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The latest evidence for practice

Choice picks from the research journals,
with some choice comment …

Una Adderley
Community Tissue
Viability Prescribing
Nurse

Does screening for breast cancer with mammography reduce mortality and morbidity?

The UK breast screening programme currently invites all women aged between 50 and 70 years to attend for mammogram screening every three years, and women over 70 are encouraged to continue to have mammograms every three years. However, the evidence for the effectiveness of mammography in reducing breast cancer mortality is not clear.
This Cochrane systematic review sought randomised controlled trials that compared mammography screening with no mammography screening in women without previously diagnosed breast cancer. Seven trials met the inclusion criteria of which only two had adequate randomisation. A meta-analysis of the trials with adequate randomisation found that there was no evidence that mammography reduced breast cancer mortality. However, mammography was associated with an increased risk of breast surgery (mastectomies and lumpectomies) and radiotherapy.

A commentary notes that mammography detects malignant lesions before they become clinically apparent, but these lesions may not become health-threatening or life-threatening cancers. Currently, it is unclear which types of breast lesion are likely to evolve into life-threatening cancers and consequently which groups of patients will benefit from treatment. Therefore, mammography may be contributing to overdiagnosis and overtreatment, which in itself will result in psychological distress from false positives. The commentary notes that the results of this review contribute to the debate regarding how effective the UK screening programme is.

Reference
Gøtzsche PC, Nielsen M. Screening for breast cancer with mammography. Cochrane Database Syst Rev 2006;18:CD001877.

Commentary
Wiernikowski J, Mohide EA. Evid Based Nurs
2007;10:80.

Do cognitive-behavioural psychological interventions reduce pain and distress associated with needle-related procedures in children and adolescents?

Inoculation sessions for children can be traumatic for both the children and the nurses.  This Cochrane review sought randomised controlled trials that compared cognitive and behavioural interventions with a control in healthy children or adolescents aged between two and 19 years who received needle-related medical procedures. Patients with known needle phobias and studies of dental or other surgeries and body piercings or tattoos were excluded. The review found 16 randomised controlled trials that met the inclusion criteria.
The meta-analysis found that hypnosis and distraction alone reduced self-reported pain. Combined cognitive-behavioural therapy (CBT) hypnosis and distraction with nurse coaching was more effective in reducing distress compared with usual care or no intervention. Suggestion, blowing out air, memory alteration, and distraction with parent coaching did not differ from control for pain and distress.

A commentary notes that it should not be surprising to clinicians that the use of distraction was found to reduce pain and discomfort associated with needle-related procedures in children. However, this review suggests that there are additional benefits when cognitive and/or behavioural interventions are used with simple distraction.
 
CBT and hypnosis are interventions that require expertise outside of usual nursing practice and may not be appropriate for young children. They will also add time to the procedure, so widespread implementation may be challenging. However, the review provides evidence to support which interventions are more effective when required and appropriate, and where resources are available.

Reference
Uman LS, Chambers CT, McGrath PJ, et al. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev
2006;4:CD005179.

Commentary
Robertson J. Evid Based Nurs 2007;10:75.