Preventive Health Maintenance

1
Preventive Health Maintenance

• Common Ambulatory Topics
• July 2007
• Lisa L. Willett MD
• J. R. Hartig MD

2
Roadmap

• Breast Cancer Screening
• Colorectal Cancer Screening
• Cervical Cancer Screening
• Adult Vaccinations
• Osteoporosis Screening
• Recreational Activities
• Lipid Screening
• Abdominal Aortic Aneurysm Screening

3
Breast Cancer

• Projected 211,000 new cases in US and 40,400
  deaths in women in 2005
• Second cause of cancer related death in women
• More common in older women
• Risk 1 in 25 for ages 40-59
• Risk 1 in 15 for ages 60-79

4
Question Breast cancer screening

• 34 yoF presents for routine follow up. After
  spending the visit discussing her HTN and DM
  care, you turn to her health maintenance. She
  has a family history of breast cancer in her
  great aunt. You recommend which of the
  following?
• Clinical breast exam
• Screening mammography beginning at age 35
• Screening mammography beginning at age 40
• Screening mammography beginning at age 50
• Screening breast ultrasound beginning at age 35

5
Methods of screening

• Clinical Breast Exam (CBE)
• Breast Self Exam (BSE)
• Mammography

6
Recommendations

• US Preventive Services Task Force (USPSTF)
• Canadian Task Force of Preventive Health Care
  (CTFPHC)
• Both evidence based, explicit methodology
• Others AMA, ACS, ACOG, AAFP
• Literature review and expert opinion

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Summary of Recommendations
Zoorob, AFP 2001631101-12
8
USPSTF Grades and Recs
9
USPSTF

• Evidence is strongest for 50-69
• Weaker for 40-49, but most studies show mortality
  benefit (but less than 50-69)
• Difficult to account for delay in observed
  benefit
• Insufficient evidence for optimal screening
  interval
• Insufficient data for CBE, BSE (I)

www.ahrq.gov/clinic/uspsft/uspsbrca.htm Ann
Intern Med 2002137344-46
10
Question Breast cancer screening

• 34 yoF presents for routine follow up. After
  spending the visit discussing her HTN and DM
  care, you turn to her health maintenance. She
  has a family history of breast cancer in her
  great aunt. You recommend which of the
  following?
• Clinical breast exam
• Screening mammography beginning at age 35
• Screening mammography beginning at age 40
• Screening mammography beginning at age 50
• Screening breast ultrasound beginning at age 35

11
Question Breast cancer screening

• 34 yoF presents for routine follow up. After
  spending the visit discussing her HTN and DM
  care, you turn to her health maintenance. She
  has a family history of breast cancer in her
  great aunt. You recommend which of the
  following?
• Clinical breast exam
• Screening mammography beginning at age 35
• Screening mammography beginning at age 40
• Screening mammography beginning at age 50
• Screening breast ultrasound beginning at age 35

12
FAQs

• When can I stop screening?
• Evidence is strongest for 50-69
• Can generalize to 70 without co-morbidities
• higher absolute risk of breast cancer
• What about high risk women (family history,
  previous abnormal breast biopsy, first childbirth
  30)?
• Start sooner, perhaps annually

13
Colorectal Cancer

• Epidemiology
• 3rd most common cancer in the U. S.
• 3rd leading cause of cancer death
• At age 50 a person has 5 lifetime chance
• Pathology
• 80 arise from adenomatous polyps
• Screening Rates
• 25 report FOBT in last 12 months
• 38 report any form of endoscopy in 5 years

Source American Cancer Society, 2007.
14
Question Colorectal Cancer

• According to USPSTF, which of the following
  strategies for colorectal cancer screening is
  acceptable?
• Colonoscopy every 5-7 years after 50yo for
  low-risk individuals
• Annual in-office DRE and FOBT after 50yo
• Flex sig and DCBE every 5 years after 50yo
• Annual home FOBT beginning age 50
• Virtual colonoscopy every 10 years after 50yo

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Methods of Screening
16
S_at_
17
Screening Methods and Trials
18
Summary of Recommendations

• 1 http//www.ahrq.gov/clinic/3rduspstf/colorectal/
  colorr.pdf

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USPSTF

• Clinical factors influencing recommendations
• Cost effectiveness likely any strategy ok
• Choice of strategy individualized based on
  patient and availability of services

