{"id":5732,"date":"2015-01-07T21:34:12","date_gmt":"2015-01-08T02:34:12","guid":{"rendered":"http:\/\/blogs.nejm.org\/?p=5732"},"modified":"2015-06-04T14:19:26","modified_gmt":"2015-06-04T18:19:26","slug":"are-the-sti-screening-guidelines-for-gay-men-overkill-and-pedro-video","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/are-the-sti-screening-guidelines-for-gay-men-overkill-and-pedro-video\/2015\/01\/07\/","title":{"rendered":"Are the STI Screening Guidelines for Gay Men Overkill? (And Pedro Video.)"},"content":{"rendered":"

\"Dominican<\/a>Our “healthcare system” recently distributed a set of guidelines entitled,\u00a0Primary care for gay men: screening and treatment recommendations.<\/em><\/p>\n

It included, among other things, recommendations for screening for sexually transmitted infections (STIs) and anal cancer. The former it adopted from CDC guidelines<\/a>, which are this\u00a0this:<\/p>\n

Screening at least once a year for syphilis, chlamydia, and gonorrhea for\u00a0<\/span>all sexually active gay, bisexual, and other men who have sex with men (MSM)<\/strong>. [Emphasis theirs.] MSM who have multiple or anonymous partners should be screened more frequently for STDs (i.e., at 3-to-6 month intervals)<\/span><\/p>\n

The anal cancer screening guidelines were kind of made up — pretty much like all recommendations for this form of cancer, since we don’t have solid data linking screening to\u00a0a reduction in cases of invasive anal cancer and\/or death. But in essence the guidelines recommend annual screening with anal pap smears for HIV positive men, and to “consider” screening HIV negative gay men every 2-3 years.<\/p>\n

(Brief reminder here: \u00a0Cancer screening — prostate<\/a>, breast<\/a>, colon<\/a>, lung<\/a>, ovarian<\/a>, you name it — is kind of a complex issue. That, my friends, is so far the understatement of this baby year. In short, just because we can<\/em> screen for some cancers, doesn’t mean we should<\/em>. )<\/p>\n

Anyway, the release of these guidelines\u00a0prompted an email from one of my colleagues, a primary care physician, as follows:<\/p>\n

I was reading the guidelines regarding recommendations for STI screening in all MSM (including annual HIV, urethral\/rectal GC\/chlamydia swabs, pharyngeal gonorrhea swab and syphilis testing) — is this something that you recommend in practice? I have a number of MSM patients in monogamous relationships so my approach has been to screen if new partners, etc. — and I have not been screening for everything, e.g., asymptomatic pharyngeal gonorrhea… seems silly, what’s the evidence?
\nThey are also recommending consideration of anal pap 2-3 years in MSM who are HIV negative… Is that something you recommend? I worry that the benefits of downstream evaluation\/treatment are not clear. Thanks so much for your wisdom!
\nEmily [Not her real name #1]<\/p>\n

Moments after this Emily query, along came this, from a different physician-colleague, who is a gay man:<\/p>\n

Hi Paul,
\nWondering what you think of these recommendations for STI and anal cancer screening for gay men. I\u00a0can tell you that my PCP read aloud the guidelines from his computer screen during a routine office visit. He did not ask me about specific risk behaviors and did not take a sexual history, but recommended anal pap because \u201caccording to the guidelines\u201d I should have it done. Because I respected and liked him so much, I did not object, even though I thought it was a ridiculous waste of time and money.\u00a0It would be helpful to know the strength of the evidence for doing an anal pap in HIV-negative men.
\nCharles [Not his real name #2]<\/p>\n

So what’s going on here? Why did both these smart doctors\u00a0— one as a clinician, the other as a patient — question the guidelines?<\/p>\n

As usual, when faced with this kind of clinical quandary, I turned to the most brilliant<\/em>\u00a0person I know about patient dynamics, challenging encounters, and the mysterious emotional world of the people we see in clinic — our extraordinary social worker Susan Larrabee<\/a>. Here’s her comment, quoted in full since it gets “right to the heart” of the issue, if I may use a phrase commonly employed by one\u00a0of my favorite writers.<\/a><\/p>\n

Is it possible some MD\u2019s avoid difficult conversations (i.e. conversations they are uncomfortable having) by doing tests? And perhaps some of these same MDs are making these recommendations? I\u2019m not above this in my own life, especially with my teenage kids\u00a0and their visits with their pediatricians… they’re certainly not telling me (or maybe not their doc) everything. That is to say, there are many difficult conversations and many ways to compensate for our discomfort or the discomfort of our patients, with over-testing perhaps being one.
\nSusan [her real name]<\/p>\n

This is, of course, exactly the issue. In fact, if one reads the guidelines carefully, it includes this key phrase: “these recommendations should be tailored to an individual patient\u2019s risk profile.”<\/p>\n

In other words, you can modify\u00a0the screening according to the risk behaviors of the patient — but only if you take the time to assess it. Cynics will say that everyone<\/em> lies about their sexual behaviors, but do we know if that’s really true? Better to ask and to talk about this stuff than just proceed blindly.<\/p>\n

Speaking of brilliant, I enthusiastically agree that Pedro Martinez deserved his first-ballot induction into the Hall of Fame. \u00a0(OK, admittedly a sudden transition, hence the Dominican Republic flag above.) He was perhaps the most extraordinary\u00a0pitcher I’ve ever seen pitch live, and I’ve seen this guy<\/a>, this guy<\/a>, and this guy\u00a0too<\/a>.<\/p>\n

Baseball fans, see what you think:<\/p>\n