Academic detailing may increase physician knowledge and history taking practice
This 2002 research study explored the effectiveness of academic detailing on physician knowledge and practices related to preventative care for women exposed to synthetic estrogen (DES).
Physician participants were visited by a trained physician and received educational materials, management guidelines, chart reminders, medical history forms, office posters and brochures. They were informed about the reasons of why it was important to take a DES history. A lecture was featured to introduce the goals of this educational program to the participants. Physicians took a pre-intervention and post-intervention test that evaluated the change in their knowledge. To help assess study outcomes, patients likewise engaged in pre-intervention and post intervention surveys. While the study relied on self-reported outcome measures, the results revealed that academic detailing may increase physician knowledge and history taking practice.
BACKGROUND Diethylstilbestrol (DES), a synthetic estrogen prescribed during pregnancy between 1938 and 1971, was later shown to have serious health effects, including higher risks of cancer in daughters and mothers. The authors report results of an intervention to increase health care providers’ awareness of preventive care for women exposed to DES before birth.
A controlled trial enrolled 20 to 25 health care providers in each of three communities to test the effectiveness of an academic detailing intervention. Outcomes (knowledge, routine screening) were assessed by provider questionnaires and patient surveys.
DES knowledge, familiarity with national guidelines, and screening for exposure increased significantly in the intervention communities but not in the control communities. The intervention effect for DES screening was significant (p = 0.01). Patient surveys confirmed provider self-report.
Academic detailing can increase DES knowledge and history taking among primary care providers. This intervention could be disseminated to increase knowledge of DES preventive care.
The National DES Education Program: effectiveness of the California Health Provider Intervention, Journal of cancer education: the official journal of the American Association for Cancer Education, NCBI PMID:12000106, 2002 Spring.
NATIONAL DES EDUCATIONAL PROGRAM FOR HEALTH PROFESSIONALS AND THE PUBLIC,NIH Guide, Volume 22, Number 15, April 16, 1993.
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None of the third-generation daughters were found to have changes usually associated with DES exposure
To examine a group of women (third-generation daughters) whose mothers were exposed in utero to diethylstilboestrol (DES) and compare their findings on pelvic examination with those noted in their mothers.
Letters were mailed to women documented to have been exposed in utero to DES who had given birth to a female offspring, inviting them to have their daughters come in for a detailed history and pelvic examination. Records of the mothers whose daughters appeared for examination were reviewed, and findings noted at the time of their initial examination were recorded. Detailed pelvic examination of the third-generation daughters included colposcopic examination and iodine staining of the vagina and cervix and Papanicolaou smear. The findings observed in these women were compared with those noted in their mothers at the time of their mothers’ first examination.
Twenty-eight third-generation daughters were examined. Three of the daughters were delivered from one mother. Review of the mothers’ records indicated that 16 (61.5%) of the mothers exposed to DES during their pregnancy demonstrated structural changes of the cervix, upper vagina, or vaginal epithelial changes consisting of adenosis, nonstaining vaginal epithelium after application of iodine solution, or white epithelium within the vagina. None of the daughters were found to have changes usually associated with DES exposure.
The absence of abnormalities in the lower genital tract in third-generation women compared with the high frequency of these abnormalities in their mothers suggests that third-generation carryover effects of in utero DES exposure are unlikely.
Findings in female offspring of women exposed in utero to diethylstilbestrol, NCBI, PMID: 11814496,
Obstet Gynecol. 2002 Feb;99(2):197-200.
Transgenerational effects of Diethylstilbestrol (DES) have been reported in animals, but effects in human beings are unknown. Alerted by two case reports, we aimed to establish the risk of hypospadias in the sons of women who were exposed to DES in utero.
We did a cohort study of all sons of a Dutch cohort of 16284 women with a diagnosis of fertility problems. We used a mailed questionnaire assessing late effects of fertility treatment to identify boys with hypospadias. We compared the prevalence rate of hypospadias between boys with and without maternal DES exposure in utero.
16284 mothers (response rate 67%) reported 8934 sons. The mothers of 205 boys reported DES exposure in utero. Four of these children were reported to have hypospadias. In the remaining 8729 children, only eight cases of hypospadias were reported (prevalence ratio 21.3 [95% CI 6.5-70.1]). All cases of hypospadias were medically confirmed. Maternal age or fertility treatment did not affect the risk of hypospadias. Children conceived after assisted reproductive techniques such as in-vitro fertilisation were not at increased risk of hypospadias compared with children conceived naturally (1.8, 0.6-5.7).
Our findings suggest an increased risk of hypospadias in the sons of women exposed to DES in utero. Although the absolute risk of this anomaly is small, this transgenerational effect of DES warrants additional studies.
The overall 40% excess risk in DES Daughters, arising exclusively from the subset of estrogen receptor-positive cases, raises a concern calling for continued investigation
DES Follow-up Study Summary
The question of whether daughters of women who took Diethylstilbestrol (DES) while pregnant with them will have a greater chance of getting breast cancer has been of great interest to both the DES population and researchers. Questionnaire data collected in 1994 and 1997 from participants in the combined follow-up study were used to investigate this question. 4821 exposed and 2095 unexposed women completed one or both of the follow-up questionnaires, answering questions on reproductive factors, health habits, and disease outcomes. Reports of breast cancer were confirmed by checking medical records or death certificates. There were 43 cases of breast cancer among the DES-exposed and 15 among the unexposed women.
Overall, exposed daughters did not have a statistically significant increase in the risk of breast cancer. Although the relative risk was 1.4, this elevation could have been a chance finding due to the small number of breast cancer cases. However, among the subgroup of women aged 40 and older, those exposed to DES were estimated to have 2.5 times the risk of breast cancer, and this result was statistically significant. Follow-up in the study has continued, and a new analysis that includes additional cases diagnosed since 1997 has begun. The new analysis will likely provide more definitive results.
2002 Study Abstract
A synthetic estrogen, Diethylstilbestrol (DES), was widely prescribed to pregnant women during the 1950s and 1960s but was later discovered to be associated with an increased risk of clear-cell carcinoma of the vagina and cervix in female offspring. DES has not been linked to other cancers in female offspring, but studies of other prenatal factors such as twin gestation and pre-eclampsia have indicated that in-utero estrogen levels may influence breast cancer risk. We evaluated the relation of in-utero DES exposure to the risk of adult breast cancer.
A cohort of 4821 exposed women and 2095 unexposed women, most of whom were first identified in the mid-1970s, were followed by mailed questionnaires for an average of 19 years. Reported cancer outcomes were validated by medical record review. Breast cancer incidence in DES-exposed daughters was compared with cancer incidence in unexposed daughters with use of Poisson regression analysis, adjusting for year of birth, age at menarche, age at first birth, and number of births.
The rate ratio for incidence of invasive breast cancer in exposed versus unexposed women was 1.4 (95% confidence interval (CI) = 0.7-2.6). DES exposure was not associated with an increased risk of breast cancer in women under 40 years, but among women aged 40 and older the rate ratio was 2.5 (95% CI = 1.0-6.3). The rate ratio for the association of DES exposure with estrogen receptor-positive tumors was 1.9 (95% CI = 0.8-4.5).
While not statistically significant, the overall 40% excess risk, arising exclusively from the subset of estrogen receptor-positive cases, raises a concern calling for continued investigation.
Risk of breast cancer in women exposed to diethylstilbestrol in utero: prelimiinary results (United States),NCBI, PMID: 12420954, 2002 Oct;13(8):753-8.
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