20
Question Colorectal Cancer

• According to USPSTF, which of the following
  strategies for colorectal cancer screening is
  acceptable?
• Colonoscopy every 5-7 years after 50yo for
  low-risk individuals
• Annual in-office DRE and FOBT after 50yo
• Flex sig and DCBE every 5 years after 50yo
• Annual home FOBT beginning age 50
• Virtual colonoscopy every 10 years after 50yo

21
Question Colorectal Cancer

• According to USPSTF, which of the following
  strategies for colorectal cancer screening is
  acceptable?
• Colonoscopy every 5-7 years after 50yo for
  low-risk individuals
• Annual in-office DRE and FOBT after 50yo
• Flex sig and DCBE every 5 years after 50yo
• Annual home FOBT beginning age 50
• Virtual colonoscopy every 10 years after 50yo

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Colorectal Cancer FAQs

• Screening for colon cancer should begin?
• Screen all adults beginning at age 50
• Earlier if family history or personal risks exist
• When can I stop screening?
• FOBT has been proven effective 50-80yo
• How should I screen for colorectal cancer?
• Depends on patient and situation. Insurance!!!
• At what interval should I screen for this method?
• Depends on method used. FOBT q1, Flex sig q5,
  ACBE q5-10, Colon q10.

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Cervical Cancer

• 13,000 new cases and 4,100 deaths in the US in
  2002
• Mean age of diagnosis 47 yrs
• Risks early onset of sexual activity, greater
  number of lifetime partners, HIV, cigarette
  smoking

25
HPV infection

• Human papilloma virus (HPV) necessary precursor
  plus host factors
• High risk types 16,18
• Peak incidence and prevalence in women most are transient
• Less prevalent in older women

26
Question Cervical cancer screening

• 22 yoF presents for primary care. She has been
  sexually active since 19, with 2-4 partners per
  year and uses oral contraception. Her college
  medical records show a normal pap 1 year ago.
  You recommend which of the following?
• Cervical smear for HPV testing
• Cervical smear for HSV testing
• Colonoscopy
• Pap smear now
• Pap smear in three years

27
Summary of Recommendations
www.preventiveservices.ahrq.gov Zoorob, AFP
2001631101-12
28
Cervical cytology Pap Smear

• Sensitivity for single test is 60-80
• Most organizations recommend annual screening
  until 2-3 normal

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Human papillomavirus (HPV)

• Human papillomavirus (HPV) testing
• Limited evidence to determine risk/benefits
• Trials underway will clarify
• Useful in decision making for ASCUS
• If HPV negative with ASCUS, annual screening
• If HPV positive with ASCUS, refer for colposcopy

30
Question Cervical cancer screening

• 22 yoF presents for primary care. She has been
  sexually active since 19, with 2-4 partners per
  year and uses oral contraception. Her college
  medical records show a normal pap 1 year ago.
  You recommend which of the following?
• Cervical smear for HPV testing
• Cervical smear for HSV testing
• Colonoscopy
• Pap smear now
• Pap smear in three years

31
Question Cervical cancer screening

• 22 yoF presents for primary care. She has been
  sexually active since 19, with 2-4 partners per
  year and uses oral contraception. Her college
  medical records show a normal pap 1 year ago.
  You recommend which of the following?
• Cervical smear for HPV testing
• Cervical smear for HSV testing
• Colonoscopy
• Pap smear now
• Pap smear in three years

32
Cervical Cancer FAQs

• Do I screen women with a total hysterectomy?
• NO, if done for benign purposes
• Do I screen women never sexually active?
• Although unlikely, most recommend screen 21
• At what age can I stop doing pap smears?
• If adequate prior screening, normal paps and not
  otherwise high risk 65 USPSTF or 70 ACS

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Adult Vaccinations

• Rates of immunization are improving?
• 1989 to 2003 in adults 65 years of age
• Pneumococcal vaccine 15 to 64
• Influenza vaccine 33 to 70
• 1995 data on younger adults 18-49 years old
• 12 with indications had received pneumococcal
• 20 with indications had received influenza
• Tetanus/diphtheria
• Only 47 adults had protective antibody levels

Source CDC statistics/MMWR
35
Advisory Committee on Immunization Practices
(ACIP)

