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Objectives The see-and-treat (S&T) approach is increasingly utilized for the treatment of cervical intraepithelial neoplasia (CIN). However, its recognition remains limited compared to the traditional three-step management. This study aims to systematically review and compare the outcomes of studies that directly assess the S&T and three-step approaches in CIN treatment. Methods A comprehensive literature search was conducted in MEDLINE, EMBASE, and the Cochrane Library up to December 10, 2024. Eligible studies directly compared the overtreatment rate, medical costs, and psychological impact of the S&T and three-step approaches for abnormal cervical smears. The inclusion criteria for women undergoing S&T had to align with those for three-step management. Data on overtreatment risk, medical costs, and psychological effects were extracted and analyzed. Comparative results were presented using forest plots, stratified by different smear categories. Results Twelve publications were included, comprising three randomized controlled trials (RCTs) and nine observational studies. Among women with ASC-H or HSIL, the overtreatment risk following S&T was comparable to that of the three-step approach (ASC-H, RR 1.40, 95% CI 0.75–2.60; HSIL, RR 0.93, 95% CI 0.71–1.23). However, in the LSIL/AS-CUS subgroup, the S&T approach was associated with a significantly higher overtreatment risk compared to the three-step method (RR 2.03, 95% CI 1.92–2.15). The S&T approach was associated with lower medical expenses for HSIL cases and a reduction in patients’ negative emotional responses compared to the three-step procedure. Conclusions The S&T approach may be a suitable alternative for women with HSIL/ASC-H smear results, considering its comparable overtreatment risk, potential cost savings, and psychological benefits. However, its use in LSIL/ASC-US cases should be carefully evaluated due to the increased risk of overtreatment.

Aims/hypothesisMore than 25% of older adults (age ≥75 years) have diabetes and may be at risk of adverse events related to treatment. The aim of this study was to assess the prevalence of intensive glycaemic control in this group, potential overtreatment among older adults and the impact of overtreatment on the risk of serious events.MethodsWe conducted a retrospective, population-based cohort study of community-dwelling older adults in Ontario using administrative data. Participants were ≥75 years of age with diagnosed diabetes treated with at least one anti-hyperglycaemic agent between 2014 and 2015. Individuals were categorised as having intensive or conservative glycaemic control (HbA1c <53 mmol/mol [<7%] or 54–69 mmol/mol [7.1–8.5%], respectively), and as undergoing treatment with high-risk (i.e. insulin, sulfonylureas) or low-risk (other) agents. We measured the composite risk of emergency department visits, hospitalisations, or death within 30 days of reaching intensive glycaemic control with high-risk agents.ResultsAmong 108,620 older adults with diagnosed diabetes in Ontario, the mean (± SD) age was 80.6 (±4.5) years, 49.7% were female, and mean (± SD) diabetes duration was 13.7 (±6.3) years. Overall, 61% of individuals were treated to intensive glycaemic control and 21.6% were treated to intensive control using high-risk agents. Using inverse probability treatment weighting with propensity scores, intensive control with high-risk agents was associated with nearly 50% increased risk of the composite outcome compared with conservative glycaemic control with low-risk agents (RR 1.49, 95% CI 1.08, 2.05).Conclusions/interpretationOur findings underscore the need to re-evaluate glycaemic targets in older adults and to reconsider the use of anti-hyperglycaemic medications that may lead to hypoglycaemia, especially in setting of intensive glycaemic control.

ContextLow-risk differentiated thyroid cancer (DTC) is overdiagnosed, but true incidence has increased as well. Owing to its excellent prognosis with low morbidity and mortality, balancing treatment risks with risks of disease progression can be challenging, leading to several areas of controversy. Evidence AcquisitionThis mini-review is an overview of controversies and difficult decisions around the management of all stages of low-risk DTC, from diagnosis through treatment and follow-up. In particular, overdiagnosis, active surveillance vs surgery, extent of surgery, radioactive iodine (RAI) treatment, thyrotropin suppression, and postoperative surveillance are discussed. Evidence SynthesisRecommendations regarding the diagnosis of DTC, the extent of treatment for low-risk DTC patients, and the intensity of posttreatment follow-up have all changed substantially in the past decade. While overdiagnosis remains a problem, there has been a true increase in incidence as well. Treatment options range from active surveillance of small tumors to total thyroidectomy followed by RAI in select cases. Recommendations for long-term surveillance frequency and duration are similarly broad. ConclusionClinicians and patients must approach each case in a personalized and nuanced fashion to select the appropriate extent of treatment on an individual basis. In areas of evidential equipoise, data regarding patient-centered outcomes may help guide decision-making.

Ductal carcinoma in situ (DCIS) accounts for 15–25% of all breast cancer diagnoses. Its prognosis is excellent overall, the main risk being the occurrence of local breast events, as most cases of DCIS do not progress to invasive cancer. Systematic screening has greatly increased the incidence of this non-obligate precursor of invasion, lending urgency to the need to identify DCIS that is prone to invasive progression and distinguish it from non-invasion-prone DCIS, as the latter can be overdiagnosed and therefore overtreated. Treatment strategies, including surgery, radiotherapy, and optional endocrine therapy, decrease the risk of local events, but have no effect on survival outcomes. Active surveillance is being evaluated as a possible new option for low-risk DCIS. Considerable efforts to decipher the biology of DCIS have led to a better understanding of the factors that determine its variable natural history. Given this variability, shared decision making regarding optimal, personalised treatment strategies is the most appropriate course of action. Well designed, risk-based de-escalation studies remain a major need in this field.

