cataracts, and tibolone caused strokes in older women.

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                                                                                                                                                                          • Powles, T., R. Eeles, S. Ashley, et al. 1998. Interim analysis of the incidence of breast cancer in the Royal Marsden Hospital tamoxifen randomized chemoprevention trial. The Lancet 352.9112: 98–101.

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                                                                                                                                                                            Following on the apparent success of tamoxifen in Fisher, et al 1998, this trial tested the ability of tamoxifen to prevent breast cancer in healthy women who were at high risk because of a family history of breast cancer. Study did not show any effect of tamoxifen on the incidence of breast cancer in healthy women.

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                                                                                                                                                                            • US Preventive Services Task Force. 2002. Chemoprevention of breast cancer: Recommendations and rationale. Rockville, MD: US Preventive Services Task Force.

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                                                                                                                                                                              Summarizes the rationale for the task force’s recommendations that tamoxifen and raloxifene not be used routinely for the primary prevention of breast cancer in women with average risk, but that clinicians should discuss such use with women with high risk for breast cancer and low risk for adverse effects.

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                                                                                                                                                                              • Veronesi, U., P. Maisonneuve, A. Costa, et al. 1998. Prevention of breast cancer with tamoxifen: Preliminary finding from the Italian randomised trial among hysterectomised women. The Lancet 352.9122: 93–97.

                                                                                                                                                                                DOI: 10.1016/S0140-6736(98)85011-3Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                Because of the apparent promise of tamoxifen in preventing breast cancer in certain candidates, and because of its adverse effect of increasing endometrial cancer, this study tested tamoxifen as a chemopreventive agent in breast cancer in women who had been hysterectomized. The results at almost four years did not show an apparent protective effect.

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                                                                                                                                                                                Prostate Cancer

                                                                                                                                                                                Most of the chemoprevention trials that have been attempted with prostate cancer have used agents that elicit a hormonal response. Thompson, et al. 2003; Thorpe, et al. 2007; and Andriole, et al. 2010 report on studies that have used the 5α-reductase inhibitors finasteride and dutasteride. 5α-reductase is the enzyme responsible for the conversion of circulating testosterone to the more potent dihydrotestosterone, which is responsible for prostate epithelial proliferation. Each of these studies showed that the 5α-reductase inhibitors have the ability to reduce the incidence of prostate cancer. Goodman, et al. 2006 describes the design and complicating biases inherent in the Prostate Cancer Prevention Trial, one of the earliest chemoprevention trials looking at prostate cancer, and Thompson, et al. 2006 uses the data from that trial to develop a predictive model of prostate cancer. Kramer, et al. 2009 summarizes the use of 5α-reductase inhibitors in the prevention of prostate cancer and develops an evidence-based guideline for their use in chemoprevention. Walsh 2010 takes a contrarian view of the promise of the 5α-reductase inhibitors, stating that they do not prevent prostate cancer but merely temporarily shrink tumors that have low potential for being lethal. Walsh feels this may give patients a false sense of security that may delay the diagnosis of high-grade prostatic cancers, which has been one of the adverse findings in these studies. Lippman, et al. 2009 takes a different tack in the battle against prostate cancer. The authors studied the antioxidants selenium and vitamin E, in the Selenium and Vitamin E Cancer Prevention Trial (SELECT). These agents, in combination and alone, did not prevent prostate cancer in a population of relatively healthy men.

                                                                                                                                                                                • Andriole, Gerald L., David G. Bostwick, Otis W. Brawley, et al., for the REDUCE Study Group. 2010. Effect of dutasteride on the risk of prostate cancer. New England Journal of Medicine 362.13: 1192–1202.

                                                                                                                                                                                  DOI: 10.1056/NEJMoa0908127Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                  Reports on a four-year, multicenter, randomized, double-blind, placebo-controlled parallel-group study of dutasteride, a 5α-reductase inhibitor similar to finsteride but with greater activity on 5α-reductase isoenzymes, to determine if it reduces the risk for prostate cancer. Dutasteride reduced the relative risk incidence of prostate cancer by almost 23 percent and improved outcomes related to benign prostatic hypertrophy.

