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Preventive Medicine (Cancer Screening & Immunizations) in Adults. Michael Adams, M.D., FACP Program Director Assistant Professor of Medicine Georgetown University Medical Center. Cancer screening: Definitions Breast cancer Cervical cancer Colorectal cancer Prostate cancer Skin cancer

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preventive medicine cancer screening immunizations in adults

Preventive Medicine(Cancer Screening & Immunizations) in Adults

Michael Adams, M.D., FACP

Program Director

Assistant Professor of Medicine

Georgetown University Medical Center

outline
Cancer screening:

Definitions

Breast cancer

Cervical cancer

Colorectal cancer

Prostate cancer

Skin cancer

Chemoprevention

Controversies

Vaccinations

Outline
definitions
Definitions

Screening:

  • testing for disease in average (or low) risk, asymptomatic population
  • may be considered a form of primary prevention
  • goals:
    • early detection
    • treating to reduce morbidity or mortality
  • no diagnostic intent
  • average prevalence (by definition)
definitions1
Definitions

Case-finding:

  • testing in patients at higher risk
    • patients seeking medical care because of a complaint
    • patients with familial risks / exposures / other diagnosis
  • may be a form of secondary prevention
    • disease present, reduce mortality / recurrence rate
  • diagnostic intent
  • usually higher than average disease prevalence
operating characteristics
Operating characteristics
  • high sensitivity
  • low burden
  • early detection
  • ability to modify course of disease
  • higher prevalence = better positive predictive value
guidelines
GUIDELINES
  • ACP, USPSTF, CTF, NCI, NIH, AMA, ACC, AHA, AUA, ACOG, IOM
  • USPSTF
    • evidence-based
    • frequent updates
    • factor in net benefit, quality of the evidence
us preventive services task force uspstf
US Preventive Services Task Force (USPSTF)
  • http://www.ahcpr.gov/clinic/uspstfix.htm
uspstf ratings
USPSTF Ratings
  • Recommendation: A - routinely provide to eligible patients.

The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.

  • Recommendation: B - routinely provide to eligible patients.

The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.

uspstf ratings1
USPSTF Ratings
  • Recommendation: C - no recommendation for or against routine provision of [the service]

At least fair evidence that [the service] can improve health outcomes but concludes that the balance of the benefits and harms is too close to justify a general recommendation.

  • Recommendation: D - recommends against routinely providing [the service] to asymptomatic patients

The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.

uspstf ratings2
USPSTF Ratings
  • Recommendation: I - evidence is insufficient to recommend for or against

Evidence that [the service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.

breast cancer
Breast Cancer
  • North America: leading cancer in women, 2nd leading cause of cancer death
  • 2001: 192,000 diagnoses, 40,200 deaths
  • >50%: no known major predictors
  • Risk increases with age, atypical hyperplasia
  • BRCA-1 and -2

BRCA-1 BRCA-2

breast breast

ovary ovary

colon colon?

prostate prostate?

male breast? male breast

pancreatic?

breast cancer mammography
Breast Cancer: mammography
  • Sensitivity 56-95%
    • Lower in younger, dense breasts, HRT
  • Specificity 94-97%
    • More false positives (less specific) in younger women
  • Abnormal mammogram & chance of cancer:
    • 40-49: 2-4% PPV
    • 50-59: 5-9%
    • 60+: 7-19%
breast cancer clinical breast exam
Breast Cancer: Clinical Breast Exam
  • Sensitivity 40-69%
  • Specificity 86-99%
  • 4% of patients with abnormal CBE diagnosed with cancer in a large community trial
  • These trials compared CBE with mammography, mortality trials use both CBE & mammogram
breast cancer age considerations
Breast Cancer: age considerations
  • Most screening trials 50-69
  • 40-49: weaker evidence, delay in benefit (lower prevalence in younger women)
    • Interval for screening is unknown
  • Over 70:
    • evidence generalized unless comorbid conditions reduce life expectancy
    • Higher absolute risk of cancer
  • Mammography benefits (absolute) increase with age
  • Mammography risks (RELATIVE) diminish with age
breast cancer1
Breast Cancer
  • The (USPSTF) recommends screening mammography, with or without clinical breast examination (CBE), every 1-2 years for women aged 40 and older.

B recommendation

breast cancer cbe
Breast Cancer: CBE
  • The USPSTF concludes that the evidence is insufficient to recommend for or against routine CBE alone to screen for breast cancer.