De-implementing inappropriate health interventions is essential for minimizing patient harm, maximizing efficient use of resources, and improving population health. Research on de-implementation has expanded in recent years as it cuts across types of interventions, patient populations, health conditions, and delivery settings. This commentary explores unique aspects of de-implementing inappropriate interventions that differentiate it from implementing evidence-based interventions, including multi-level factors, types of action, strategies for de-implementation, outcomes, and unintended negative consequences. We highlight opportunities to continue to advance research on the de-implementation of inappropriate interventions in health care and public health.

Preferences for risk-reducing, active, treatments are higher when people make treatment decisions for others as opposed to themselves.13 And evidence suggests that clinicians recommend treatments for their patients different from those they would choose for themselves—prioritising survival rates for their patients over other outcomes such as the risk of adverse side effects.14 In summary, there are fundamental human tendencies towards action in the face of uncertainty, a preference for certainty even at a cost and a desire to protect one’s own patients from the risk of serious harm (figure 1). [...]guidelines and directives can encourage and legitimise decisions to avoid active treatment, but can be difficult to implement in practice: evidence about treatment value at population level may be seen as uninformative for individual-level decisions.17 Here, shared decision-making can play an important role. [...]in cancer treatment decisions, conversations supported by decision tools can help in assessing the value of treatment for an individual patient and can enable discussion about goals of care and the appropriateness of active (or more aggressive) intervention.18 In the case of antibiotic overuse, shared decision-making with patients or their relatives (when feasible) can provide an opportunity for a balanced discussion of uncertainties, risk and preferences.19 Shared decision-making approaches can also play a role in addressing clinicians’ tendencies towards more risk-averse approaches to treatment when making decisions for others. The role of guidelines and shared decision-making in resolving these tensions is limited, as decision-making requires balancing of individual and collective risks and moral reasoning.22 A more promising line of enquiry might be to explore the strategic reframing of alternatives to active treatment.

It is important for general practitioners (GPs) to protect elderly patients with diagnosis of diabetes type 2 (DM2) from overtreatment. To analyse the metabolic control and treatment of elderly patients with DM2 in general practices. This cross-sectional study involved 46 general practices in a federal state of Germany. Inclusion criteria for patients were diagnosis of DM2, age of 70 years or above, no palliative care and at least one practice contact within the last six months. A study nurse randomly selected 10 eligible patients and extracted data on haemoglobin A1c (HbA1c), diabetes treatment, secondary prevention and GP's characteristics. Risk of overtreatment was defined as having a HbA1c <47.5 mmol/mol (6.5%) and receiving glucose-lowering drugs, and overtreatment as being at risk of overtreatment and being aged 80 years or above or living in a nursing home. Among 460 participants, 36.0% received oral-antidiabetic drugs, 16.7% insulin, 16.2% both and 31.1% received diet/exercise. Overtreatment occurred in 12% of elderly patients with DM2, risk of overtreatment in 24%. Overtreatment was significantly associated with urban residency (OR 2.17). Female elderly patients with DM2 were significantly less often at risk of overtreatment (OR 0.59). Cluster effects were evident between general practices' treatment and monitoring of elderly patients with DM2 in quantitative data. Overtreatment is a relevant problem in elderly patients with DM2 for which GPs should regularly check and start deprescribing. Cluster effects suggest heterogeneity between general practices in diabetes management and monitoring.

Objective: levothyroxine prescriptions have increased remarkably during the last decade, and it is most likely to be prescribed in subclinical hypothyroidism. The aim of this review was to present data on when levothyroxine treatment should be initiated, and the effects of treatment in subclinical hypothyroidism on symptoms such as weight, quality of life, vitality, cognition, and cardiovascular disease. We also discuss evidence for different thyroid-hormone medications. In addition, the option to withhold medication when there is uncertain diagnosis or lack of clinical improvement is discussed. Methods: a literature search in PubMed on the term “treatment of subclinical hypothyroidism” in combination with “quality of life”, “weight”, “cognition”, and “cerebrovascular disease”. Results: current research supports that levothyroxine should be initiated in patients with a thyroid stimulating hormone (TSH) >10 mIU/L. Treatment for hypothyroidism is becoming more frequent. Symptoms related to vitality, weight, and quality of life in subclinical disease often persist with levothyroxine treatment, and other causes should be explored. Patients with cardiovascular-risk factors may benefit from treatment, especially younger patients. Caution is necessary when treating elderly subjects with levothyroxine. Conclusion: lifelong treatment with levothyroxine should normally only be considered in manifest hypothyroidism. However, in subclinical hypothyroidism with a TSH >10 mIU/L, therapy is indicated. In milder subclinical forms, a wait-and-see strategy is advocated to see if normalization occurs. Subgroups with cardiovascular risk and subclinical hypothyroidism may benefit from levothyroxine therapy.

Renal cell carcinoma (RCC) incidence is increasing worldwide. A high proportion of individuals are asymptomatic at diagnosis, but RCC has a high mortality rate. These facts suggest that RCC meets some of the criteria for screening, and a new analysis shows that screening for RCC could potentially be cost-effective. Targeted screening of high-risk individuals is likely to be the most cost-effective strategy to maximize the benefits and reduce the harms of screening. However, the size of the benefit of earlier initiation of treatment and the overall cost-effectiveness of screening remains uncertain. The optimal screening modality and target population is also unclear, and uncertainties exist regarding the specification and implementation of a screening programme. Before moving to a fully powered trial of screening, future work should focus on the following: developing and validating accurate risk prediction models; developing non-invasive methods of early RCC detection; establishing the feasibility, public acceptability and potential uptake of screening; establishing the prevalence of RCC and stage distribution of RCC detected by screening; and evaluating the potential harms of screening, including the impact on quality of life, overdiagnosis and over-treatment.Renal cell carcinoma (RCC) incidence is increasing worldwide. Here, the authors consider the potential benefits and harms of screening for RCC and discuss whether enough evidence is available to begin a clinical trial of RCC screening.