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                                                                                                                                                                                  • Goodman, Phyllis J., Ian M. Thompson Jr., Catherine M. Tangen, John J. Crowley, Leslie G. Ford, and Charles A. Coltman Jr. 2006. The Prostate Cancer Prevention Trial: Design, biases and interpretation of study results. Journal of Urology 175.6: 2234–2242.

                                                                                                                                                                                    DOI: 10.1016/S0022-5347(06)00284-9Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                    A description of the complexities of the Prostate Cancer Prevention Trial and some of its inherent biases that worked for and against the treatment side of the controlled study. These biases made necessary an end-of-study biopsy to evaluate the trial objectives.

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                                                                                                                                                                                    • Kramer, Barnett S., Karen L. Hagerty, Stewart Justman, et al. 2009. Use of 5α-reductase inhibitors for prostate cancer chemoprevention: American Society of Clinical Oncology/American Urological Association 2008 clinical practice guidelines. Journal of Urology 181.4: 1642–1657.

                                                                                                                                                                                      DOI: 10.1016/j.juro.2009.01.071Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                      Clinical practice guideline from a panel of experts who reviewed fifteen randomized clinical trials on the use of 5α-reductase inhibitors (5-ARIs) for the prevention of prostate cancer. Both asymptomatic men with normal prostate-specific antigen scores who anticipate annual screening and men who are taking 5-ARIs for benign conditions may benefit from a discussion about the benefits of 5-ARIs for the prevention of prostate cancer.

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                                                                                                                                                                                      • Lippman, Scott M., Eric A. Klein, Phyllis J. Goodman, et al. 2009. Effect of selenium and vitamin E on risk of prostate cancer and other cancers: The Selenium and Vitamin E Cancer Prevention Trial (SELECT). Journal of the American Medical Association 301.1: 39–51.

                                                                                                                                                                                        DOI: 10.1001/jama.2008.864Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                        To determine whether selenium, vitamin E, or both could prevent prostate and other cancers, 35,533 relatively healthy men from three countries were randomized into one of four groups: placebo only, vitamin E and placebo, selenium and placebo, and selenium and vitamin E. After a median follow-up of 5.46 years, there were no significant reductions in prostate cancer or other cancers in any of the groups.

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                                                                                                                                                                                        • Thompson, Ian M., Donna Pauler Ankerst, Chen Chi, et al. 2006. Assessing prostate cancer risk: Results from the Prostate Cancer Prevention Trial. Journal of the National Cancer Institute 98.8: 529–534.

                                                                                                                                                                                          DOI: 10.1093/jnci/djj131Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                          The authors used data from men in the placebo side of the Prostate Cancer Prevention Trial to develop a predictive model of prostate cancer. Higher PSA levels, family history of prostate cancer, and abnormal digital rectal examinations predicted prostate cancer, and higher PSA levels, abnormal digital rectal examinations, older age at biopsy, and African American race predicted high-grade disease.

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                                                                                                                                                                                          • Thompson, Ian M., Phyllis J. Goodman, Catherine M. Tangen, et al. 2003. The influence of finasteride on the development of prostate cancer. New England Journal of Medicine 349.3: 215–224.

                                                                                                                                                                                            DOI: 10.1056/NEJMoa030660Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                            Study showed almost a 25-percent reduction in prostate cancer over seven years in average-risk males treated prophylactically with finasteride, which inhibits the conversion of testosterone to the primary androgen in the prostate, but also an increase in negative sexual side effects and the risk of high-grade prostate cancers.

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                                                                                                                                                                                            • Thorpe, J. F., S. Jain, T. H. Marczylo, A. J. Gescher, W. P. Steward, and J. K. Mellon. 2007. A review of phase III clinical trials of prostate cancer chemoprevention. Annals of the Royal College of Surgeons of England 89.3: 207–211.

