Age Appropriate Screening

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Age Appropriate Screening

• Stephen J. Titus MD

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Objectives

• Review the US Preventive Services Task Force
  recommendations for
• Cervical Cancer
• Breast Cancer
• Colon Cancer
• Prostate Cancer
• Abdominal Aortic Aneurysm
• Osteoporosis screening
• Testable Tid-Bits
• Practice Questions

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USPSTF

• Level of recommendation
• A Strongly recommended, good evidence supporting
  improved clinical outcomes
• B Recommended, fair evidence
• C No recommendation, fair evidence supporting
  improved clinical outcomes, but balance of
  risk/benefit too close
• D Recommends against, fair evidence that harms
  outweigh benefits
• I No recommendation due to lacking evidence

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Cervical Cancer Screening

• Strong recommendation (A) to screen women who
  have a cervix and have been sexually active.
• Optimal age to initiate unknown
• Data on HPV infections natural progression
  suggests its safe to delay until 3yrs after
  sexual activity begins or age 21 (whichever is
  first)
• High prevelence of sexual activity by age 18-21
  and concern that clinicians may not obtain
  accurate sexual history
• There was no direct evidence that annual
  screening provided better outcomes than every 3
  years

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Cervical Cancer Screening

• Majority of cancers occur in women who have never
  been screened or have not been screened in the
  last 5 years
• Sensitivity of a single pap for high grade
  lesions 60-80
• American Cancer Society (ACS) recommends annual
  screening with coventional paps and bienniel
  screeing with liquid based cytology until age 30
  before lenthening the screening interval
• American College of Obstetricians and
  Gynecologists (AGOG) lists previous HPV infection
  or other STDs or high risk behavior as reasons to
  continue annual screening.

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Cervical Cancer Screening

• Recommends against (D) screening women 65 if
  they have had adequate recent screening and not
  otherwise at high risk
• Optimal age to discontinue unknown
• USPSTF says 65
• American Cancer Society says 70
• ACS defines adequate screening as 3 or more
  documented normal/negative, techinically adequate
  paps and no abnormal results in the last 10
  years.

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Cervical Cancer Screening

• Recommends against (D) routine pap smears for
  women s/p a total hysterectomy for benign
  disease.
• Clinicians need to confirm that a total
  hysterectomy was performed either by visual
  inspection for a cervix or by reviewing surgical
  record.
• ACS and ACOG recommend continued screening for
  women with a h/o invasive cervical cancer or DES
  exposure
• Increased risk of vaginal neoplasms

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Breast Cancer

• Recommends (B) screening mammography, with or
  without a clinical breast exam(CBE) every 1-2
  years for women 40 and older.
• Evidence is insufficient (I) to recommend for or
  against CBE alone to screen for breast cancer
• Evidence is insufficient (I) to recommend for or
  against teaching or performing routine breast
  self-examination.

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Breast Cancer

• The balance of benefit and potential harms from
  mammography improves with increasing age between
  40-70
• Those most likely to benefit are those at
  increased risk
• FMHx in a mother or sister
• Previous biopsy with atypical hyperplasia
• First childbirth after age 30

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Breast Cancer

• Trials looking at improved breast cancer
  mortality, no difference was seen between annual
  and bienniel mammography.
• However, most expert recommendations are for
  annual mammography due to the low sensitivty of
  the test

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Breast Cancer

• The age to discontinue mammography is uncertain
• Only 2 RCTs looked at patients 69, and only 1
  at patients 74
• Older women have a higher probablity of getting
  and dying from breast cancer, but also a greater
  risk of death from other causes
• Women with comorbid conditions limiting their
  life expectancy are unlikely to benefit from
  screening mammography

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Breast Cancer

• There currently is insufficient evidence showing
  that CBEs and SBEs affect breast cancer
  mortality.
• They are likely to increase biopsies and
  assessments.

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Colon Cancer

• Strongly recommends (A) screening men and women
  50 years and older for colorectal cancer.
• Fecal Occult Blood Testing (FOBT)
• Flexible Sigmoidoscopy
• FOBT Flexible Sigmoidoscopy
• Colonoscopy
• Double Contrast Barium Enema

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Colon Cancer

• Screening strategy should be based on available
  options, medical contraindicatons, patient
  preference and adherence. Risks and benefits of
  each should be discussed with patients.
• Testing interval depends of test.
• FOBT done annually has the greatest reduction in
  mortality

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Colon Cancer

• 10 years for Colonoscopy based on the natural
  history of an adenomatous polyp.
• 5 year intervals for both Flex Sigs and double
  contrast barium enema is based on their lower
  sensitivity, but case control studies suggest 10
  year intervals may be just as effective
• Initiating screening at age high risk individuals and those with a family
  member with colon cancer at an age

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Colon Cancer

• Age to discontinue is unknown
• Studies have been limited to patients younger
  then 80
• Cancer mortality rates begin to decrease within 5
  years of starting screening
• Discontinuing is reasonable for those whose age
  or conditions limit life expectancy

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Colon Cancer

• Neither Digital Rectal Exam or a single stool
  specimen is recommended as adequate testing
• FOBT should include 3 specimens
• Combination of FOBT and Flex sig detect more
  cancers and more large polyps than either alone
• Colonoscopy is the most sensitive and specific
  for detecting cancers and large polyps, but has
  higher risks then others

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Prostate Cancer

• Evidence is insufficient (I) to recommend for or
  against routine prostate cancer screening using
  prostate specific antigen (PSA) or digital rectal
  exam (DRE).
• PSA and DRE can detect prostate cancer in early
  pathologic stages
• Recent evidence suggests radical prostatectomy
  can reduce mortality in men whose cancer was
  detected clinically.

