PREVENTATIVE CARE SCREENING REVIEW Doralyn Jones DO

OBJECTIVES Understand how USPSTF guidelines are developed and the ratings classification Recognize the differences in screening guidelines and be able to describe the USPSTF guidelines for various cancer screenings Know recommendation screening for common sexually transmitted diseases Define current screening practices for: coronary artery disease, diabetes, hypertension, hyperlipidemia, peprostate, colon and lung cancer Know preventative care screening guidelines for various male and female conditions

Why do we Screen? To Prevent morbidity and mortality Stop damage before symptoms appear Identify people who are particularly vulnerable to disease Protect the public from spread of disease

I have a healthy person, what screening tests to use? Burden of disease must be sufficient to warrant screening; does it cause severe disease, disability, death; what is prevalence and are there high risk groups Test is high quality, accurate detection when asymptomatic, high sensitivity and specificity, reproducible results, safe, simple, cost effective

What screening tests to use? Screening reduces morbidity and mortality, effective treatment for disease, early detection improves survival, outweigh adverse effects of screening, treatment, early diagnosis, randomized control trial of screening shows benefit DON’T FORGET the importance of a thorough History and Physical!

United States Preventative Services Task Force (USPSTF) Task force sponsored by Agency for Healthcare Research and Quality (AHRQ) Independent panel of experts in primary care and prevention Independent of the US government; NOT an official position of the US Department of Health and Human Services Considered as “the gold standard” by many in health care Last block, she had everything but this last bullet pt….may be a test question

United States Preventative Services Task Force (USPSTF) The Guide to Clinical Preventive Services 2012 http://www.ahrq.gov/professionals/clinicians-providers/guidelinesrecommendations/guide/abstract.html

United States Preventative Services Task Force (USPSTF) Systematic review of the literature to answer key questions: 1) Quality rating of the literature used (MEDLINE, COCHRANE, etc) 2) Estimation of benefits and harms 3) Determination of balance of net benefits and harms 4) Recommendations linked to a letter grade

Grading System of USPSTF A Strongly recommends B Recommends C Makes no recommendation D Recommends against E Insufficient evidence She will likely ask the grading system….bc it’s Dr. Jones

Grading System of the USPSTF Strongly recommends (A) Good evidence that the service improves important health outcomes There is high certainty that the net benefit is substantial OFFER THIS SERVICE!

Grading System of the USPSTF Recommends (B) There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Benefits outweigh harms OFFER THIS SERVICE!

Grading System of the USPSTF Makes no recommendation (C) At least fair evidence that the service improves health outcomes Balance of benefits and harms too close to call Selectively offer or provide this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.

Grading System of the USPSTF Recommends against (D) Moderate evidence or high certainty that the service is ineffective OR Harms outweigh benefits

Grading System of the USPSTF Insufficient evidence (I) Evidence lacking, poor quality or conflicting Balance of benefits and harms cannot be determined

Suggestions for Practice Grade Definition Suggestions for Practice A The USPSTF recommends the service. There is high certainty that the net benefit is substantial. Offer or provide service B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Offer or provide service C The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small. Offer or provide service for selected patients depending on individual circumstances D The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. Discourage use of service I Statement The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms. Last OMM test, she said know A and B …and asked questions on them both

Breast Cancer Ten Leading Cancer Types for the Estimated New Cancer Cases and Deaths By Sex, United States, 2011. CA: A Cancer Journal for Clinicians Volume 61, Issue 4, pages 212-236, 17 JUN 2011 DOI: 10.3322/caac.20121

Breast Cancer Most common cancer diagnosed in women Breast cancer is the second-leading cause of cancer death among women in the United States Film mammography is the standard for detecting breast cancer

BREAST CANCER Risk factors Age greater than 50 years Prior history of breast cancer Family history Early menarche, before age 12 Late menopause, after age 50 Nulliparity Age greater than 30 at first birth Obesity High socioeconomic status Atypical hyperplasia on biopsy Ionizing radiation exposure

Breast Cancer Screening Summary of 2009 USPSTF Recommendations The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. Grade: B recommendation. 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. Grade: C recommendation. The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. Grade: I Statement.

Breast Cancer Screening Other screening guidelines American Congress of Obstetricians and Gynecologists (ACOG) American Cancer Society (ACS) Yearly mammograms for healthy women staring at age 40 Yearly mammograms starting age 40 *AAFP same as USPSTF *AAFP=American Academy of Family Physicians Uhhhhh no….. Last OMM test we were only asked USPSTF. I’d only waste time learning that.