                                                                                                                                                                                              DOI: 10.1308/003588407X179125Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                              A review of all of the phase III trials of prostate cancer chemoprevention that are concluded or currently ongoing. At this time, finasteride is the only chemoprevention therapy shown to reduce the incidence of prostate cancer, but its side effects, particularly the increased risk of high-grade prostate cancer, must be thoroughly discussed with any patients interested in its use.

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                                                                                                                                                                                              • Walsh, Patrick C. 2010. Chemoprevention of prostate cancer. New England Journal of Medicine 362.13: 1237–1238.

                                                                                                                                                                                                DOI: 10.1056/NEJMe1001045Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                Editorial that asks whether or not progress is being made in the chemoprevention of prostate cancer. Concludes that we probably are not. The use of 5α-reductase inhibitors may merely shrink tumors that have low potential for being lethal and do not reduce the risk of positive biopsy in men with elevated PSA levels. By suppressing PSA levels, these drugs may give men a false sense of security and may delay diagnosis of high-grade disease.

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                                                                                                                                                                                                Colorectal Cancer

                                                                                                                                                                                                Chemoprevention for cancers other than those that are hormonally modulated have not fared well. Studies looking at chemoprevention and colorectal cancer have focused on numerous biological theories and agents. Bonithon-Kopp, et al. 2000 looks at the use of calcium and fiber in the prevention of colorectal adenoma recurrence, but rather than prevent adenomas, the fiber group actually had a significant increase in them. Das, et al. 2007; Herszényi, et al. 2008; Half and Arber 2009; Cooper, et al. 2010; and Dubé, et al. 2007 each review the agents that have been examined in studies or postulated as chemopreventive for colorectal cancer, concluding that an effective chemopreventive agent has not yet been identified, and that chemoprevention cannot yet be accepted as standard medical practice.

                                                                                                                                                                                                • Bonithon-Kopp, Claire, Ole Kronborg, Attilio Giacosa, Ulrich Räth, and Jean Faivre. 2000. Calcium and fibre supplementation in prevention of colorectal adenoma recurrence: A randomised intervention trial. The Lancet 356.9238: 1300–1306.

                                                                                                                                                                                                  DOI: 10.1016/S0140-6736(00)02813-0Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                  Reports on a study based on the suggested evidence that increased fiber and calcium may reduce colorectal carcinogenesis. After three years of intervention with either calcium, fiber, or placebo, the fiber group had a significant increase in the recurrence of colorectal adenomas.

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                                                                                                                                                                                                  • Cooper, K., H. Squires, C. Carroll, et al. 2010. Chemoprevention of colorectal cancer: Systematic review and economic evaluation. Health Technology Assessment 14.32: 1–206.

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                                                                                                                                                                                                    Reports on a literature search for randomized controlled trials (RCT) of chemopreventive agents for colorectal cancer. RCTs were found for aspirin (10), nonaspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) (9), calcium and/or vitamin D (6), and antioxidants (16). All of the agents studied showed no significant effect on the prevention of colorectal cancer and/or significant side effects or gastrointestinal toxicity.

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                                                                                                                                                                                                    • Das, Debasish, Nadir Arber, and Janusz A. Jankowski. 2007. Chemoprevention of colorectal cancer. Digestion 76.1: 51–67.

                                                                                                                                                                                                      DOI: 10.1159/000108394Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                      Reviews the current state of chemoprevention in colorectal cancer, including the major models of colorectal carcinogenesis and the chemoprevention agents that have shown the most promise. At the time, chemoprevention could only be practically considered in individuals with very high risk of colorectal cancer and would need to be used in conjunction with surveillance colonoscopy.

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                                                                                                                                                                                                      • Dubé, Catherine, Alaa Rostom, Gabriela Lewin, et al. 2007. The use of aspirin for primary prevention of colorectal cancer: A systematic review prepared for the US Preventive Services Task Force. Annals of Internal Medicine 146.5: 365–375.

