1. Age-based screening recommendations for adults
Wednesday morning clinical rounds
June 8th 2011

2. 44 year old female wants a screening mammogram 75 year old man—someone else’s patient--comes in for routine visit and expects his annual PSA test. 42 year old female, smoker, alcoholic who has rheumatoid arthritis. Any special screening test for her? 55 year old who refuses colonoscopy. What advise should you give him?

3. objectives
Improve your ability to organize and describe screening recommendations during preventive exams
Acknowledge broad and somewhat conflicting range of recommendations
Provide intellectual tools that will help ground your ability to engage with patients about A FEW of these decisions
Become familiar with

4. Avoidances (these topics are all coming other Wednesday mornings)
Screening recommendations for:
Children
Pregnant women
Immigrant populations
Specific strategies to help patients make informed decisions will come later

5. Your thoughts please:
How do you decide which screening tests to recommend? What tools do you use during your clinic encounters? Have you ordered a test that you or the patient later regretted? How would you do this differently in the future?
1. For the purposes of our curriculum, we value the role of the AHRQ (agency for healthcare Research and Quality) who publishes the USPSTF recommendations. They are an independent panel of non-federal experts in prevention and evidence-based medicine is composed of primary providers (internists, peds, FM, OB/GYN, RN, health behavioral specialists)
And AAFP.
Develop insight about yourself: why do you order the tests you do? Recommended, tied to performance measures, recall anecdotally “catching” conditions that would have not been caught when ordering a test (CBC, UA), you take the recommendation of a specialist that you work with.
Tests are useful only when there is “value added” , if they provide additional diagnostic information that would not otherwise been caught during a history and physical.
3. The majority of abnormal screening tests are false positives. Communication about this requires a lot of time in the office.

6. Other patients just want your opinion.
Some patients are ready to discuss risks and benefits of screening recommendations
Other patients just want your opinion.
The Screening Dilemma
By Kate Pickert Thursday, June 02, 2011

7. Musical recommendations
Gather together 2-3 per group
When the music starts fill in your best guess for age-based USPSTF [A & B] recommendations
When the music stops pass your paper to the next team
* The same recommendations may appear in different age groups
* You will get a chance to fill out all 8 papers
* Write small

8. Women 18-21 annual visits key screening recommendations
Cervical cancer: begin 3 years after initial sexual activity or at 21 [USPSTF A]
Chlamydia: annual for sexually active women [USPSTF A]
Folic acid supplementation: all women planning or capable of pregnancy, dose μg [USPSTF A]
Blood pressure: every 1-2 years [USPSTF A]
Depression [USPSTF B]
risk stratified recommendations
BRCA mutation testing for high risk [USPSTF B]
Lipid screening: age q 5 years if increased risk for CHD [USPSTF B]
Diabetes type II: q 2 years if sustained BP >135/80 [USPSTF B]
HIV & syphilis: no interval, adults and adolescents at increased risk [USPSTF A]
vaccinations
Tetanus-diphtheria q 10 years
Flu vaccine annually
counseling
Obesity / healthy diet
STI prevention
Tobacco and alcohol misuse [USPSTF B]

9. Cervical cancer screening
< 21
21-30
31-65
Interval
3 yrs after 1st intercourse
1-2 years
Q 3 years after 3 normal pap & HPV
Order
Pap only
Pap with HPV reflex
Pap & HPV
Follow up
ASCCP guidelines
- HPV & - pap  q 3 years
ASCUS & - HPV  q 1 year
ASCUS & + HPV  colpo
> ASCUS colpo

10. Cervical cancer screening
Annual screening
(1) CIN II-III or invasive disease
if HPV neg, routine screening x 20 years [ASCCP]
annual screening x 20 years [ACOG]
(2) HIV-positive or immunosuppressed.
- absence of endocervical cells on previous pap
(3) DES (diethylstilbesterol) in mother. (Last used during pregnancy in 1975)
(4) after hysterectomy for women with a history of invasive cervical cancer
Stop screening:
(1) > 65 with 3 previous normal pap & HPV [USPSTF]
(2) Total hysterectomy & no history of CIN (as different from supravervical hysterectomy for which you screen according to guidelines)
(3) lifetime abstinence

