Ned Calonge, MD, MPH; Gurvaneet Randhawa, MD, MPH
The U.S. Preventive Services Task Force (USPSTF) formulates evidence-based recommendations for clinical preventive services. These recommendations are communicated by letter grades that reflect the quality of evidence and the magnitude of net health benefit expected from delivering the preventive service. When the USPSTF finds insufficient evidence to determine the balance of health benefits or harms of delivering a preventive service, because of a lack of studies, poor-quality studies, or good-quality studies with conflicting results, the USPSTF assigns the service an I letter grade. The USPSTF found insufficient evidence to recommend for or against screening for hepatitis C virus infection in high-risk individuals (I letter grade). This recommendation reflects the need for further research that would provide adequate evidence to assess the net health benefit for persons screened for hepatitis C virus infection.
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Amy L. Webb
University of Texas Health Science Center at San Antonio
December 15, 2004
Importance of Screening High-Risk Patients for HCV
To the Editor:
I disagree with the USPSTF Grade I recommendation on screening high- risk patients for hepatitis C (HCV). They were based on lack of research studies, not lack of evidence (trials with unfavorable results). I agree with Alter et al and other respected members of the foremost hepatology society, and offer two additional points.
First, the morbidity and mortality of HCV were underestimated. At least 20% of HCV-infected patients develop cirrhosis after 20 years (not 10-20% after 20-30 years) with the median patient developing cirrhosis after 38 years and HIV-coinfected after 28 years. The incidence of HCC is already increasing . The mortality from HCV will increase in less than a decade and thereafter decline. Before the results of long-term prospective trials are compiled, many patients will succumb or have serious disease ineligible for treatment. Without systematic identification of asymptomatic infected patients for treatment, the future disease burden will remain high.
The second point likens HCV to HIV. Prior to HAART, the prognosis of HIV was poor. There were no recommendations against screening because of lack of treatment or profound social consequences. Had restrictions in HIV screening existed, perhaps therapeutic developments would have been hampered. In contrast, HCV screening is scrutinized at a time when short- term RCTs demonstrate cure in most patients and prospective treatment data are nearing completion (HALT-C and COPILOT). Discouraging HCV screening may adversely affect research and allow undiagnosed patients to act as reservoirs of infection. Recognizing this, the VA and Red Cross routinely screen for HCV with beneficial results.
I urge practitioners to screen high-risk patients. The opinion that a diagnosis of HCV may cause "anxiety and labeling" is not supported by the literature. A change in society's view similar to that of the HIV movement in the 1990's could remedy discrimination. A transformation of physicians' stance, from passive to proactive in the management of HCV, should lead this movement.
Amy Webb, MD University of Texas Health Science Center at San Antonio San Antonio, TX 78229
Calonge N, Randhawa G. The Meaning of the U.S. Preventive Services Task Force Grade I Recommendation: Screening for Hepatitis C Virus Infection. Ann Intern Med. 2004;141:718-719. doi: 10.7326/0003-4819-141-9-200411020-00014
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Published: Ann Intern Med. 2004;141(9):718-719.
Infectious Disease, Prevention/Screening.
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