                                                                                                                                                                                                        DOI: 10.7326/0003-4819-146-5-200703060-00009Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                        Concludes that aspirin appears to be effective in reducing the incidence of colorectal adenomas and cancer at high doses for more than ten years, but due to the high risk of possible harms, more evaluation is needed.

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                                                                                                                                                                                                        • Half, Elizabeth, and Nadir Arber. 2009. Colon cancer: Preventive agents and the present status of chemoprevention. Expert Opinion on Pharmacotherapy 10.2: 211–219.

                                                                                                                                                                                                          DOI: 10.1517/14656560802560153Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                          Much research is being done on chemoprevention in colorectal cancer, but at this time the only FDA-approved agent is celecoxib, a cyclo-oxygenase-2 inhibitor with known cardiovascular side effects. It is only approved for use in high-risk patients with familial adenomatous polyposis (FAP). Aspirin and sulindac have demonstrated some efficacy, but have increased risk of gastrointestinal toxicity.

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                                                                                                                                                                                                          • Herszényi, László, Fabio Farinati, Pál Miheller, and Zsolt Tulassay. 2008. Chemoprevention of colorectal cancer: Feasibility in everyday practice? European Journal of Cancer Prevention 17.6: 502–514.

                                                                                                                                                                                                            DOI: 10.1097/CEJ.0b013e3282f0c080Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                            Reviews many of the agents that have been proposed for the chemoprevention of colorectal cancer, and concludes that chemoprevention cannot yet be accepted as standard medical practice or a substitute for surveillance colonoscopy.

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                                                                                                                                                                                                            Cardiovascular Disease

                                                                                                                                                                                                            Cardiovascular disease (CVD) is the leading cause of death in most of the world, so it would be expected that much work has been done to identify chemopreventive agents for CVD, and indeed this is the case. Most studies have been done on decreasing risk factors for heart disease, such as increased cholesterol, hypertension, diabetes mellitus, obesity, or lifestyle choices that are detrimental to health. Too many studies have been done on the treatment and control of cholesterol and other blood lipids to include here, but one example is Frick, et al. 1987, which reports on an early study that focused on cholesterol. The authors were able to show a 34-percent decrease in the incidence of coronary heart disease with the use of a lipid-lowering chemopreventive agent. Meister 2002 reports on lipid-lowering agents and lifestyle changes that positively impact cardiovascular disease. Nordenskjӧld, et al. 2005 and Hackshaw, et al. 2011 report on a serendipitous finding from studies of tamoxifen and breast cancer. These studies have shown that the use of tamoxifen decreases mortality from coronary heart disease, particularly in women aged fifty to fifty-nine, and that the longer tamoxifen is used, the greater the decrease in CVD mortality. One of the known mechanisms for mortality in coronary artery disease is thromboembolic activity. Because of this, the use of anticoagulants, such as aspirin and dipyridamole, has been extensively studied. ESPIRIT Study Group 2006; Greving, et al. 2008; Antithrombotic Trialists’ Collaboration 2009; and US Preventive Services Task Force 2002 report on and summarize the growing body of evidence that aspirin, either alone or in combination with other agents such as dipyridamole, is a cost-effective chemoprevention agent that leads to significantly less vascular events in those at increased risk, but its adverse side effect of major bleeds and strokes may limit its usefulness. It is, however, one of the few chemopreventive agents that is now regularly prescribed in low doses for the primary prevention of disease. Hayden, et al. 2002 reviews the evidence for the US Preventive Services Task Force’s recommendation on the use of aspirin for the primary prevention of cardiovascular events, concluding that its net benefit actually increases with the increasing cardiovascular risk of the user.

                                                                                                                                                                                                            • Antithrombotic Trialists’ (ATT) Collaboration. 2009. Aspirin in the primary and secondary prevention of vascular disease: Collaborative meta-analysis of individual participant data from randomised trials. The Lancet 373.9687: 1849–1860.

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                                                                                                                                                                                                              Reports that aspirin for the primary prevention of occlusive vascular disease is of uncertain net value due to an increase in major bleeds.