11. When folic acid is especially important (?)
Accompany anti seizure medications (dilantin, carbamazepine,tegretol,and phenobarbital, depakote.)
Personal or family history of neural tube defects
Maternal diabetes
Maternal obesity

12. HIV risks (?) Men having sex with men
Unprotected sex with multiple partners
Injection drug user
Sex worker
History of sex partners who are HIV +, bisexual, or IVDU
History of STD
Transfusion between
Patient requests

13. BRCA risk (?) Women of Ashkenazi Jewish heritage:
1st degree (or two 2nd degree) with breast or ovarian cancer
Other women, not of Ahskenazi Jewish heritage:
Two 1st degree with breast cancer, diagnosed < 50
Three 1st or 2nd degree relatives diagnosed any age
both breast and ovarian cancer among 1st & 2nd degree
1st degree with bilateral breast cancer
Two or more 1st or 2nd degree with ovarian cancer
breast cancer in a male family member

14. Screening for diabetes
Which tests?
Fasting blood sugar
< 126 mg/dL
Inexpensive
2 hour post glucose load
> 200mg/dL
- More variable than FBS
- More sensitive for early diabetes
HbA1c
> 6.5 mg/dL
- Less variable than FBS
Not appropriate in pregnancy, hemoglobinopathy, abnormal erythrocyte turn over
screening range controversial
HbA1c
Likelihood of diabetes
< 5.5% 1%
5.6-6%
7.8 %
57.4% %
91.1 %
> 7%
100 %
Your choice [ADA, USPSTF]
Ref Diabetes Care Apr;33(4): Epub 2010 Jan 12.

15. proposed protocol: UK & Australian
check FBS- ≥ 126 mg/dL  diagnose diabetes
If FBS < 126 mg/dL  check HbA1c, < 6%  rule out diabetes
If FBS < 126 mg/dL  check HbA1c, ≥ 6%  check 2-hour GTT if ≥ 200 mg/dL  diabetes
use of this algorithm has > 90% sensitivity and 100% specificity for diabetes
Diabet Med 2009 Feb;26(2):115

16. Women 22-49 visits every 1-3 years
key screening recommendations
Breast cancer: counsel women about risks and benefits of mammography and clinical breast exam [AAFP]
Cervical cancer: 1-3 years [USPSTF A]
21-29 q2 years, pap alone. If ASCUS reflexive HPV
> 30 after three nl, q 3 year pap + HPV
Chlamydia: annually <25, then those at risk [USPSTF A]
Folic acid supplementation: all women planning or capable of pregnancy, dose μg [USPSTF A]
Blood pressure: every 1-2 years [USPSTF A]
Depression [USPSTF B]
risk stratified recommendations
Breast cancer chemoprotection:once in women at high risk [USPSTF B]
BRCA mutation testing for high risk [USPSTF B]
Lipid screening: age q 5 years, age > 45 decrease interval based on risk factors for CHD [USPSTF B]
Diabetes type II: q 2 years if sustained BP >135/80
HIV & syphilis: no interval, adults and adolescents at increased risk [USPSTF A]
vaccinations
Tetanus-diphtheria q 10 years
Flu vaccine annually
counseling
Obesity / healthy diet
STI prevention
Tobacco and alcohol misuse [USPSTF B]

17. Breast cancer screening
Every 1-2 years based on risk factors or personal choice beginning at age 40, yearly breast exams
Mammography: Every 1-2 years 40-49
&
Physicians should customize their approach with mammography and clinical breast exams
2002 USPSTF [B] mammogram annually starting at age 40

18. Mammography 2009 Guideline based on:
[ USPSTF C ]
“The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms”.
2009 Guideline based on:
- Systematic review including a RCT
- Cancer Intervention and surveillance modeling network. (considered mortality and life-years gained)
conclusion: Most efficient screening starting at age 50.
Systematic Evidence Review Update for the U.S. Preventive Services Task Force. Evidence Review Update No. 74. AHRQ Publication No EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2009.

