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Physicians: .25 AMA PRA Category I CreditsTM
Family Physicians: .25 Prescribed credits
Nurse Practitioners: .25 Contact hours

Release Date: July 8, 2015
Expiration Date: July 8, 2016

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon above.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:

1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD
Assistant Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Executive Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP
Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint providership of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: This enduring material activity, DynaMed EBM Focus Volume 10+, has been reviewed and is acceptable for up to 13.25 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins April 29, 2015. Term of approval is for one year from this date. Each weekly update is approved for .25 Prescribed credits. Credit may be claimed for one year from the date of each update. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 13.0 contact hour(s) of continuing education by the American Association of Nurse Practitioners. Program ID 1504207. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards.

Critical Appraisal of the Medical Literature: A Simplified Approach

July 8 – 9, 2015 – Portland State University - Portland, Oregon.

Join our Editorial Board members Sheri Strite and Michael Stuart and improve your critical appraisal skills. We aim to make critical appraisal of the medical literature meaningful, useful, simple, and doable. This program will be particularly helpful to those who routinely evaluate the medical literature.

Visit the Seminar page for more details.

Last week 346 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 88 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to inform clinical practice," one article was selected by the DynaMed Editorial Team.

Surgery May Not Improve Survival in Women with Low-Grade Ductal Carcinoma In Situ

Reference: JAMA Surg 2015 Jun 3 early online (level 2 [mid-level] evidence)

With the increasing prevalence of mammography for breast cancer screening has come an increase in the diagnosis of ductal carcinoma in situ (DCIS), a spectrum of abnormal cells in the breast ducts not invading surrounding tissues (NIH Consens State Sci Statements 2009 Sep 24;26(2):1). DCIS is associated with an increased risk of invasive breast cancer, but it is also associated with a low risk of breast cancer-specific mortality (Arch Intern Med 2000 Apr 10;160(7):953, Am J Surg 2006 Oct;192(4):416). Although current recommendations suggest primary DCIS treatment should include a lumpectomy plus whole breast radiation therapy (National Comprehensive Cancer Network (NCCN) guideline, Ann Oncol 2011 Sep;22 Suppl 6:vi12), the wide variations in DCIS pathology are associated with differential risks of invasive carcinoma. A recent retrospective cohort study evaluated the effect of surgery on survival in 57,222 women diagnosed with DCIS between 1988 and 2011 in the Surveillance, Epidemiology, and End Results (SEER) database.

Ninety-eight percent of women were treated surgically, of whom 61% had a partial mastectomy and 29% had a mastectomy.  Of the 2% of women not treated surgically, 46.8% did not have a physician recommend surgery and 9.8% refused surgery after a physician recommendation.  A large percentage of women (40.9%) not having surgery received a physician recommendation for surgery, but the reasons it was not performed were unknown.  Over the median follow-up of 72 months, 1% of women died from breast cancer and 6.4% died from other causes.  A propensity score-weighted analysis was performed to balance baseline patient characteristics between the surgical and nonsurgical groups.  In this analysis, the estimated 10-year breast cancer-specific survival was 98.5% with surgery and 93.4% without surgery (p = 0.003).  These results were not consistent across all DCIS nuclear grades, however.  While women with high-grade or intermediate-grade DCIS had significantly increased survival with surgery compared to no surgery (98.4% vs. 90.5% for high grade DCIS, p < 0.001 and 98.6% vs. 94.6% for intermediate grade DCIS, p < 0.001), there were no significant differences in breast cancer-specific survival in women with low-grade DCIS (98.6% vs. 98.8%).  Consistent results were found in the analysis of estimated 10-year overall survival.

Although this study is only a retrospective database analysis, it is still significant because it included a large number of women who were not treated with surgery, even though this was a small percentage of the total.  Given the observational nature of this study, it is not surprising that the characteristics of women were not well balanced between the surgical and nonsurgical groups, but propensity score-weighted analyses were used to adjust for these differences.  Surgery was found to significantly increase survival in women with intermediate to high-grade DCIS, in line with the current recommendations. However the failure of surgery to increase survival in women with low-grade DCIS suggests less invasive treatments may be an appropriate option for this subset.  Further prospective studies are required to determine the best course of management for women with low-grade DCIS.

For more information see the Ductal carcinoma in situ topic in DynaMed.

EBSCO Health’s New DynaMed Plus Delivers Trusted, Evidence-Based Content to Physicians on Any Platform

EBSCO Health recently launched DynaMed Plus, a cross-platform, evidence-based clinical decision support tool that provides clinicians with the ideal blend of evidence and expertise to help them determine optimal patient care paths.

DynaMed Plus helps medical professionals quickly find evidence-based answers to make the best treatment decisions in any location. With DynaMed Plus, clinicians (and their patients) will benefit from:

  • Quickest time-to-answer—Including intelligent auto-suggest, direct-to-section search results, exact match summary display, dynamic linking and quick access to relevant calculators.
  • Concise, accurate overviews and recommendations—For the most common conditions as well as evidence-based recommendations for action.
  • Comprehensive image library—Over 4,000 full-color medical graphics and images to help clinicians make the best decisions.
  • Rigorous editorial process—Subject-specific experts review topics on a daily basis using the DynaMed Plus proprietary evidence-based methodology and quality assurance process.
  • Access to specialty content—Clinicians can view thousands of topics covering emergency medicine, cardiology, oncology, infectious disease, pediatrics, obstetrics and gynecology, and much more.
  • Anywhere, anytime accessDynaMed Plus can be used on iOS and Android mobile devices, making access fast and easy, and providing clinicians with an intuitive and elegant mobile experience.

To read the press release and for more information on DynaMed Plus, click here. For free trial information, click here.

DynaMed Careers

The DynaMed editorial team is seeking specialist editors in the following fields: Gastroenterology, Nephrology, Oncology (especially Breast cancer and Pancreatic cancer), Ophthalmology, and Pediatric Neurology.

If interested, please send a recent copy of your CV to Rachel Brady at rbrady@ebsco.com.

DynaMed Contribution Opportunities

Become a DynaMed Resident Focus Reviewer
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