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                                                                                                                                                                                                              • ESPRIT Study Group. 2006. Aspirin plus dipyridamole versus aspirin alone after cerebral ischaemia of arterial origin (ESPRIT): Randomised controlled trial. The Lancet 367.9523: 1665–1673.

                                                                                                                                                                                                                DOI: 10.1016/S0140-6736(06)68734-5Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                Randomized controlled trial using aspirin plus dipyridamole versus aspirin alone to determine which combination should be preferred as antithrombotic therapy after cerebral ischemia of arterial origin. Results showed that the combination group had significantly fewer subsequent vascular events than did those on aspirin alone.

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                                                                                                                                                                                                                • Frick, Heikki M., Olli Elo, Kauko Haapa, et al. 1987. Helsinki Heart Study: Primary-prevention trial with gemfibrozil in middle-aged men with dyslipidemia. New England Journal of Medicine 317.20: 1237–1245.

                                                                                                                                                                                                                  DOI: 10.1056/NEJM198711123172001Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                  Early study on the use of chemopreventive agents to lower blood lipids to reduce the incidence of coronary heart disease. Gemfibrozil increased HDL cholesterol while decreasing total cholesterol, low-density lipoprotein, and non-HDL cholesterol and triglycerides, leading to a 34-percent reduction in the incidence of coronary artery disease, but no difference in the total death rate compared to the placebo group.

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                                                                                                                                                                                                                  • Greving, Jacoba P., Erik Buskens, Hendrik Koffijberg, and Ale Algra. 2008. Cost-effectiveness of aspirin treatment in the primary prevention of cardiovascular disease events in subgroups based on age, gender, and varying cardiovascular risk. Circulation 117.22: 2875–2883.

                                                                                                                                                                                                                    DOI: 10.1161/CIRCULATIONAHA.107.735340Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                    Assessment of the cost-effectiveness of aspirin for the primary prevention of cardiovascular events in various subgroups. Reports that aspirin treatment for primary prevention is cost-effective for men with a ten-year cardiovascular disease risk of >10 percent and for women with a risk of >15 percent.

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                                                                                                                                                                                                                    • Hackshaw, Allan, Michael Roughton, Sharon Forsyth, et al. 2011. Long-term benefits of 5 years of tamoxifen: 10-year follow-up of a large randomized trial in women at least 50 years of age with early breast cancer. Journal of Clinical Oncology 29.13: 1657–1663.

                                                                                                                                                                                                                      DOI: 10.1200/JCO.2010.32.2933Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                      Discusses the serendipitous finding that tamoxifen lowers the risk of cardiovascular disease and death as a result of cardiovascular disease, particularly among women aged fifty to fifty-nine years.

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                                                                                                                                                                                                                      • Hayden, Michael, Michael Pignone, Christopher Phillips, and Cynthia Mulrow. 2002. Aspirin for the primary prevention of cardiovascular events: A summary of the evidence for the US Preventive Services Task Force. Annals of Internal Medicine 136.2: 161–172.

                                                                                                                                                                                                                        DOI: 10.7326/0003-4819-136-2-200201150-00016Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                        Meta-analysis of five trials that examined the effect of aspirin on cardiovascular events in patients with no previous cardiovascular disease. Concludes that the net benefit of aspirin chemoprevention increases with increasing cardiovascular risk.

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                                                                                                                                                                                                                        • Meister, Kathleen A. 2002. Chemoprevention of coronary heart disease. New York: American Council on Science and Health.

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                                                                                                                                                                                                                          Easy-to-read report that summarizes the use of chemoprevention for coronary heart disease and concludes that compelling scientific evidence indicates that cholesterol-lowering agents can reduce the risk of heart attacks by about 30 percent. Discusses lifestyle changes that also reduce risk of cardiovascular disease.

