Preventing Disease An evidence-based approach M Jawad Hashim MD

Recommendations Men 35 chol Women 45 chol 50 colon 18 Chlamydia 2565 Pap Mammogram 70 osteoporosis 70

Levels of Recommendation [A]Strongly recommended [B]Recommended [C]No rec. (balanced benefits and harms) [D]Harmful [I]Insufficient evidence USPSTF (2003). Guide to Clinical Preventive Services, 3 rd ed.

[I] Insufficient evidence Abdominal aortic aneurysm Back pain prevention counseling Dementia Dental disease in preschool children Drug abuse Family violence Glaucoma Hearing in newborns Lung cancer Oral cancer Suicide risk Skin cancer

[I] Insufficient evidence (cont’d) Healthy diet Physical activity Weight loss counseling

[D] Harmful Chemoprevention of breast cancer in normal risk women Bladder cancer Carotid artery stenosis Coronary artery disease Depression in children Diabetes in healthy adults Hepatitis C Genital herpes simplex Ovarian cancer Pancreatic cancer

[D] Harmful (cont’d) Scoliosis in adolescents Testicular cancer Thyroid disease Bacteriuria in non- pregnant adults Peripheral arterial disease

[B] Recommended Alcohol abuse Breastfeeding Fluoride supplements Depression Diabetes in HTN and high cholesterol Vision in children Healthy diet in high cholesterol Obesity in adults Mammograms Hearing impairment in elderly Osteoporosis (after age 65)

[A] Strongly recommended 1. Aspirin for primary prevention of cardiovascular events 2. Hypertension 3. Cervical cancer 4. Chlamydia in women younger than Colorectal cancer 6. Cholesterol 7. Immunizations a

The Mammogram Controversy

The Lancet Jan 2000

Major findings: 1.All but 2 trials had randomization flaws with significant baseline differences between intervention and control groups. 2.Women with mammographically- detected cancers had worse outcomes. 3.No effect of mammography on all-cause mortality in Sweden since No effect of mammography on all-cause mortality in Sweden since 1985.

American Cancer Society.

National Cancer Institute Breast cancer mortality Blacks White

Does early detection lead to… mammogram Incidentally finds a lump Patient A Patient B Dies 20-yr survival Dies 10-yr survival Onset of cancer at the same time! Lead-time bias

Stamp sales yield $37 million for breast cancer research Susan G Komen Foundation raised $106 million in 2003 National Cancer Institute budget $4.7 billion

National Cancer Institute

Average Years of Life Lost Per Person Dying of Cancer 1991 National Cancer Institute

All-cause mortality in colon cancer screening with FOBT Goezsche (Denmark). The Lancet Feb screening detected only 25-27% of the cancers that occurred in the screening group

Prioritizing Coffield et al. (Washington DC). Am J Prev Med

Prioritizing Estimates of QALY lost Estimates of Effectiveness Estimates of Clinically-Preventable Burden Estimates of Cost-Effectiveness Scores added and ranked

Prioritizing 1. Childhood immunizations 2. Tobacco smoking screen/counseling 3. Screening for vision impairment in elderly 4. Adolescent alcohol and drug screen/counsel 5. Cervical cancer screening 6. Colorectal cancer screening 7. Neonatal metabolic screening PKU 8. Hypertension screening 9. Influenza vaccination 10. Chlamdyia screening in young women

Screening in high risk groups AnemiaPregnancy, high risk infants Aspirin A Adults at risk for cardiovascular events GonorrheaHigh risk women and pregnancy Hearing lossElderly RubellaChildbearing age women

Screening Effectiveness Adolescent scoliosis exam Variable accuracy Poor follow-up Most cases do not need intervention Clinically-significant cases will be detected by patient/family

American Cancer Society.

Highest yield American Cancer Society.

Recommendations Men 35 chol Women 45 chol 50 colon 18 Chlamydia 2565 Pap Mammogram 70 osteoporosis 70