• Group of physicians/scientists at CDC
• Responsible for vaccine recommendations
• Schedules
• Notification of changes / shortages
• Reports published in MMWR
• www.cdc.gov/mmwr
• Generally in concert with other medical societies
  (ACP, AAP, ACOG, AAFP)

36
The National Childhood Vaccine Injury Act of 1986

• Requires healthcare providers to follow
  directives, record and maintain records and
  report adverse events
• Provide appropriate Vaccine Information
  Statements (VIS)
• Vaccine Adverse Event Reporting System
• (VAERS) www.vaers.org [phone]
• Vaccine Injury Compensation Program
• www.hrsa.gov/osp/vicp [phone]

37
Vaccine Information Sheets (VIS)
Source www.immunize.org
38
VIS available in many languages
Source www.immunize.org
39
Question Immunizations

• A 66yo M with a 7 year history of diet
  controlled-DM comes to your office for a routine
  visit. After providing appropriate care for his
  DM, you review his immunization record
• Last Pneumococcal vaccine 7 years ago.
• Last tetanus he cannot recall, none documented
• Your best plan today is
• Obtain old records and update shots at next visit
• Td today, IM Flu if season, and Pneum. in 3 years
• Td today, IM Flu if season, Pneum. today
• Td today, Intranasal Flu if season, Pneum. today
• Td later, Intranasal Flu if season, Pneum. in 3
  years

40
Adult Immunization Schedule
Source CDC MMWR
41
Pneumococcal Vaccines

• Capsular polysaccharide vaccine
• First used in 1945
• Currently use 23 valent vaccine (1983)
• Pneumococcal Polysaccharide Vaccine (PPV23)
• Nonrandomized studies significant benefit
• Cochrane Review1
• not effective in preventing death or pneumonia
• Does reduce invasive pneumococcal disease

• 1 Dear KB G, Andrews RR, Holden J, Tatham DP.
  Vaccines for preventing pneumococcal infection in
  adults. The Cochrane Database of Systematic
  Reviews 2003, Issue 4. Art. No. CD000422. DOI
  10.1002/14651858.CD000422.

42
Indications for Pneumococcal Vaccine

• Adapted from MMWR 2003 52739-40

43
Influenza Vaccines

• Epidemiology
• Annually 36,000 deaths/year in 1990-1999
• Complications highest in 2yo, 65yo and
  individuals with certain diseases (DM, asthma)
• School absenteeism 25, Lost work productivity,
  increased medical burden
• Vaccine products
• Whole virus vs Split product - intramuscular
• Live attenuated influenza vaccine (LAIV)

44
Indications for Influenza Vaccine

• If 6moxmonth. 6-10wks later
• Adapted from MMWR June 29, 2007 internet release

45
Contraindications to Influenza Vaccine

• Anaphylactic hypersensitivity to eggs
• Anaphylactic history to vaccine or component
• Acute febrile illness (relative)
• Guillain-Barré syndrome
• 1976 swine influenza vaccine
• High risk probably vaccinate low risk
  probably not
• No LAIV if age 50, or essentially any
  true indication to receive influenza vaccine

46
Indications for Tetanus Vaccine

• Described by Esdall in 1976 as
  The inexcusable disease
• Incidence in the US 0.16 per million (43/year)

Adapted from MMWR
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Tdap

• Dont forget
• Everyone should receive one Tdap in place of the
  usual Td booster vaccine

49
Question Immunizations

• A 66yo M with a 7 year history of diet
  controlled-DM comes to your office for a routine
  visit. After providing appropriate care for his
  DM, you review his immunization record
• Last Pneumococcal vaccine 7 years ago.
• Last tetanus he cannot recall, none documented
• Your best plan today is
• Obtain old records and update shots at next visit
• Td today, IM Flu if season, and Pneum. in 3 years
• Td today, IM Flu if season, Pneum. today
• Td today, Intranasal Flu if season, Pneum. today
• Td later, Intranasal Flu if season, Pneum. in 3
  years

50
Question Immunizations

• A 66yo M with a 7 year history of diet
  controlled-DM comes to your office for a routine
  visit. After providing appropriate care for his
  DM, you review his immunization record
• Last Pneumococcal vaccine 7 years ago.
• Last tetanus he cannot recall, none documented
• Your best plan today is
• Obtain old records and update shots at next visit
• Td today, IM Flu if season, and Pneum. in 3 years
• Tdap today, IM Flu if season, Pneum. today
• Td today, Intranasal Flu if season, Pneum. today
• Td later, Intranasal Flu if season, Pneum. in 3
  years

