Board Review Clinical Epi and Prevention Cristin Colford, MD June 15 th, 2008

USPSTF strongly recommends screening for cervical cancer in women who have been sexually active and have a cervix –Start within 3 years of the onset of sexual activity or age 21; –Screen at least every 3 years –Insufficient evidence to recommend for or against liquid based cytology –Insufficient evidence to recommend for or against HPV testing for primary prevention Recommends against routinely screening women over age 65 if they have had adequate recent screening with normal pap smears and are not otherwise at high risk for cervical cancer Recommends against routine PAP smear screening in women who have a total hysterectomy for benign disease Cervical Cancer Screening

Options for Management of ASCUS (atypical squamous cells of undetermined significance) Repeat cytology Immediate colposcopy Reflexive HPV DNA testing

Refer for immediate colpo LGSIL (Low Grade Squamous Intraepitheliel Lesion) HGSIL (High Grade Squamous Intraepitheliel Lesion)

Breast Cancer Screening Annual screening begins at age 40 to 50 Mammography Most agree that an annual breast exam by a clinician is also warranted, but USPSTF is a bit equivocal

Colon Cancer Screening Start at age 50 This year USPSTF put upper age limit of 75 –Probably won’t make it to your test Many options –Colonoscopy every 10 years –FOBT annually –Sigmoidoscopy every 5 years with or without annual FOBT –Barium enema

Prostate Cancer Screening Insufficient evidence to recommend uniformly Shared decision process starting at age 50 –Inform of risks and benefits –Annual PSA with or without DRE If screening, may start earlier in high risk men. African Americans or family history of first degree relative start age 45 Update 2008: Do not screen men > 75

Cancers we don’t screen for Ovarian Endometrial Gastric cancer Pancreatic cancer Lung cancer Renal cell cancer Thyroid cancer

AAA Screening USPSTF Recommends one time abdominal ultrasound in men aged who have EVER smoked DO NOT screen women (harms outweigh benefits)

Heart Disease Prevention Know ATP III Guidelines for cholesterol targets JNC Guidelines for blood pressure targets We should calculate overall risk and adjust our treatment based on that, but I’m guessing that will not be on boards

A healthy 43 y/o woman presents as a new patient. Her only chronic medical problem is hypertension. She works as a flight attendant and lives with a roommate. She does not smoke; she drinks alcohol in moderation. She has never been sexually active and has not been assaulted. Her father developed colon cancer at age 75, and a maternal aunt developed ovarian cancer in her 60s. The patient has never had a Pap test and wonders whether she is at risk for ovarian cancer. Her most recent mammogram was 2 years ago. What is the most appropriate screening test to recommend to this patient? A) Pap smear B) Mammograhy C) colonoscopy D) CA-125 testing E) Pelvic ultrasonography

B) Mammography Current recommendations suggest screening between is reasonable Pap smear is optional. She as extremely low risk if she has never had sex. Colon—begin age 50 unless family history Ovarian cancer—no screening program

A 37 y/o white woman presents as a new patient. She is in good health. She wonders, however, whether she should be tested for the breast cancer gene because her 45 y/o sister was just diagnosed with invasive breast cancer. She has no personal history of breast problems, and has not yet had a mammogram. She has menarche at age 13 years, and has no children. Which of the following statements about genetic susceptibility testing for BRCA1 or BRCA2 in this patient is most accurate? A) She has a 50% chance of testing positive for a BRCA1 or a BRCA2 mutation and should be tested. B) This patient's risk of breast cancer by age 40 years is 30%; mammography is indicated regardless of testing results C) A positive test for BRCA1 or BRCA2 would have no impact on decision making about screening mammography, so testing is not indicated D) Knowing the result of BRCA1/BRCA2 testing on her sister would be helpful in decision making for this patient

D) Get the sister’s result

52 y/o man is a new patient. Wants annual physical and PSA testing. He exercises, doesn’t smoke, rare etoh. Old records show well controlled BP, negative ETT 4 years ago, various lab tests all of which are normal. Only medicine is atenolol. Previously had colonoscopy 2 yrs ago and PSA values of yr ago and yrs ago. Previous doctor told him level was borderline and waited for repeat measurement. DRE exam is normal, PSA is 5.0 A) prescribe tamsulosin therapy B) perform serial PSA measurements C) Order free PSA assay D) Refer for urologic evaluation E) prescribe finasteride

D) Off to urology for biopsy The cut point is 4. If over 4, kind of need to go to urology Some recommend “velocity”. If PSA rise greater than 0.75/year. However, already over 4, so send him. Of course, the patient can refuse to go. But the guidelines tell us you should recommend he have a biopsy…..

55y/o white man inquires about PSA screening during routine visit. Generally healthy and no urinary symptoms and no family history of cancer. In this age group, prevalence is 10% -42%. Positive predictive value of PSA exceeding 4 for carcinoma of the prostate is 28%- 35% and the negative predictive value is approximately 75% What should you tell the patient? A) His risk of prostate cancer is between 10% and 42% and screening is warranted B) Because an elevated PSA would likely be falsely positive, screening is unwarranted C) A PSA less than 4 would mean prostate cancer is highly unlikely D) False-positive PSA results are approximately twice as common as true positives

D) False positives are twice as likely as true positives Interpret the PPV. PPV probability of disease given a positive test. PPV of 28-35% is about 1/3. Thus, false positive rate is 65-72% or about twice the true positive rate (PPV)

65 year old pt here for routine visit has a loud, harsh systolic murmur hear loudest at 2 nd intercostal space, heard at apex and radiates to carotids. Otherwise normal cardiac exam. No hx of CP, SOB, syncope, dizziness. No hx of CAD. Never had an echo. Textbook tells you the positive LR for such a murmur is 1.8. What do you tell the patient? A) He has an innocent flow murmur and needs no further evaluation B) He likely has severe narrowing of the aortic valve C) He has a narrowing of his aortic vavle with a 40% chance that it is severe D) He may have a narrowing of his aortic valve but the chance that it is severe is low.

Positive LR Probability of that finding in patients with that condition (ie severe AS) in relation to probablity of the finding in patients without the condition LR 1.8 is above 1, but not that high to change your pretest prob much An echo is warranted to exclude severe AS