19. A decision that involves both patient and doctor
Age
Number of mammograms needed to screen to detect one cancer
Absolute mortality benefit(1)
Number of mammograms to save one life (2)
(pseudo-disease)
40-49
1904
4 per 10,000 at 10.7 years
9600
(reduced ½ with biennial screening)
50-59
1339
5 per 1,000 at 10.7 years
1000
Age 40-49: add diagnostic exams biopsies
(1)Effect of mammographic screening from age 40 years on breast cancer mortality at 10 years' follow-up: a randomized controlled trial. Lancet 368 (9552): , 2006. 
(2)J Am Board Fam Med 2010 Nov-Dec;23(6):775

20. Mammography Potential Harms. false-positive test results
adverse patient experience is common
Costs
office visits
cost of f/u tests
low radiation exposure

21. Further guidance Better understanding of tumor biology
How age, race, breast density, and other factors may predispose certain women toward tumors with faster growth rates and greater lethality.

22. Clinical breast exams USPSTF [I]
Useful if it is the only method of screening available (developing countries)
Potential Harms.
false-positive test results & anxiety
repeated visits
unwarranted imaging and biopsies.
Costs. patient encounter, follow up tests
Improving approach to CBE would likely benefit patients.

23. Teaching self breast exams
USPSTF [D]
adequate evidence
not associated with a decrease in breast cancer mortality rates
Harms outweigh benefits

24. Chemoprevention tamoxifen or raloxifene
USPSTF [B]
Use 5-year risk for developing breast cancer: National Cancer Institute Breast Cancer Risk tool – the Gail Model
Best candidates are women in 40s or 50s at high risk and have no predisposition to thromboembolic events.
Risks: family history of breast cancer, known genetic risk, history of atypical cells on breast biopsy

25. Women 50-64 visits every 1-2 years
key screening recommendations
Breast cancer: mammogram with or without CBE q 1-2 years age [USPSTF B]
Lipid screening: < 5 years [USPSTF A]
Colorectal cancer screening: years. sensitivity: colonoscopy q10> sigmoidoscopy q5 > fecal immuniochemical q1 > hemoccult
Discussion of asa (81mg) for stroke prevention: age [USPSTF A]
Cervical cancer: 1-3 years [USPSTF A]
21-29 q2 years, pap alone. If ASCUS reflexive HPV
> 30 after three nl, q 3 year pap + HPV
Chlamydia: annually <25, then those at risk [USPSTF A]
Blood pressure: every 1-2 years [USPSTF A]
Depression [USPSTF B]
risk stratified recommendations
DEXA: use FRAX tool, consider if 9.3% 10 year risk [USPSTF B]
Breast cancer chemoprotection:once in women at high risk [USPSTF B]
BRCA mutation testing for high risk [USPSTF B]
Diabetes type II: q 2 years if sustained BP >135/80
HIV & syphilis: no interval, adults and adolescents at increased risk [USPSTF A]
vaccinations
Shingles vaccine: once age > 60 (not for immosupressed)
Tetanus-diphtheria q 10 years
Flu vaccine annually
counseling
Obesity / healthy diet
STI prevention
Tobacco and alcohol misuse [USPSTF B]

26. Chose one of three effective methods
Colorectal screening
Chose one of three effective methods
Focus on adherence
Benefit of screening not seen until ~ 7 years (consider life expectancy)
Similar life-years gained: (1) - colonoscopy every 10 years - fecal immunochemical testing - sigmoidoscopy every 5 years + fecal immunochemical testing
Less effective:
- Annual Hemoccult II
- flexible sigmoidoscopy every 5 years alone
(1) Evaluating test strategies for colorectal cancer screening: a decision analysis for the U.S. Preventive Services Task Force. Ann Intern Med Nov 4;149(9): Epub 2008 Oct 6.

