Age-based screening recommendations for adults

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 http://epss.ahrq.gov

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?

6. 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

9. Cervical cancer screening

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-positiveor 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 1978-1985 • 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? Your choice [ADA, USPSTF] Ref Diabetes Care. 2010 Apr;33(4):817-9. 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

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 [ 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. 10-05142-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2009.

19. A decision that involvesboth patient and doctor (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): 2053-60, 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. Chemopreventiontamoxifen 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

26. 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. 2008 Nov 4;149(9):659-69. Epub 2008 Oct 6.

27. Bone density screeningprior to age 65 Use FRAX tool: www.shef.ac.uk/FRAX/ 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

29. Men 18-21 annual visits

30. Men 22-49 annual visits

31. Men 50-64 visits every 1-2 years

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 50-75 [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 involvesboth 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 PSA cut off values (1) • JAMA. 2005 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

37. AAA screening - men aged > 60 years with first-degree relatives with AAA - men aged 65-75 years who have ever smoked [B] men 65-75 who have ever smoked [C] 65-75 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 (1) Ann Intern Med 2005 Feb 1;142(3): 198