Cervical Cancer Screening-USPSTF The USPSTF recommends screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. HPV testing, and screening interval. Grade: A. The USPSTF recommends against screening for cervical cancer in women younger than age 21 years. Grade: D The USPSTF recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. Grade: D USPSTF MARCH 2012 UPDATE

Cervical Cancer Screening The USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (i.e., cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer. Grade: D.

Cervical Cancer (ACS) 2nd most common cancer among women in developing countries. 75% decrease incidence/mortality in developed world (Pap smear) Risk Factors; Early onset of sexual activity Multiple sexual partners High-risk sexual partner History of sexually transmitted diseases (chlamydia) Smoking (not adenocarcinoma) 2x risk High parity; 3 or more pregnancies; also pregnancy before age 17 Immunosuppression (HIV) Low socioeconomic status Prolonged use of oral contraceptives ; after 5 years doubles Hx of vaginal or vulvar cancer Obesity, diet low in fruits and vegetable Fam hx 2-3 x more likely Uworld would like to inform you that nuns are not likely to get cervical cancer. Bahahahaha

Cervical Cancer Screening Guidelines from other organizations are essentially the same

Population USPSTF ACOG/ASCCP/ASCP/ACS <21 yrs old Recommends against screening. Grade: D recommendation Women should not be screened regardless of the age of sexual initiation or other risk factors. 21-29 years Recommends screening with cytology every 3 years. Grade: A recommendation. Screening with cytology alone every 3 years is recommended. 30-65 Recommends screening with cytology every 3 years or for women who want to lengthen the screening interval, screening with a combination of cytology and HPV testing every 5 years. Grade: A recommendation Women with evidence of adequate negative prior screening and no history of CIN2+ within the last 20 years should not be screened. Screening should not be resumed for any reason, even if a woman reports having a new sexual partner. >65 Recommends against screening women who have had adequate prior screening¶ and are not otherwise at high risk for cervical cancer. Grade: D recommendation. After hysterectomy Recommends against screening in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (ie, CIN 2 or 3) or cervical cancer. Women of any age following a hysterectomy with removal of the cervix who have no history of CIN2+ should not be screened for vaginal cancer. Evidence of adequate negative prior screening is not required. Screening should not be resumed for any reason, including if a woman reports having a new sexual partner. HPV vaccinated Women who have been vaccinated should continue to be screened. Recommended screening practices should not change on the basis of HPV vaccination status. ACOG= American Congress of Obstetricians and Gynecologists; ASCCP=American Society for Colposcopy and Cervical Pathology; ASCP= American Society for Clinical Pathology; ACS= American Cancer Society We had test questions on this last time too. Know anything that is A or B recommendation

Ovarian Cancer Screening USPSTF Do not screen (grade D) AAFP against routine screening (grade D) ACS no recommended screen ACOG no recommended routine screening

Endometrial Cancer Screening NO screening routine recommended Inform your post-menopausal patients that any bleeding AFTER menopause should be brought to a doctor’s attention Post menopausal vaginal bleeding is considered malignancy until proven otherwise

OSTEOPOROSIS The USPSTF recommends screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. Grade: B. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men. Grade: I

OSTEOPOROSIS INCREASED RISK DISEASES Body weight < 70 kg * Smoking, weight loss, family history, decreased physical activity, alcohol, caffeine, cigarette, low calcium and vitamin D intake, ethnicity, menstrual hx (started at age 15 or >) DISEASES Intestinal malabsorption: celiac, crohn’s s/p gastrectomy Hyperthyroidism Hyperparathyroidism MS Thalassemia Liver and renal disease Multiple myeloma www.shef.ac.uk/FRAX/ Fracture Risk Assessment Tool

STD Screening Guidelines HIV USPSTF The USPSTF strongly recommends that clinicians screen for human immunodeficiency virus (HIV) in all adolescents and adults at increased risk for HIV infection Grade: A Recommendation. The USPSTF makes no recommendation for or against routinely screening for HIV in adolescents and adults who are not at increased risk for HIV infection Grade: C Recommendation. The USPSTF recommends that clinicians screen all pregnant women for HIV. Grade: A Recommendation.

