The edition · Top Clinical Updates
Hot flushes: oestrogen still works best, and is the best value
A 90-trial review for the American College of Physicians ranks the drugs for menopausal vasomotor symptoms. Also today: immunotherapy alone delays progression longer than chemotherapy in mismatch-repair-deficient endometrial cancer, where AI chatbots over-order, and how device harms go under-reported.
The edition in brief
A systematic review of 90 randomised trials, done for the American College of Physicians and published 6 October, found oestrogen (with or without a progestogen, or with bazedoxifene) and oxybutynin reduced both the frequency and severity of menopausal vasomotor symptoms, while neurokinin receptor antagonists, SSRIs, SNRIs, gabapentin and progestogens reduced frequency only. Oestrogen was of high economic value; fezolinetant was of low value. In KEYNOTE-C93, first-line pembrolizumab alone in 299 patients with mismatch-repair-deficient advanced endometrial cancer gave median progression-free survival of 38.2 versus 8.4 months with carboplatin–paclitaxel (HR 0.57), with fewer severe side effects (18% vs 51%); overall survival was not yet significantly different, and the trial did not compare against immunotherapy plus chemotherapy. A benchmark of six commercial chatbots on 225 Choosing Wisely scenarios found overuse in 5.4% of answers, concentrated in thyroid ultrasound for small incidental nodules (43%) and routine ECGs in low-risk adults (28%). A BMJ analysis of FDA device adverse-event summary reports found most missing problem descriptions and 55% filed late, with about 11,900 events undercounted.
Pembrolizumab alone outperformed chemotherapy first-line in mismatch-repair-deficient endometrial cancer
Make sure endometrial cancers have mismatch repair testing; for dMMR disease, chemotherapy-free first-line immunotherapy is now a tested option.
Chatbots rarely withheld needed care, but over-ordered thyroid ultrasound and routine ECGs
Treat AI suggestions to add a test with the same scepticism as any other source, especially for incidental thyroid nodules and screening ECGs.
Device harm reports to the FDA are often incomplete, late and undercounted
Report device-related harm yourself; manufacturer summaries in the main US database are frequently incomplete and late.
The incidental thyroid nodule under 1 cm usually needs nothing more
Without high-risk features, an incidental thyroid nodule under 1 cm needs a TSH and a history, not more imaging.
Menopausal hot flushes: oestrogen reduces frequency and severity, and offers the best value
For troublesome hot flushes without contraindications, consider oestrogen first; use SSRIs, SNRIs or gabapentin when it is unsuitable.
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