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                                                                                                                                                                                                                          • Nordenskjöld, Bo, Johan Rosell, Lars-Erik Rutqvist, et al. 2005. Coronary heart disease mortality after 5 years of adjuvant tamoxifen therapy: Results from a randomized trial. Journal of the National Cancer Institute 97.21: 1609–1610.

                                                                                                                                                                                                                            DOI: 10.1093/jnci/dji342Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                            Discusses the beneficial side effect of decreased coronary heart disease mortality with the use of tamoxifen. Reports that longer use (five years vs. two years) of tamoxifen increases the benefit. No significant increase in mortality from other heart diseases, cerebrovascular diseases, or other vascular diseases were observed.

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                                                                                                                                                                                                                            • US Preventive Services Task Force. 2002. Aspirin for the primary prevention of cardiovascular events: Recommendation and rationale. Annals of Internal Medicine 136.2: 157–160.

                                                                                                                                                                                                                              DOI: 10.7326/0003-4819-136-2-200201150-00015Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                              Finds good evidence that aspirin decreases the incidence of coronary heart disease in those at increased risk, but also increases gastrointestinal bleeding and strokes. Concludes that aspirin may be a good chemopreventive drug for patients at high risk for coronary heart disease.

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                                                                                                                                                                                                                              Controversial Recommendations and Challenges

                                                                                                                                                                                                                              The use of and advocacy for clinical preventive medical measures do not come without risks. There have been several important conversations and controversies over recommendations and guidelines for the use of clinical preventive services. This section highlights only one of the serious controversies in clinical preventive medicine that fairly recently led to anger, confusion, and political posturing. US Preventive Services Task Force 2009 changed a long-standing recommendation for the use of screening mammography, based on a systematic review that led the task force to believe the adverse consequences of their recommendation outweigh its benefits in certain groups of women. Screening is not an innocuous activity. No screening test is perfect, and both false positives and false negatives occur, with resulting detrimental effects. False negatives may suffer the consequences of never receiving needed medical services, or receiving them too late. False positives may undergo further testing that can be costly and may even lead to unwarranted morbidity or mortality. The screening test itself may cause damage, such as increased exposure to radiation. Based on Nelson, et al. 2009, an analysis of the systematic review, the task force recommended that women of average risk for breast cancer between the ages of forty and forty-nine no longer be advised to have annual mammograms, as had been recommended in the past, and that women aged fifty to seventy-five need only have mammograms performed biennially. This caused an immediate outcry from some specialty societies, women’s health groups, and other outraged citizens. In part because health-care reform was then being debated in the United States, some claimed that the government and insurance companies were behind the changed recommendations to save on health-care costs. Catherine D. DeAngelis and Phil B. Fontanarosa, well-known medical experts with wide credibility, came to the defense of the task force (see DeAngelis and Fontanarosa 2010). Other efforts to calm the controversy include Woolf 2010 and Woloshin and Schwartz 2010, which in careful detail describe how the task force makes its recommendations and what the trade-offs between benefits and harms may be with screening tests. The American Cancer Society, however, continued to support and advocate for its guidelines (see American Cancer Society 2012), which call for annual screening mammograms to begin at age forty and to continue indefinitely as long as the woman is in good health. The ACS also disagreed with changes the task force had made in recommendations for clinical breast examinations and self-breast examinations. The controversy quickly spilled over into the lay press in America. Parker 2009 and Brawley 2009 extended the discussion of screening and its uses and abuses into the Washington Post, one of the most influential newspapers in the country. The US Senate also got involved, passing an amendment to require insurers to provide free preventive services for women, including screening for breast cancer, ovarian cancer, lung cancer, and other cancers. The fact that there are no evidence-based tests for either ovarian cancer or lung cancer did not sway their zeal.

                                                                                                                                                                                                                              • American Cancer Society. 2012. Breast cancer: Early detection. Atlanta: American Cancer Society.

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                                                                                                                                                                                                                                Reviews breast cancer risk factors, signs and symptoms of breast cancer, screening tests available, and breast self-examination. Reiterates the ACS recommendations for annual screening mammograms to begin at age forty and continue indefinitely as long as the patient is in good health. Recommends clinical breast examination every three years between ages twenty and forty, and yearly after age forty. Recommends breast self-examination as an option for women starting at age twenty, and education on the technique during physical examinations from their health professional.