STD SCREENING GUIDELINES HIV CDC Recommends screening individuals age 13-64 at least once screening high risk individuals annually

STD SCREENING GUIDELINES Gonorrhea and Chlamydia USPSTF The USPSTF recommends that clinicians screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection (that is, if they are young or have other individual or population risk factors). Grade: B Recommendation. The USPSTF found insufficient evidence to recommend for or against routine screening for gonorrhea infection in men at increased risk for infection. Rating: I Statement. The USPSTF recommends against routine screening for gonorrhea infection in men and women who are at low risk for infection. Rating: D Recommendation. The USPSTF found insufficient evidence to recommend for or against routine screening for gonorrhea infection in pregnant women who are not at increased risk for infection. Rating: I Statement. USPSTF currently updating these guidelines

STD Screening Guidelines Gonorrhea and Chlamydia CDC Sexually active females < 25 yrs old should be tested annually

Prostate Cancer Screening The U.S. Preventive Services Task Force (USPSTF) recommends against PSA blood screening in men younger than age 75 years. Grade: D AAFP – same as USPSTF ACS – Starting at age 50, men should talk to a doctor about the pros and cons of testing. Men who are African American or have a father or brother who had prostate cancer before age 65, should have this talk with a doctor starting at age 45. Testing includes the PSA blood test with or without a rectal exam. How often they are tested will depend on their PSA level. AUA – may start screening as young as age 40 with PSA and DRE Klosterman did everything male for the last block OMM test…. From this slide on, Jones added this stuff in as new into to her lecture from block 7. I would know this stuff better since she took the time to add this into her old lecture.

Colorectal Cancer Screening, USPSTF The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods may vary. Grade: A The USPSTF recommends against routine screening for colorectal cancer in adults 76 to 85 years of age. There may be considerations that support colorectal cancer screening in an individual patient. Grade: C The USPSTF recommends against screening for colorectal cancer in adults older than age 85 years. Grade: D The USPSTF concludes that the evidence is insufficient to assess the benefits and harms of computed tomographic colonography and fecal DNA testing as screening modalities of colorectal cancer. Grade: I

Lung Cancer Screening The U.S. Preventive Services Task Force USPSTF) concludes that the evidence is insufficient to recommend for or against screening asymptomatic persons for lung cancer with either low dose computerized tomography (LDCT), chest x-ray (CXR), sputum cytology, or a combination of these tests. Grade: I

Skin Cancer Screening, USPSTF Recommendation: The U.S. Preventive Services Task Force (USPSTF) concludes that the current evidence is insufficient to assess the balance of benefits and harms of using whole-body skin examination by a primary care clinician or patient skin self-examination for the early detection of cutaneous melanoma, basal cell cancer, or squamous cell skin cancer in the adult general population. Grade: I

Coronary heart disease screening; USPSTF The U.S. Preventive Services Task Force (USPSTF) recommends against routine screening with resting electrocardiography (ECG), exercise treadmill test (ETT), or electron-beam computerized tomography (EBCT) scanning for coronary calcium for either the presence of severe coronary artery stenosis (CAS) or the prediction of coronary heart disease (CHD) events in adults at low risk for CHD events. Grade: D The USPSTF found insufficient evidence to recommend for or against routine screening with ECG, ETT, or EBCT scanning for coronary calcium for either the presence of severe CAS or the prediction of CHD events in adults at increased risk for CHD events. Grade: I AAFP- same guidelines

CAD RISKS Smoking Hypertension Dyslipidemia  high LDL , low HDL DM Obesity/ BMI Metabolic syndrome Sedentary lifestyle Age, male > 45 , female > 55 Fam hx of early CAD male before age 55 , female before age 65

Hyperlipidemia screening, USPSTF The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening men aged 35 and older for lipid disorders. Grade: A The USPSTF recommends screening men aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease. Grade: B. The USPSTF strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease. Grade: A The USPSTF recommends screening women aged 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease. Grade: B The USPSTF makes no recommendation for or against routine screening for lipid disorders in men aged 20 to 35, or in women aged 20 and older who are not at increased risk for coronary heart disease. Grade: C

Abdominal Aortic Aneurysm USPSTF: 65-74 y/o males who have ever smoked (at least 100 cig) Grade A

Diabetes screening ; uspstf Summary of Recommendation: The U.S. Preventive Services Task Force (USPSTF) recommends screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. Grade: B

Hypertension screening ; uspstf Summary of RecommendationThe U.S. Preventive Services Task Force (USPSTF) recommends screening for high blood pressure in adults aged 18 and older. Grade: A

Annual TB screening Medical risk – CRF, DM, immune suppressed Mycobacterium = SIC LUNGS Medical risk – CRF, DM, immune suppressed Socioeconomic – homeless, etoh, IV drug users Immigration - < than 5 years from endemic area Career – healthcare, prison guard, lab worker Long term care facility - nursing home, prison, mental health facility

Obesity Screening, USPSTF The USPSTF recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults. Grade: B.

Tobacco Screening The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. Grade: A

References USPSTF www.ahrq.gov AAFP www.aafp.org New Physicians and Residents Program: Preventive Medicine/USPSTF Recommendations, Michael E. Srulevich, DO, MPH CDC www.cdc.gov