27. Bone density screening prior to age 65
Use FRAX tool:
predicts 10-year fracture risk
Screen those with risk = 65 yo patient = 9.3% 10-year risk of fracture
Risks
family hx of fracture
age
BMI
race (Asian, Caucasian)
F sex
steroid use
smoking
excessive alcohol use
examples
60 yo F with BMI < 21, daily alcohol use
50 yo smoker with BMI < 21, daily alcohol use, parental fracture history
55 yo with parental fracture history

28. Women 65 and older visits every year
key screening recommendations
Breast cancer: mammogram with or without CBE q 1-2 years through age 75 [USPSTF B]
Lipid screening: < 5 years through 74, consider > 75. [USPSTF A]
Colorectal cancer screening: through age 75 years, consider > 75 sensitivity: colonoscopy q10> sigmoidoscopy q5 > fecal immuniochemical q1 > hemoccult
Discussion of asa (81mg) for stroke prevention: age [USPSTF A]
Blood pressure: every year [USPSTF A]
DEXA:>65 interval not clear (> 2 years) [USPSTF B, AAFP]
Cervical cancer: 1-3 years through age 65 [USPSTF A]
Depression [USPSTF B]
risk stratified recommendations
Breast cancer chemoprotection:once in women at high risk [USPSTF B]
BRCA mutation testing for high risk [USPSTF B]
Diabetes type II: q 2 years if sustained BP >135/80
HIV & syphilis: no interval, adults and adolescents at increased risk [USPSTF A]
vaccinations
Pneumococcal vaccine: once age > 65
Shingles vaccine: once age > 60 (not for immosupressed)
Tetanus-diphtheria q 10 years
Flu vaccine annually
counseling
Obesity / healthy diet
STI prevention
Tobacco and alcohol misuse [USPSTF B]

29. Men 18-21 annual visits Key screening recommendations
Chlamydia: annually for sexually active men
Depression screening [USPSTF B]
risk stratified recommendations
Lipids: age > 5 years if increased risk for CHD [USPSTF A]
Diabetes II: q 3 years if sustained BP > 135/80 [USPSTF B]
HIV & syphilis: no interval, adults and adolescents at increased risk [USPSTF A]
vaccinations
Tetanus-diphtheria q 10 years
Flu vaccine annually
counseling
Obesity / healthy diet
STI prevention
Tobacco and alcohol misuse [USPSTF B]

30. Men 22-49 annual visits Key screening recommendations
Blood pressure check: q 2 years [USPSTF A]
Lipids: starting age 35 q < 5 years [USPSTF A]
Discussion about aspirin use: (81mg) for prevention of CHD age [USPSTF A]
Chlamydia: annually for sexually active men [USPSTF A]
Depression screening [USPSTF B]
risk stratified recommendations
Lipids: age > 5 years if increased risk for CHD
Diabetes II: q 3 years if sustained BP > 135/80 [USPSTF B]
HIV & syphilis: no interval, adults and adolescents at increased risk [USPSTF A]
vaccinations
Tetanus-diphtheria q 10 years
Flu vaccine annually
counseling
Obesity / healthy diet
STI prevention
Tobacco and alcohol misuse [USPSTF B]

31. Men 50-64 visits every 1-2 years
Key screening recommendations
Blood pressure check: q 2 years [USPSTF A]
Lipids: q < 5 years [USPSTF A]
Discussion about aspirin use: (81mg) for prevention of CHD age [USPSTF A]
Colorectal cancer screening: colonoscopy q10> sigmoidoscopy q5 > fecal immuniochemical q1 > hemoccult
Prostate: discuss [AAFP], not routinely recommended [USPSTF]
Chlamydia: annually for sexually active men
Depression screening [USPSTF B]
risk stratified recommendations
Lipids: age > 5 years if increased risk for CHD
Diabetes II: q 3 years if sustained BP > 135/80 [USPSTF B]
HIV & syphilis: no interval, adults and adolescents at increased risk [USPSTF A]
vaccinations
Shingles vaccine: once age > 60 (not for immosupressed)
Tetanus-diphtheria q 10 years
Flu vaccine annually
counseling
Obesity / healthy diet
STI prevention
Tobacco and alcohol misuse [USPSTF B]