“I” recommendation

breast cancer self breast exam
Breast Cancer: Self Breast Exam
  • Sensitivity 26-41%
  • Specificity unknown
  • No known mortality difference
  • Risks of abnormal self exam (anxiety, testing, biopsy)
breast cancer self exam
Breast Cancer: self-exam
  • The USPSTF concludes that the evidence is insufficient to recommend for or against teaching or performing routine breast self-examination (BSE).

“I” recommendation

breast cancer other considerations
Breast Cancer: other considerations
  • Patient preferences, clinical judgment
  • Family history
  • BRCA
  • Other organizations have varying recommendations:
    • Yearly after age 40: AMA, ACOG, ACS, ACR
    • Yearly after 50: CTF, AAFP, ACPM
    • Interval varies (q1, q2 between 40-49)
    • BSE: ACOG, ACS, AMA, AAFP favor teaching
cervical cancer
Cervical Cancer
  • 13,000 cases yearly
  • 4,100 deaths (2002)
  • Risks:
    • early intercourse
    • increased # of sexual partners
    • smoking
    • HPV (95-100% of squamous cell CA of cervix)
cervical cancer1
Cervical Cancer
  • Natural history of HPV – slow transition to cancer
    • “orderly fashion from less severe to more severe dysplasia”
    • Not faster in HIV+ women (prevalence higher)
      • Every 6-12 months
    • Younger women: HPV may be transient
    • Older women: higher chance of progression to cancer
  • PAP smear: 60-80% sensitive
  • New technologies (“ThinPrep”): no good data yet
cervical cancer hpv testing
Cervical Cancer – HPV testing
  • Sensitivity 82%
  • Specificity 78%
  • Benefits untested
  • 8 ongoing studies
cervical cancer timing
Cervical Cancer - timing
  • Interval: every 3 years after 2-3 normals
    • Sensitivity 60-80% for high grade lesions for a single PAP test
    • ACS: wait until age 30 to extend screening interval
    • Annual screening: cervical neoplasia, HPV, other STDs, high risk sexual behavior
  • Cessation of screening
    • Low predictive value for women over 65 (ACS: 70), no abnormal PAP in past 10 years
    • Hysterectomy for benign disease (only cancer in 1995 study of 10,000 PAP smears was vaginal squamous cell CA)
cervical cancer2
Cervical Cancer
  • The USPSTF strongly recommends screening for cervical cancer in women who have been sexually active and have a cervix.

A recommendation

cervical cancer3
Cervical Cancer
  • The USPSTF recommends against routinely screening women older than age 65 for cervical cancer if they have had adequate recent screening with normal Pap smears and are not otherwise at high risk for cervical cancer.

D recommendation

cervical cancer4
Cervical Cancer
  • The USPSTF recommends against routine Pap smear screening in women who have had a total hysterectomy for benign disease.

D recommendation

cervical cancer5
The USPSTF concludes that the evidence is insufficient to recommend for or against the routine use of human papillomavirus (HPV) testing as a primary screening test for cervical cancer.

The USPSTF concludes that the evidence is insufficient to recommend for or against the routine use of new technologies to screen for cervical cancer.

