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

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Presentation on theme: "Age-based screening recommendations for adults Wednesday morning clinical rounds June 8 th 2011."— Presentation transcript:

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

2 44 year old female wants a screening mammogram 75 year old mansomeone elses 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 1.Improve your ability to organize and describe screening recommendations during preventive exams 2.Acknowledge broad and somewhat conflicting range of recommendations 3.Provide intellectual tools that will help ground your ability to engage with patients about A FEW of these decisions 4.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 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? Your thoughts please:

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

7 Musical recommendations 1.Gather together 2-3 per group 2.When the music starts fill in your best guess for age- based USPSTF [A & B] recommendations 3.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 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 < Interval3 yrs after 1 st intercourse 1-2 yearsQ 3 years after 3 normal pap & HPV OrderPap onlyPap with HPV reflex Pap & HPV Follow upASCCP 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 HbA1cLikelihood of diabetes < 5.5%1% 5.6-6% %57.4% %91.1 % > 7%100 % Ref Diabetes Care Apr;33(4): Epub 2010 Jan 12. 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 Which tests? Your choice [ADA, USPSTF]

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 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] 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 Physicians should customize their approach with mammography and clinical breast exams & 2002 USPSTF [B] mammogram annually starting at age 40

18 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; 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. Mammography [ USPSTF C ]

19 A decision that involves both patient and doctor AgeNumber of mammograms needed to screen to detect one cancer Absolute mortality benefit (1) Number of mammograms to save one life (2) (pseudo-disease) per 10,000 at 10.7 years 9600 (reduced ½ with biennial screening) per 1,000 at 10.7 years 1000 (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): , (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 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] 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 Colorectal screening 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 Chose one of three effective methods Focus on adherence Benefit of screening not seen until ~ 7 years (consider life expectancy) (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 Risks family hx of fracture age BMI race (Asian, Caucasian) F sex steroid use smoking excessive alcohol use Use FRAX tool: predicts 10-year fracture risk Screen those with risk = 65 yo patient = 9.3% 10-year risk of fracture examples a)60 yo F with BMI < 21, daily alcohol use b)50 yo smoker with BMI < 21, daily alcohol use, parental fracture history c)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: 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 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 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 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 Provide information regarding risks and benefits No published guidelines Age [I] insufficient to recommend for or against screening Age > 75 or < 10 year life expectancy [D] against screening 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

33 A decision that involves both patient and doctor (1)JAMA Jul 6;294(1): ng/mL4 ng/mL5 ng/mL Sensitivity59%44%33% Specificity87%92% Age 50-59: 98% Age 60-69: 87% Age 60-69: 81% 95% PSA cut off values (1) 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

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

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 Number needed to screen to prevent 1 death in 5 years Ever smoker500 Never a smoker1783 (1) Ann Intern Med 2005 Feb 1;142(3): 198 (1) Men age 54-74

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