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Prostate Cancer

• The benefits vs risks balance of early treatment
  of cancers detected early via screening is still
  uncertain
• Reduction of cancer mortality/morbidity
• VS.
• False Positives, unnecessary biopsies, surgical
  complications

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Prostate Cancer

• Likely to show up on a question
• Clinicians should not order a PSA without first
  discussing with patients the uncertainties of the
  test and possible harms
• Ages most likely to benefit from screening are
  men 50-70 at average risk and men 45 and older at
  increased risk (FMH or African American)
• Life expectancy

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Prostate Cancer

• PSA is more sensitive then DRE
• PSA with a cut off of 4.0 ng/ml detects a
  majority of cancers but can miss 10-20

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Abdominal Aortic Aneurysm(AAA)

• Recommends (B) one-time screening for AAA by
  ultrasound in men aged 65-75 who have ever
  smoked.
• Recommends against (D) screening women
• AAA risk factors
• Age 65
• Male
• Smoking (100 cigarettes)

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Abdominal Aortic Aneurysm(AAA)

• 500 men who have smoked age 65-74 need to be
  screened to prevent 1 AAA-related death over 5
  years.
• Low incidence of AAA-related death in women
• Operative mortality for open AAA repair is 4-5
• Endovascular AAA repair has shown better short
  term perioperative mortality and morbidity, no
  long term evidence.
• Ultrasound has a sensitivity of 95 and
  specificity near 100

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Abdominal Aortic Aneurysm(AAA)

• Open repair of aneurysms at least 5.5cm lead to
  43 reduction in AAA-specific mortality in older
  men who underwent screening
• For AAAs 4.0-5.4cm periodic surveillance offers
  equivalent mortality benefit compared with
  elective repair
• No benefit has been shown for any intervention on
  AAAs 3.0-3.9cm
• Expert opinion recommends repeat Ultrasonography

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Osteoporosis

• Recommends (B) women 65 and older be screened
  routinely for osteoporosis. Screening should
  begin at age 60 for women at increased risk.
• Weight presence of osteoporosis
• Dual energy xray absorptiometry (DEXA) at the
  femoral neck is the best predictor of hip
  fracture

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Osteoporosis

• No studies have evaluated the optimal interval
  for repeat screening.
• No data to determine age to stop screening and
  very little data on the treatment of osteoporosis
  after age 85

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Testable Tid-Bits

• The As
• Chlamydia Screening
• Tobacco Screening
• The Ds
• Ovarian Cancer Screening
• Testicular Cancer Screening
• Idiopathic Scoliosis Screening

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Testable Tid-Bits

• Strongly recommends (A) clinicians routinely
  screen all sexually active women 25 and younger
  and those at increased risk for chlamydial
  infection.
• Evidence is insufficient (I) to recommend
  routinely screening asymptomatic men for
  chlamydia.

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Testable Tid-Bits

• Strongly recommends (A) clinicians screen all
  adults for tobacco use and provide tobacco
  cessation interventions for those who use tobacco
  products.
• (I) Insufficient evidence to recommend screening
  children/adolescents

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Testable Tid-Bits

• Recommends against (D) routine screening for
  ovarian cancer.
• Includes
• CA-125
• Ultrasound
• Pelvic Exam
• No evidence showing that these interventions
  reduce ovarian cancer mortality

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Testable Tid-Bits

• Recommends against (D) routine screening for
  testicular cancer in asymptomatic adolescent and
  adult males.
• Low incidence
• Favorable outcomes
• No evidence showing that self exams, even in high
  risk individuals, improve outcomes

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Testable Tid-Bits

• Recommends against (D) routine screening for
  idopathic scoliosis is asymptomatic adolescents.

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Practice Questions

• A 56 y.o. female presents for a health
  maintenance examination. She has a history of a
  total hysterectomy for benign disease 4 years
  ago. You are able to document that the
  hysterectomy pathology was benign and that she
  has had normal Pap tests for 10 years. The
  patient asks about regular Pap smears. Which one
  of the following would be the most appropriate
  recommendation?

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Practice Questions

• Routine pap smears should be continued until age
  70
• A pap smear should be done every 3 years
• A pap smear is not indicated
• A pap smear should be done yearly for 3 years and
  only if indicated thereafter

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Practice Questions

• Routine pap smears should be continued until age
  70
• A pap smear should be done every 3 years
• A pap smear is not indicated
• A pap smear should be done yearly for 3 years and
  only if indicated thereafter

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Practice Questions

• According to the U.S. Preventive Services Task
  Force, which one of the following strategies for
  osteoporosis screening is supported by current
  clinical evidence?