Cervical Cancer

“I” recommendation

“I” recommendation

colorectal cancer
Colorectal Cancer
  • 4th most common cancer in US
  • 2nd leading cause of cancer death
  • At age 50, 5% risk of being diagnosed with colon cancer
  • Adenomatous polyps – precursor
  • Hereditary polyposis syndromes (FAP, HNPCC) – 6% of all colon cancers
colorectal cancer dre
Colorectal Cancer - DRE
  • Little evidence
  • Sensitivity much less than multiple test cards
  • False negatives – no stool in vault
  • False positives – rectal trauma
  • Therefore, not recommended as a tool for colorectal cancer screening
colorectal cancer fobt
Colorectal Cancer - FOBT
  • sensitivity 26 - 92%, specificity 90-99%
  • 3 samples, rehydrated cards improve sensitivity (diminishes specificity)
  • Annual screening has detected 49% of incident cancers
  • FOBT: 33% reduction in mortality over controls
  • inexpensive
colorectal cancer sigmoidoscopy
Colorectal Cancer - sigmoidoscopy
  • Alone:
    • detects approximately 7 cancers and 60 large polyps/1000 exams
    • estimated detection of significant colonic lesions of 80%
      • Sigmoid abnormalities often trigger colonoscopy
  • Combination with FOBT:
    • detects 65-75% of polyps and 40-65% of cancers
    • reduces mortality by 60%
    • detects an additional 7 cancers over FOBT alone
colorectal cancer dcbe
Colorectal Cancer - DCBE
  • Limited studies: sensitivity 86-90% for cancer / polyps
  • Only 48% sensitive for polyps > 1cm in National Polyp Study
  • Specificity 85%
  • No outcome data
colorectal cancer colonoscopy
Colorectal Cancer - colonoscopy
  • Sensitivity 90% for large polyps, 75% for small polyps
  • Specificity difficult to define
  • Minority of patients who have polypectomy would have developed cancer
  • PROS: view entire colon, ability to biopsy/treat during procedure
  • CONS: cost, complications, prep/discomfort
colorectal cancer colonoscopy1
Colorectal Cancer - colonoscopy
  • The effectiveness of colonoscopy to prevent colorectal cancer or mortality has not been tested in a randomized clinical trial.1
  • Comparisons with historical controls: estimates 76-90% reduction in cancers.

1USPSTF website: http://www.ahcpr.gov/clinic/3rduspstf/colorectal/colorr.htm

colorectal cancer ct colography virtual colonoscopy
Colorectal Cancer – CT colography (“virtual colonoscopy”)
  • Non-invasive
  • 10-15 minutes
  • 85-90% sensitive in research setting
  • Prep still necessary
  • No outcome data
  • New software?
colorectal cancer costs
Colorectal Cancer - costs
  • Costs for screening, 2002
    • Stool hemoccult $7-10
    • Flexible sigmoidoscopy $176-299
    • Colonoscopy $670-981 excluding facility fee

Among 6 high-quality cost-effectiveness analyses examining only direct costs, the average cost-effectiveness ratio values for screening adults older than 50 with each of the major strategies were under $30,000 per life-year saved (Year 2000 dollars). Studies varied as to which strategy was most cost-effective, however. (USPSTF)

colorectal cancer1
Colorectal Cancer
  • The USPSTF strongly recommends that clinicians screen men and women 50 years of age or older for colorectal cancer.

A recommendation

colorectal cancer2
Colorectal Cancer
  • Other considerations:
    • Family history of colon cancer <60: test earlier
    • “The choice of screening strategy should be based on patient preferences, medical contraindications, patient adherence, and resources for testing and followup.” (USPSTF)
    • Timing (American Cancer Society)
      • FOBT: yearly
      • Sigmoid: every 5 years
      • DCBE: every 5 years
      • Colonoscopy: every 10 years
      • (One-in-a-lifetime after age 55)
prostate cancer
Prostate Cancer
  • 2nd leading cause of cancer death among men in US
  • 2002: 189,000 new cases
  • Risk increases with age (6.5% by age 60)
  • Ethnic differences (mortality):
    • Asian/Pacific Islanders: 1.0
    • Latino/Hispanic 1.08
    • White 1.67
    • Black 3.33
  • Black men have higher incidence rate
  • Most men will not die of their disease (3% out of 15%)
prostate cancer1
Prostate Cancer
  • Considerations:
    • DRE, PSA accuracy
      • DRE: <60% sensitivity, operator-dependent
      • PSA: 60-80% sensitive using 4.0 as abnormal
    • Early detection
    • Mortality benefit?
      • Scant evidence, some showing reduced deaths from prostate cancer after prostatectomy but complications not considered
    • Complications of treatment
    • Age of patient
      • Screening is most likely to benefit the following:
        • 50-70 year old men at average risk
        • Men over 45 with risk factors (Black men, Family hx)
prostate cancer uspstf
Prostate Cancer - USPSTF
  • “Despite the absence of firm evidence of effectiveness, some clinicians may opt to perform prostate cancer screening for other reasons.   Given the uncertainties and controversy surrounding prostate cancer screening, clinicians should not order the PSA test without first discussing with the patient the potential but uncertain benefits and the possible harms of prostate cancer screening. Men should be informed of the gaps in the evidence, and they should be assisted in considering their personal preferences and risk profile before deciding whether to be tested.”
prostate cancer2
Prostate Cancer
  • Prostate cancer guidelines
    • USPSTF: do not recommend screening
    • ACS, AUA, AAFP, AMA: consider DRE at age 40, PSA over 50 (40 for Black men)
    • CTF: recommend against PSA, do not recommend discontinuation of DRE
    • ACP: do not recommend screening
    • All groups advise physicians to give information to patients about screening, risk/benefit, treatment & individualize testing
prostate cancer3
Prostate Cancer
  • The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routine screening for prostate cancer using prostate specific antigen (PSA) testing or digital rectal examination (DRE).

