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This Week in NEJM: Oct 27, 2011


In NEJM this week, an international team of researchers reports a study on the effects of the HPV vaccine against anal HPV infection and anal cancer. The rate of anal cancer is increasing among both men and women, though particularly in men who have sex with men, the researchers write. Anal cancer is preceded by high-grade anal intraepithelial neoplasia, caused by infection with human papillomavirus type 16 or 18. For this study, the team randomly assigned 602 healthy men who have sex with men to receive either the HPV vaccine or a placebo. Efficacy of the vaccine against anal intraepithelial neoplasia associated with HPV types 6, 11, 16, or 18 was 77.5 percent among the men who finished the protocol. In addition, the team found, the rate of grade 2 or 3 anal intraepithelial neoplasia related to infection with HPV-6, 11, 16, or 18 was reduced by 74.9 percent in the men who finished the treatment protocol. "Use of the qHPV vaccine reduced the rates of anal intraepithelial neoplasia, including of grade 2 or 3, among men who have sex with men," the authors write. "The vaccine had a favorable safety profile and may help to reduce the risk of anal cancer."

Also in NEJM this week, Harvard Medical School's Mary McNaughton-Collins and Michael Barry respond to the US Preventive Services Task Force's recent recommendation to stop routine screening for prostate-specific antigen in healthy men. McNaughton-Collins and Barry praise the panel's careful review of the evidence and its analysis on the utility of PSA screening. However, the authors write, although they agree with the task force's "synthesis of evidence and conclusions regarding the substantial harms that can be associated with PSA-based screening and treatment of screening-detected prostate cancer," they have a different perspective on the benefits of testing, and suggest perhaps it should be done on a case-by-case basis. The task force's recommendation was a grade D, a recommendation against screening in all asymptomatic patients. McNaughton-Collins and Barry, however, say the recommendation should be grade C, which would not be a recommendation for or against the screening, but would leave it up to physicians. "Our perspective is that evidence of a possible small but finite benefit from the largest trial would best support a grade C recommendation for men 55 to 69 years of age," the authors write. "With a grade C recommendation, the task force would be recommending 'against routinely providing the service' while indicating that 'there may be considerations that support providing the service in an individual patient' and stipulating that 'there would need to be at least moderate certainty that the net benefit is small.'" A grade C recommendation would allow the patient to be involved in decisions about testing, and would place more responsibility on primary care physicians, they add. "To make a grade C recommendation appropriate, we primary care clinicians must ensure there is no more routine, indiscriminate PSA screening — and no washing our hands of responsibility once the patient is referred to a specialist for prostate-cancer treatment," McNaughton-Collins and Barry write.