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                                                                                                                                                                                                                                • Brawley, Otis W. 2009. Let’s stick with mammograms. Washington Post, 19 November.

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                                                                                                                                                                                                                                  Editorial by the chief medical officer of the American Cancer Society in support of the society’s recommendations for routine mammograms for women between the ages of forty and forty-nine. Brawley believes that the US Preventive Services Task Force has underestimated mammography’s lifesaving value, and that the benefits of screening between ages forty and forty-nine outweigh its limitations.

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                                                                                                                                                                                                                                  • DeAngelis, Catherine D., and Phil B. Fontanarosa. 2010. U.S. Preventive Services Task Force and breast cancer screening. Journal of the American Medical Association 303.2: 172–173.

                                                                                                                                                                                                                                    DOI: 10.1001/jama.2009.1990Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                    Editorial supporting the use of unbiased, rigorous, objective evaluations of recommendations for screening, such as those the US Preventive Services Task Force and the Institute of Medicine committees use, to provide objective appraisals, reports, and guidelines.

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                                                                                                                                                                                                                                    • Nelson, Heidi D., Kari Tyne, Arpana Naik, Christina Bougatsos, Benjamin K. Chan, and Linda Humphrey. 2009. Screening for breast cancer: An update for the U.S. Preventive Services Task Force. Annals of Internal Medicine 151.10: 727–737.

                                                                                                                                                                                                                                      DOI: 10.7326/0003-4819-151-10-200911170-00009Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                      Documents the evidence on which the recommendations of the US Preventive Services Task Force made the changes for screening for breast cancer, which are outlined above.

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                                                                                                                                                                                                                                      • Parker, Kathleen. 2009. Calm in a cancer storm. Washington Post, 18 November.

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                                                                                                                                                                                                                                        Example of lay media author’s response to the controversy over screening mammography recommendations. Balances women’s concerns about their health and how these recommendations may impact them with statements from experts outside the US Preventive Services Task Force that support the changes.

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                                                                                                                                                                                                                                        • US Preventive Services Task Force. 2009. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine 151.10: 716–726.

                                                                                                                                                                                                                                          DOI: 10.7326/0003-4819-151-10-200911170-00008Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                          Recommendation statement that recommends against routine screening mammography in women aged forty to forty-nine years, and that the decision to start regular, biennial screening mammography before age fifty should be an individual one. It also concludes that there is insufficient evidence to recommend mammography in women seventy-five years or older, or to recommend the use of breast self-examination, and that there is insufficient evidence to assess the addition of clinical breast examination to screening mammography in women forty years or older.

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                                                                                                                                                                                                                                          • Woloshin, Steven, and Lisa M. Schwartz. 2010. The benefits and harms of mammography screening: Understanding the trade-offs. Journal of the American Medical Association 303.2: 164–165.

                                                                                                                                                                                                                                            DOI: 10.1001/jama.2009.2007Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                            Reviews both the benefits and harms that can come from screening, including excess testing and overdiagnosis leading to unnecessary surgery, chemotherapy, radiation, or some combination of these. Calls for openness to balanced information and warns against the politicization of medical care.

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                                                                                                                                                                                                                                            • Woolf, Steven H. 2010. The 2009 breast cancer screening recommendations of the U.S. Preventive Services Task Force. Journal of the American Medical Association 303.2: 162–163.

                                                                                                                                                                                                                                              DOI: 10.1001/jama.2009.1989Save Citation »Export Citation »E-mail Citation »

                                                                                                                                                                                                                                              Response to the public controversy and media coverage elicited by the changes in the recommendations for screening for breast cancer from the US Preventive Services Task Force. Attempts to describe the work of the task force and its use of evidence in making recommendations. Calls for the depoliticizing of medicine and clinical guidelines.

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