Cancer constitutes an enormous burden on society in more and less economically developed countries alike. The occurrence of cancer is increasing because of the growth and aging of the population, as well as an increasing prevalence of established risk factors such as smoking, overweight, physical inactivity, and changing reproductive patterns associated with urbanization and economic development. Based on GLOBOCAN estimates, about 14.1 million new cancer cases and 8.2 million deaths occurred in 2012 worldwide. Over the years, the burden has shifted to less developed countries, which currently account for about 57% of cases and 65% of cancer deaths worldwide. Lung cancer is the leading cause of cancer death among males in both more and less developed countries, and has surpassed breast cancer as the leading cause of cancer death among females in more developed countries; breast cancer remains the leading cause of cancer death among females in less developed countries. Other leading causes of cancer death in more developed countries include colorectal cancer among males and females and prostate cancer among males. In less developed countries, liver and stomach cancer among males and cervical cancer among females are also leading causes of cancer death. Although incidence rates for all cancers combined are nearly twice as high in more developed than in less developed countries in both males and females, mortality rates are only 8% to 15% higher in more developed countries. This disparity reflects regional differences in the mix of cancers, which is affected by risk factors and detection practices, and/or the availability of treatment. Risk factors associated with the leading causes of cancer death include tobacco use (lung, colorectal, stomach, and liver cancer), overweight/obesity and physical inactivity (breast and colorectal cancer), and infection (liver, stomach, and cervical cancer). A substantial portion of cancer cases and deaths could be prevented by broadly applying effective prevention measures, such as tobacco control, vaccination, and the use of early detection tests.

/pdf/global-cancer-statistics-2012-18pecqxl5v.pdf

Global cancer statistics, 2012

Chronic obstructive pulmonary disease (COPD) remains a major public health problem. It is the fourth leading cause of chronic morbidity and mortality in the United States, and is projected to rank fifth in 2020 in burden of disease worldwide, according to a study published by the World Bank/World Health Organization. Yet, COPD remains relatively unknown or ignored by the public as well as public health and government officials. In 1998, in an effort to bring more attention to COPD, its management, and its prevention, a committed group of scientists encouraged the U.S. National Heart, Lung, and Blood Institute and the World Health Organization to form the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Among the important objectives of GOLD are to increase awareness of COPD and to help the millions of people who suffer from this disease and die prematurely of it or its complications. The first step in the GOLD program was to prepare a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD, published in 2001. The present, newly revised document follows the same format as the original consensus report, but has been updated to reflect the many publications on COPD that have appeared. GOLD national leaders, a network of international experts, have initiated investigations of the causes and prevalence of COPD in their countries, and developed innovative approaches for the dissemination and implementation of COPD management guidelines. We appreciate the enormous amount of work the GOLD national leaders have done on behalf of their patients with COPD. Despite the achievements in the 5 years since the GOLD report was originally published, considerable additional work is ahead of us if we are to control this major public health problem. The GOLD initiative will continue to bring COPD to the attention of governments, public health officials, health care workers, and the general public, but a concerted effort by all involved in health care will be necessary.

https://www.who.int/respiratory/copd/GOLD_WR_06.pdf

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary.

https://caltcm.memberclicks.net/assets/documents/acc_aha_chf_2013_guidelines.pdf

2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

Background In patients with high cholesterol levels, lowering the cholesterol level reduces the risk of coronary events, but the effect of lowering cholesterol levels in the majority of patients with coronary disease, who have average levels, is less clear. Methods In a double-blind trial lasting five years, we administered either 40 mg of pravastatin per day or placebo to 4159 patients (3583 men and 576 women) with myocardial infarction who had plasma total cholesterol levels below 240 mg per deciliter (mean, 209) and low-density lipoprotein (LDL) cholesterol levels of 115 to 174 mg per deciliter (mean, 139). The primary end point was a fatal coronary event or a nonfatal myocardial infarction. Results The frequency of the primary end point was 10.2 percent in the pravastatin group and 13.2 percent in the placebo group, an absolute difference of 3 percentage points and a 24 percent reduction in risk (95 percent confidence interval, 9 to 36 percent; P = 0.003). Coronary bypass surgery was needed in 7.5 per...

The Effect of Pravastatin on Coronary Events after Myocardial Infarction in Patients with Average Cholesterol Levels

Quality of Evidence for Treatment of Prostate Cancer—Reply

Venous Thromboembolism Prophylaxis

Does Tiotropium Reduce Hospitalizations in Chronic Obstructive Pulmonary Disease? Authors' reply

Barriers and facilitators of evidence-based psychotherapies for chronic pain in adults: A systematic review.

IN RESPONSE: We appreciate the comments from Dr. Biggs, Dr. Grimm, Dr. Lenderink-Carpenter, and Dr. Lee and colleagues. We also appreciate the opportunity that our guidance statements provide to engage in robust peer discussion. We emphasize the broad agreement among guideline groups as highlighted by our guidance statement, including for women aged 40 to 49 years (1). None of the guidelines recommends screening in women aged 40 to 45 years; the American Cancer Society suggests that starting screening at age 45 years is a weak recommendation because of the fine balance between benefits and harms and the importance of individual patient values and preferences. In women younger than 50 years, we reassert that the evidenceincluding data from 2 guidelines based on more recent trials with longer follow-up (including the U.K. Age trial and CNBSS [Canadian National Breast Cancer Screening Study])shows that the absolute risk of breast cancer screening harms is high and that the absolute benefit in breast cancer mortality reduction is very low (14). We considered many harms, including overdiagnosis, overtreatment, false-positives, and radiation exposure; psychological stressors were only one aspect. We thus disagree with Dr. Biggs, Dr. Grimm, and Dr. Lenderink-Carpenter's assessments of net benefit. We and others (2, 5) also disagree with Dr. Lenderink-Carpenter that modeling represents the most accurate assessment of overdiagnosismodeling incorporates many assumptions, some unknowable. Our understanding should be informed by all available data, which we discuss at length and summarize in Appendix Table 2 of our guidance statement (1). We appreciate Dr. Lenderink-Carpenter's agreement about the physician's role in helping patients sort through the evidence. We also appreciate Dr. Grimm's assertion that discussions should be personalized. For women aged 40 to 49 years, our guidance statement encourages physicians to discuss whether to screen for breast cancer. It thus includes data-derived talking points about the benefits and harms of screening to assist in physicianpatient communication and facilitate personalized decisions on breast cancer screening. These talking points include information so that women younger than 50 years or older than 75 years or those with a life expectancy less than 10 years understand the small average benefit of screening relative to substantial harm. This discussion should include considerations about racial disparities raised by Dr. Lee and colleagues. Although no guideline defined risk status by race or ethnicity, we agree that research is needed to understand the drivers underlying disproportionate breast cancer morbidity and mortality in black women.

Timothy J Wilt

Papers

Quality of Evidence for Treatment of Prostate Cancer—Reply

Venous Thromboembolism Prophylaxis

Does Tiotropium Reduce Hospitalizations in Chronic Obstructive Pulmonary Disease? Authors' reply

Barriers and facilitators of evidence-based psychotherapies for chronic pain in adults: A systematic review.

Screening for Breast Cancer in Average-Risk Women