32. Prostate cancer screening
Offer DRE and PSA age 50 to men with >10 year life expectancy
“PSA screening for well-informed men who wish to pursue early diagnosis.
& all discussions of treatment options include active surveillance as a consideration, since many screen-detected prostate cancers may not need immediate treatment”
Provide information regarding risks and benefits
Age [I] insufficient to recommend for or against screening
Age > 75 or < 10 year life expectancy [D] against screening
No published guidelines

33. A decision that involves both patient and doctor
No PSA cutoff level has both high sensitivity and high specificity
PSA < 4 ng/mL may still have substantial risk of prostate cancer
screening does reduce overall mortality
Screening at 2 vs 4 year intervals, similar rates of cancer detection
3 ng/mL
4 ng/mL
5 ng/mL
Sensitivity
59%
44%
33%
Specificity
87%
92%
Age 50-59: 98%
Age 60-69: 87%
Age 60-69: 81%
95%
PSA cut off values (1)
JAMA Jul 6;294(1):66-70

34. Document informed consent no group disagrees that screening is controversial
Some topics considered important to discuss:
prostate cancers detected by PSA are more likely to be confined to prostate and may be more curable than those detected by digital rectal exam (DRE) alone
natural history of prostate cancer and potential for slow growth
there is uncertainty about benefits of treating early, localized prostate cancer or whether one treatment is better than another
false negative biopsies of prostate can occur
options after prostate cancer diagnosed for early, localized prostate cancer include watchful waiting, radical prostatectomy, radiation therapy
prostate cancer often advanced and incurable by the time symptoms appear
complications of treatment (including death, impotence, urinary incontinence, radiation-related disorders)
elevated PSA test result may lead to further testing to determine presence of prostate cancer
Am J Med 1998 Oct:105(4):266

35. Further guidance PSA velocity, PSA slope or complexes PSA
Tumor biology
Genetic differences in risk

36. Men 65 and older visits every year
Key screening recommendations
Blood pressure check: annually [USPSTF A]
Lipids: q < 5 years through age 75; consider >75 [USPSTF A]
Discussion about aspirin use: (81mg) for prevention of CHD age [USPSTF A]
Colorectal cancer screening: through age 75 years, consider > 75 sensitivity: colonoscopy q10> sigmoidoscopy q5 > fecal immuniochemical q1 > hemoccult
Prostate: discuss [AAFP], not routinely recommended [USPSTF]
Chlamydia: annually for sexually active men
Depression screening [USPSTF B]
risk stratified recommendations
Abdominal aortic aneurysm screening: one time for men aged who have ever smoked cigarettes. [USPSTF B]
Lipids: age > 5 years if increased risk for CHD
Diabetes II: q 3 years if sustained BP > 135/80 [USPSTF B]
HIV & syphilis: no interval, adults and adolescents at increased risk [USPSTF A]
vaccinations
Pneumococcal vaccine: once age > 65
Shingles vaccine: once age > 60 (not for immosupressed)
Tetanus-diphtheria q 10 years
Flu vaccine annually
counseling
Obesity / healthy diet
STI prevention
Tobacco and alcohol misuse [USPSTF B]

37. [B] men 65-75 who have ever smoked [C] 65-75 who have never smoked
AAA screening
- men aged > 60 years with first-degree relatives with AAA
- men aged years who have ever smoked
[B] men who have ever smoked
[C] who have never smoked
[D] screening women

38. AAA screening considerations
Risk factors:
Family history of AAA
Smoking
Age
To note:
Women develop AAA usually > 80 years old
Operative mortality 4-5%. Complications 30%
Ultrasound has 95% sensitivity, 100% specificity
(1) Men age 54-74
Number needed to screen to prevent 1 death in 5 years
Ever smoker
500
Never a smoker
1783
(1) Ann Intern Med 2005 Feb 1;142(3): 198