“I” recommendation

skin cancer
Skin Cancer
  • The U.S. Preventive Services Task Force concludes that the evidence is insufficient to recommend for or against routine counseling by primary care clinicians to prevent skin cancer.

“I” recommendation

skin cancer1
Skin Cancer
  • The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routine screening for skin cancer using a total-body skin examination for the early detection of cutaneous melanoma, basal cell cancer, or squamous cell skin cancer.

“I” recommendation

chemoprophylaxis for neoplastic diseases
Chemoprophylaxis for Neoplastic Diseases
  • tamoxifen and raloxifene may prevent some breast cancers in women at low or average risk for breast cancer
  • tamoxifen can significantly reduce the risk for invasive ER-positive breast cancer in women at high risk for breast cancer and that the likelihood of benefit increases as the risk for breast cancer increases
  • raloxifene – consistent evidence (fewer studies)
chemoprophylaxis side effects
Chemoprophylaxis – side effects
  • VTE
  • Symptomatic side effects (hot flashes)
  • Endometrial cancer (tamixofen only)
  • Need to balance harms vs benefits
slide50

Variable

Age 45

Age 55

Age 65

Age 75

5-year risk of breast cancer, %

   No Family history

0.7

1.1

1.5

1.6

   Family history

1.6

2.3

3.2

3.4

Benefits per 1,000 women of 5 y of tamoxifen

Cases of invasive breast cancer avoided, n

   No Family history

3-4

5-6

7-8

8

   Family history

8

11-12

16

17

Cases of noninvasive breast cancer avoided, n

   No Family history

1-2

2

2-3

2-3

   Family history

2-3

3-4

4-5

5-6

Hip fractures avoided, n

<1

3

5

15

Harms per 1000 women of 5 y of tamoxifen

Cases of endometrial cancer caused, n

1-2

12

21

"22"

Strokes caused, n

1

3

9

20

Pulmonary emboli caused, n

1-2

4-5

9

18

Cases of DVT caused, n

1-2

1-2

3

4

chemoprophylaxis for neoplastic diseases1
Chemoprophylaxis for Neoplastic Diseases
  • The U.S. Preventive Services Task Force (USPSTF) recommends against the routine use of tamoxifen or raloxifene for the primary prevention of breast cancer in women at low or average risk for breast cancer.

D recommendation

chemoprophylaxis for neoplastic diseases2
Chemoprophylaxis for Neoplastic Diseases
  • The USPSTF recommends that clinicians discuss chemoprevention with women at high risk for breast cancer and at low risk for adverse effects of chemoprevention. Clinicians should inform patients of the potential benefits and harms of chemoprevention.