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Practice Questions

• A) Begin universal screening 5 years after the
  date of the last menstrual period
• B) Begin universal screening at age 65
• C) Begin universal screening at age 55
• D) Screen only those women at increased risk for
  hip fracture based on a multiple risk-assessment
  scale

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Practice Questions

• A) Begin universal screening 5 years after the
  date of the last menstrual period
• B) Begin universal screening at age 65
• C) Begin universal screening at age 55
• D) Screen only those women at increased risk for
  hip fracture based on a multiple risk-assessment
  scale

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Practice Questions

• Current American Academy of Family Physician
  guidelines for periodic health examinations
  strongly recommend which one of the following for
  women?

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Practice Questions

• A) Annual Papanicolaou smears for women of all
  ages
• B) Annual pelvic ultrasonography in women with a
  family history of ovarian cancer
• C) Routine screening for human papillomavirus in
  women age 25 or younger
• D) Screening for chlamydial infection in all
  sexually active women age 25 or younger
• E) Screening for hepatitis B at least once by
  age 25

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Practice Questions

• A) Annual Papanicolaou smears for women of all
  ages
• B) Annual pelvic ultrasonography in women with a
  family history of ovarian cancer
• C) Routine screening for human papillomavirus in
  women age 25 or younger
• D) Screening for chlamydial infection in all
  sexually active women age 25 or younger
• E) Screening for hepatitis B at least once by
  age 25

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Practice Questions

• A 45-year-old white female presents for her
  yearly health maintenance examination and
  Papanicolaou (Pap) test. She has been in good
  health and has no family history of significant
  medical disorders. Her examination is normal, and
  she asks about screening for breast cancer. Which
  one of the following screening methods would be
  most appropriate?

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Practice Questions

• A) A dedicated breast CT scan
• B) Thermography
• C) MRI
• D) Ultrasonography
• E) Mammography

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Practice Questions

• A) A dedicated breast CT scan
• B) Thermography
• C) MRI
• D) Ultrasonography
• E) Mammography

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Practice Questions

• Which one of the following is an effective
  screening method for ovarian cancer in elderly
  females at average risk?
• A) Annual CA-125 assays
• B) Annual pelvic ultrasonography
• C) Annual Papanicolaou (Pap) tests and pelvic
  examinations
• D) No currently available method

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Practice Questions

• Which one of the following is an effective
  screening method for ovarian cancer in elderly
  females at average risk?
• A) Annual CA-125 assays
• B) Annual pelvic ultrasonography
• C) Annual Papanicolaou (Pap) tests and pelvic
  examinations
• D) No currently available method

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Practice Questions

• Which one of the following is consistent with
  current recommendations?

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Practice Questions

• A) Cervical cancer screening with Papanicolaou
  (Pap) smears should begin within 1 year after the
  onset of vaginal intercourse
• B) Cervical cancer screening should begin no
  later than 18 years of age in all women
• C) Screening with vaginal cytology is not
  indicated in women who have had a total
  hysterectomy for benign gynecologic disease
• D) Cervical cytologic screening should be done
  yearly prior to the age of 30, with either a
  conventional Pap smear or liquid-based cytology
• E) Cervical cytologic screening should routinely
  cease at age 80

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Practice Questions

• A) Cervical cancer screening with Papanicolaou
  (Pap) smears should begin within 1 year after the
  onset of vaginal intercourse
• B) Cervical cancer screening should begin no
  later than 18 years of age in all women
• C) Screening with vaginal cytology is not
  indicated in women who have had a total
  hysterectomy for benign gynecologic disease
• D) Cervical cytologic screening should be done
  yearly prior to the age of 30, with either a
  conventional Pap smear or liquid-based cytology
• E) Cervical cytologic screening should routinely
  cease at age 80

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Summary

• Screen for cervical, colon and breast cancer
• Talk to your patient about screening for prostate
  cancer
• Screen for osteoporosis, AAA, smoking and
  chlamydia infection in the appropriate
  populations.
• Do not screen for scoliosis, testicular cancer
  and ovarian cancer in low risk, asymptomatic
  patients

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Questions?
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References

• U.S. Preventive Services Task Force. The Guide to
  Clinical Preventive Services 2006 ed. Agency for
  Healthcare Research and Quality, Rockville, MD
• Smith RA, Cokkinides V, et al. American Cancer
  Society Guideline for the Early Detection of
  Cervical Neoplasia and Cancer. A Cancer J Clin.
  200252(1)8-22.
• American College of Obstetricians and
  Gynecologists. Guidelines for Womens Health
  Care. 2nd ed. Washington, DC ACOG2002
  121-134,140-141.
• Cadarette SM, et al. Evaluation of decision rules
  for referring women for bone densitometry by dual
  energry xray absorpitometry. JAMA.
  2001286(1)57-63.