1. Preventing Disease An evidence-based approach M Jawad Hashim MD

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

3. www.ahrq.gov

4. 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. www.ahrq.gov

5. [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

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

7. [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

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

9. [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)

10. [A] Strongly recommended 1. Aspirin for primary prevention of cardiovascular events 2. Hypertension 3. Cervical cancer 4. Chlamydia in women younger than 25 5. Colorectal cancer 6. Cholesterol 7. Immunizations a

11. The Mammogram Controversy

12. The Lancet Jan 2000

13. 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 1985 3.No effect of mammography on all-cause mortality in Sweden since 1985.

14. American Cancer Society. www.cancer.org

15. National Cancer Institute www.cancer.gov/atlasplus Breast cancer mortality 1950 - 1994 Blacks White

17. Does early detection lead to… mammogram Incidentally finds a lump 19801985199019952000 Patient A Patient B Dies 20-yr survival Dies 10-yr survival Onset of cancer at the same time! Lead-time bias

18. 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

19. National Cancer Institute www.cancer.gov

22. Average Years of Life Lost Per Person Dying of Cancer 1991 National Cancer Institute www.cancer.gov

24. All-cause mortality in colon cancer screening with FOBT Goezsche (Denmark). The Lancet Feb 1997. screening detected only 25-27% of the cancers that occurred in the screening group

25. Prioritizing 1. 2. 3. 4. 5. 6. Coffield et al. (Washington DC). Am J Prev Med. 2001.

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

27. 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

28. 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

29. 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

30. American Cancer Society. www.cancer.org

32. Highest yield 50 - 69 American Cancer Society. www.cancer.org

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