Editorial
Reproductive health in the USA: must do better
www.populationinstitute.org
For The State of Reproductive
Health and Rights: 50-State
Report Card see http://www.
populationinstitute.org/
resources/reports/reportcard/
Jutta Klee/ableimages/Corbis
For more on the
NICE guidelines see http://
guidance.nice.org.uk/CG175
188
On Jan 7, the Washington-based Population Institute
released its second annual report card—The State of
Reproductive Health and Rights: 50-State Report Card—
which compares US states’ rankings in reproductive
health and rights. Because reproductive health and
rights in the USA have had such a long and difficult
history, the report makes for both intriguing and
disturbing reading. Over the past 3 years, there has been
a disappointing increase in restrictions on abortion
rights. Many Americans have been aware of this debate
at the national level, but uninformed about the status of
reproductive health in their own state.
According to the report card, the results for
reproductive health in the USA are neither encouraging
nor consistent across the country. The report gives the
nation a C– overall, largely due to abortion restrictions
and cutbacks in support for family planning services. The
grade is derived from a score based on four reproductive
health categories—effectiveness (maximum 30 points),
prevention (20 points), affordability (30 points), and
access (20 points); and on nine indicators including teen
Active surveillance for early-stage prostate cancer
Last week, the UK’s National Institute for Health and
Care Excellence (NICE) published new guidance for the
diagnosis and treatment of prostate cancer. This update
of their 2008 guidelines provides a clear outline of how
active surveillance should be managed consistently and
uniformly; active surveillance has long been endorsed,
but there has been great national variation. In addition,
the guidelines bring the UK into line with protocols in
other countries such as Canada.
The new guideline for active surveillance lays out
a 5-year plan of recommendations. An emphasis on
transparency in communication with patients means
that they will be better informed about the options
and the support available. NICE recommends an initial
diagnosis by MRI, biopsy, and PSA testing. The active
element of surveillance should comprise PSA tests every
3–4 months throughout year one; every 3–6 months in
the second to fourth year; and every 6 months thereafter.
Should the PSA concentration change irregularly during
this time a further MRI is recommended.
pregnancy rate, sex education, access to emergency
contraception, Medicaid family planning expansion, and
abortion access. 13 states, including Georgia, Indiana,
and Texas, received a failing grade (F). Only 17 states
received a B– or higher, with Oregon receiving the highest
composite score (A). Nine states were awarded a
C grade, including Massachusetts, mainly due to its lack
of both sex education in public schools and expansion for
Medicaid family planning services.
Norway, one of the world’s most successful countries
in terms of WHO’s reproductive health indicators (eg,
access to abortion services and contraception), sets
an excellent example for America to aspire to. Every
woman in the USA should be able to access affordable
reproductive health care irrespective of economic and
social status. Moreover, comprehensive sex education
services should be available for young people in school
regardless of where they live. All US states should
consider expanding Medicaid eligibility and reducing the
cost of accessing contraceptive services to reduce such
glaring inequalities in reproductive health. „ The Lancet
In practice, many men who are diagnosed with
prostate cancer undergo invasive treatment which can
affect sexual function, urinary function, fertility, and can
increase slightly the risk of colorectal cancer. However,
there are many circumstances in which this constitutes
overtreatment and where there is limited evidence
supporting the necessity of this degree of intervention
because the underlying indolent disease is unlikely to
cause substantial harm or any increased risk of death. It
is hoped by NICE that improved recommendations on
surveillance and how it should be managed will reduce
the overuse of unnecessary invasive treatments.
The new guidelines have been welcomed by cancer
specialists. Chris Parker, London, UK, told The Lancet
that it offers clear recommendations which should
reduce variation in clinical practice. For those men
diagnosed with early-stage disease, this introduction of
uniform surveillance and a reduction of overtreatment
will better match management with risk of disease
progression. „ The Lancet
www.thelancet.com Vol 383 January 18, 2014