51
Common Resources

• Internet
• www.immunize.org
• www.cdc.gov
• Palm OS Based and PC versions
• Shots 2007

52
Question Osteoporosis screening

• 58 yo AAF postmenopausal for 3 years, presents
  for routine visit without complaint. In regards
  to osteoporosis screening, which of the following
  are true?
• She needs a DEXA now
• She needs 1200 mg of Calcium daily
• She needs a DEXA at age 60
• She needs a DEXA at age 65

53
Osteoporosis Screening

• Women aged 65 and older (B)
• Begin at age 60 if increased risk (B)
• Weight
• Smoking, family history, alcohol, caffeine, low
  calcium/vitamin D
• DEXA minimum of 2 years
• No data on when to stop

54
Question Osteoporosis screening

• 58 yo AAF postmenopausal for 3 years, presents
  for routine visit without complaint. In regards
  to osteoporosis screening, which of the following
  are true?
• She needs a DEXA now
• She needs 1200 mg of Calcium daily
• She needs a DEXA at age 60
• She needs a DEXA at age 65

55
Question Osteoporosis screening

• 58 yo AAF postmenopausal for 3 years, presents
  for routine visit without complaint. In regards
  to osteoporosis screening, which of the following
  are true?
• She needs a DEXA now
• She needs 1200 mg of Calcium daily
• She needs a DEXA at age 60
• She needs a DEXA at age 65

56
Recreational Activities

• Sexually Transmitted Diseases
• Tobacco
• Alcohol
• Seat Belts

57
Question STDs

• A 24 yoF presents to your clinic asking for a
  refill of birth control pills. She is monogamous
  with one partner. She denies h/o STDs, vaginal
  discharge, or other symptoms and has no PMH. You
  recommend which of the following?
• Mammogram
• Clinical breast exam
• Chlamydia screening
• Gonorrhea screening
• HIV screening

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STDs

• Chlamydia
• ALL sexually active women aged 24 or less
  regardless of symptoms (A)
• ALL ages women at increased risk (A)
• Insufficient evidence for asymptomatic men (I)
• Gonorrhea
• All sexually active women if increased risk (B)
• Insufficient evidence for men at risk (I)
• HIV syphilis at increased risk pregnant (A)

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Universal HIV screening?

• September 2006, CDC published
• All individuals age 13-64 be screened for HIV
  regardless of risk
• USPSTF reviewed the quality and strength of the
  evidence and maintains C (no recommendation) for
  those not at increased risk

MMWR 200655(RR-14)1-17
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Question STDs

• A 24 yoF presents to your clinic asking for a
  refill of birth control pills. She is monogamous
  with one partner. She denies h/o STDs, vaginal
  discharge, or other symptoms and has no PMH. You
  recommend which of the following?
• Mammogram
• Clinical breast exam
• Chlamydia screening
• Gonorrhea screening
• HIV screening

61
Question STDs

• A 24 yoF presents to clinic asking for a refill
  of birth control pills. She is monogamous with
  one partner. She denies h/o STDs, vaginal
  discharge, or other symptoms and has no PMH. You
  recommend which of the following?
• Mammogram
• Clinical breast exam
• Chlamydia screening
• Gonorrhea screening
• HIV screening

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Tobacco, alcohol, seat belts

• Tobacco
• Screen all adult patients, including pregnant
  women, and provide cessation interventions (A)
• Alcohol
• Screen all adult patients, including pregnant
  women, and provide cessation interventions (A)
• Seat belts (B)

USPSTF, Clinical preventive services module (ABIM)
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Lipid Background

• Why screen?
• Primary and secondary prevention trials for CHD
• Epidemiology
• Prevalence estimated at 17.5 of men, 20 of
  women had total cholesterol (TC) 240

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Summary of RecommendationsWho to screen

• 1 http//www.ahrq.gov/clinic/ajpmsuppl/lipidrr.pdf
  
• 2 JAMA, May 16, 2001Vol 285, No. 19 2487
• 3 http//pediatrics.aappublications.org/cgi/reprin
  t/101/1/141.pdf