B recommendation

vaccinations
VACCINATIONS
  • Td
  • pneumovax
  • influenza
  • Hepatitis B
  • Varicella
  • Hepatitis A
  • Meningococcus
  • MMR
  • Polio
pneumococcal vaccine
Pneumococcal Vaccine
  • Contains capsular polysaccharides of 23 common strains
  • underused (only 45% of patients over age 65)
  • >65, chronic disease (CHF, COPD, liver disease, alcoholism, DM), HIV, splenectomy
  • Revaccinate: nephrotic syndrome, renal failure, transplant, (ab titer wanes)
  • maybe revaccinate elderly after 6 years
  • Vaccinate preganant women if high risk: after first trimester
  • safe
influenza vaccine
Influenza vaccine
  • Only 65% of patients over 65 receive flu shots
  • 2 type A strains, 1 type B strain
  • reduces illness in healthy patients (70-90%)
  • reduces mortality & hospitalizations in elderly (despite only 30-40% effectiveness)
influenza vaccine1
Influenza vaccine
  • Eligible:
    • >50
    • nursing home/long-term care facility
    • chronic illness (DM, renal, Hb-opathies, cardiopulmonary disease, immunosuppressed, long term ASA use)
    • health care / home care / day care
influenza vaccine2
Influenza vaccine
  • Adverse reactions:
    • soreness at site
    • febrile illness (24-48 hours) - not influenza
    • immediate hypersensitivity (rare, even in egg allergic patients)
    • Guillain-Barre (1976 with Swine flu vaccine, 1990-91 a few cases, very rare now)
influenza vaccine3
Influenza vaccine
  • Contraindications
    • Severe egg allergy
    • Active neurologic disease
hepatitis b vaccine
Hepatitis B vaccine
  • Safe, effective (90% immunity in healthy patients - less if older, obese, smokers, chronic disease – liver/renal/DM, HIV)
  • 0,1,6 months
  • Indications:
    • sexual exposure - multiple, homosexual
    • health care workers
    • IVDA
    • HIV (50-70% seroconversion)
    • infants born to HBsAg positive women
  • post-exposure prophylaxis
    • depends on type of exposure, patient risk
        • high: HBIG + Hep B series
        • low: Hep B series or booster
hepatitis b vaccine1
Hepatitis B vaccine
  • Adverse reactions: local
  • Pregnancy is not a contraindication
  • Non-responders:
    • 3 additional doses, check titers (30-50% response)
  • Revaccination or checking titers
    • not recommended for immunocompetent people
    • recommended for hemodialysis patients
slide61
Td
  • Tetanus rare, but fatality rate high (31-42%)
  • Primary series: 3 doses at 0,1,6 months
  • toxoid every 10 years
  • local erythema common
  • Arthus reaction uncommon
  • anaphylaxis, urticaria, angioedema, neurologic complications - very rare
  • wound prophylaxis (high risk, unvaccinated): immune globulin + Td at different sites
slide62
MMR
  • Measles (live, attenuated vaccine):
    • resurgence 1990
    • Resurgence in inner city, college campuses
    • Vaccine produces noncommunicable disease
    • Single dose is 95% effective, life long immunity
slide63
MMR
  • all adults born after 1956 & no h/o disease – revaccinate
  • travelers to endemic areas, high risk of natural disease
  • Postexposure prophylaxis: vaccinate immediately (protective within 72 hours) OR immune globulin
slide64
MMR
  • fever, rash common side effects
  • do not give 14 days before or 5 months after I.G., blood, or ab-containing blood products
  • do not give to the following:
    • acute leukemia, lymphoma
    • malignancy
    • steroid, chemotherapy, alkylating agents
    • HIV unless stable/well
    • Pregnant women, considering within 3 mos.
slide65
MMR
  • Mumps:
    • orchitis, meningitis, nerve deafness
    • live, attenuated vaccine
    • 90% effective after single dose
    • all adults born after 1956
    • parotitis, encaphalitis rare
    • same timing as measles, same contraindications
    • Egg/neomycin allergy
rubella
Rubella
  • Main issue is prevention of congenital rubella
  • Vaccinate women of child bearing age
  • MMR - 95% effective
  • joint pains – 40%, but arthritis rare
  • Arthralgias may persist up to 3 weeks
  • Rare neurologic side effects (neuritis)
  • avoid in pregnancy, neomycin allergy
  • Same contraindications as measles
polio vaccine
Polio vaccine
  • OPV, IPV - both trivalent, 95% effective
  • IPV preferred (higher risk of paralysis with OPV - 1/1.2 million)
  • Single booster for travelers to endemic areas who were immunized
  • travelers not previously immunized – complete primary series (3 doses: 0,1,6 months)
  • No need to vaccinate adults otherwise
  • IPV: hypersensitivity only
  • avoid in pregnancy, immunocompromised
hepatitis a
Hepatitis A
  • Inactivated vaccine
  • Indications: endemic areas, homosexual men, IVDA, liver disease, occupational risk
  • 95% effective after 3 weeks, 99%+ after 2nd dose
  • immune globulin if travel within 2 weeks or if food borne outbreak/close contact (diaper/sexual contact/day care)
varicella
Varicella
  • Live, attenuated vaccine
  • 85% effective in children, reduces severity of illness if contracted
  • well tolerated
meningococcus
Meningococcus
  • High risk only:
    • household contacts
    • >4 hours spent with patient for 5 of 7 days prior
    • dorms, barrack roommates, day care
    • mouth-to-mouth
  • prophylaxis:
    • rifampin (600mg q 12h x 4) - resistance
    • cipro 750 mg x 1
    • ceftriaxone 250 mg IM x 1
ad