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Summary of RecommendationsWhat to screen

• 1 http//www.ahrq.gov/clinic/ajpmsuppl/lipidrr.pdf
  
• 2 JAMA, May 16, 2001Vol 285, No. 19 2487
• 3 http//pediatrics.aappublications.org/cgi/reprin
  t/101/1/141.pdf

67
USPSTF

• Optimal intervals to screen are uncertain
• 5 years perhaps (NCEP/ATP III q5 years)
• Age to stop screening is unclear
• Levels are unlikely to rise after age 65
• ACP concludes no evidence to screen 75yo
• Clinical factors influencing recommendations
• TC and HDL can measured non-fasting
• LDL measurement requires fasting costly

68
Lipids FAQs

• At what age should I begin screening adults for
  lipid abnormalities?
• Men 35yo and women 45yo. ( 20?)
• At what age should I stop screening?
• After 65 to 75 years of age
• What tests should be ordered for screening?
• Either TC/HDL or fasting lipoprotein analysis
• How often should I screen if initial values are
  normal?
• Every 5 years (?)

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Question AAA

• According to the USPSTF which of the following
  scenarios is best supported by data in screening
  for abdominal aortic aneurysms? (Which one should
  you screen and how?)
• 77yo W with HTN, DM, CAD tob by ultrasound
• 60yo M with CAD, ? lipids, tob by exam
• 66yo M with CVAs, HTN past tob by ultrasound
• 70yo M with HTN, CABG, - tob by ultrasound
• 68yo W with CABG, tob by exam

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AAA Background

• Epidemiology
• 9,000 annual deaths associated with AAAs
• Prevalence Men 4-9 Women 1
• Deaths tend to occur in men 65 and women 80
• Risk Factors
• Age 65, male sex, history of 100 cigarettes,
  and ? Family History

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Abdominal Aortic Aneurysm Screening

• Methods of Screening
• Exam
• Ultrasonography
• CT scan
• MRI
• Interventions
• Observation and repeat study
• Surgical Repair

73
Summary of Recommendations

• 1 http//www.ahrq.gov/clinic/uspstf05/aaascr/aaar
  s.pdf
• 2 Kent KC, et al. Screening for abdominal aortic
  aneurysm a consensus statement. J Vasc Surg.
  200439267269.

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USPSTF

• Clinical factors influencing recommendations
• Effect of screening
• Harm of screening
• Cost effectiveness similar to other measures
• NNS Male smokers 500
• Male nonsmokers 1783

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Question AAA

• According to the USPSTF which of the following
  scenarios is best supported by data in screening
  for abdominal aortic aneurysms? (Which one should
  you screen and how?)
• 77yo W with HTN, DM, CAD tob by ultrasound
• 60yo M with CAD, ? lipids, tob by exam
• 66yo M with CVAs, HTN past tob by ultrasound
• 70yo M with HTN, CABG, - tob by ultrasound
• 68yo W with CABG, tob by exam

76
Question AAA

• According to the USPSTF which of the following
  scenarios is best supported by data in screening
  for abdominal aortic aneurysms? (Which one should
  you screen and how?)
• 77yo W with HTN, DM, CAD tob by ultrasound
• 60yo M with CAD, ? lipids, tob by exam
• 66yo M with CVAs, HTN past tob by ultrasound
• 70yo M with HTN, CABG, - tob by ultrasound
• 68yo W with CABG, tob by exam

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WWWD(What Would We Do?)

• Breast cancer
• Colon cancer
• Cervical Cancer

• Women age 40-69 every 1-2 years
• Screen all age 50 with annual FOBT min., other
  screening based on situation
• Women 21-70 annually for 2-3 years, then every 3
  years, but continue annually if high risk

79
WWWD?

• Vaccinations
• Osteoporosis
• STDs
• Tobacco/Alcohol/Seat Belts

• Review status annually
• Women over 65
• Women
• HIV for high risk /- all
• All patients

80
WWWD?

• Lipids
• AAAs

• M 20-35 W 20-45 once
• M 35 W 45 q 5year
• Stop after age 75
• Males 65-75 who have ever smoked

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Plenty of other topics not discussed

• Screening for DM
• Screening for HTN
• Routine labs
• Prostate cancer screening
• Vaccines
• HPV
• Hep B
• Mening.