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Update on new recommendations

Update on new recommendations. By Dr. Joel Doughten. What % of new recommendations recommended by the USPSTF is out of date by the time it is published?. A. 5% B. 9% C. 12% D. 15%. Answer. B. 9%.

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Update on new recommendations

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  1. Update on new recommendations By Dr. Joel Doughten

  2. What % of new recommendations recommended by the USPSTF is out of date by the time it is published? • A. 5% • B. 9% • C. 12% • D. 15%

  3. Answer • B. 9%

  4. What is the average length of time that a recommendation made by the USPSTF in in effect before it is revised? • A. 5.4 years • B. 7 years • C. 7.5 years • D. 10 years

  5. Answer • A. 5.4 years

  6. Should you vaccinate a 25 yo smoker with Pneumovac? • A. Yes • B. No • C. Consider

  7. Current Change by the USPSTF • Asthma and cigarette smoking have been added as indications for pneumococcal polysaccharide vaccination #7. Also, text has been added to clarify vaccine use in Alaska Natives and American Indians.

  8. Pneumococcal polysaccharide vaccine (Pneumovax) • ACIP recommendations—smokers 19 to 64 yr of age • Relative risk for pneumococcal invasive disease higher in smokers • smoking, diabetes, and asthma have comparable risk • among smokers, risk 1 per 10,000; • problems—when to administer and frequency • vaccine wears off with time • hyporesponsiveness occurs after second dose • if smokers revaccinated every 5 to 10 yr, low responsiveness expected by age 65 yr

  9. Case: patient—man 61 yr of age; smoker; last tetanus vaccine15 yr ago; never given Tdap; he is adopting a daughterfrom Guatemala in 1 month. What vacines should you give him?

  10. recommendedvaccines • Tdap based on high risk (smoker) and need for tetanus booster • pneumococcal polysaccharide based on age and high risk (smoker) • inactivated influenza vaccine • herpes zoster based on age • hepatitis A, based on daughter adopting from Guatemala • varicella not indicated (born before 1980) • hepatitis B risk not identified • Meningococcal conjugate not indicated

  11. A girl 12 yr of age presents with sportsinjury. She has no chronic illnesses and is in good health. She had all her childhood vaccinesby age 5 yr. What vaccines do you recommend?

  12. recommended vaccines • tetanus and diphtheria toxoids and acellular pertussis (Tdap) for adolescents • influenza (universal annual administration 6 mo through 18 yr of age) • varicella (catch-up if second dose not received) • quadrivalent meningococcal conjugate vaccine (all children 11-12 yr of age) • human papillomavirus (HPV all girls 11-12 yr of age) • hepatitis A (catch-up for ages 11-12 yr [depending on state regulations] and universally for ages 1-2 yr)

  13. Identify the correct statement about the Gardasil human papillomavirus (HPV) vaccine.(A) Licensed for males and females 9 to 26 yr of age(B) Protects against HPV strains 6, 11, 16, and 18(C) Protects against HPV infection even if patient has been infected with HPV in the past(D) Licensed for pregnant women

  14. Answer • (B) Protects against HPV strains 6, 11, 16, and 18

  15. Which of the following is(are) true about meningococcal vaccines?1. Meningococcal conjugate vaccine is recommended for routine use in adolescents2. Meningococcal polysaccharide vaccine is recommended for adults <50 yr of age3. Meningococcal vaccines are recommended for freshmen college students, molecular biologists, and travelers4. Meningococcal vaccines can be administered to those with a history of Guillain-Barré syndrome(A) 1, 2, 3, 4 (B) 1, 2, 3 (C) 1, 3 (D) 2, 3, 4

  16. Answer • 1. Meningococcal conjugate vaccine is recommended for routine use in adolescents • 3. Meningococcal vaccines are recommended for freshmen college students, molecular biologists, and travelers • (C) 1, 3

  17. Identify the correct statement about the herpes zoster vaccine.(A) Recommended for both adolescents and adults(B) Prevents herpes zoster and postherpetic neuralgia(C) Indicated for pregnant women(D) Stored at room temperature

  18. Answer • (B) Prevents herpes zoster and postherpetic neuralgia

  19. Hepatitis A vaccine is recommended for which of the following?1. 30-yr-old man backpacking in South America2. 28-yr-old woman adopting a child from Guatemala3. 25-yr old man addicted to drugs4. 35-yr-old homosexual man(A) 1 (B) 1, 2 (C) 1, 2, 3 (D) 1, 2, 3, 4

  20. Answer • Hepatitis A vaccine is recommended for which of the following? • 1. 30-yr-old man backpacking in South America • 2. 28-yr-old woman adopting a child from Guatemala • 3. 25-yr old man addicted to drugs • 4. 35-yr-old homosexual man • (D) 1, 2, 3, 4

  21. Whom of the following should receive the influenza vaccine?1. 6-yr-old schoolboy2. Mother of 2-yr-old twins3. Nurse who works in the emergency department4. 60-yr-old diabetic(A) 1 (B) 1, 2 (C) 1, 2, 3 (D) 1, 2, 3, 4

  22. Answer • 1. 6-yr-old schoolboy • 2. Mother of 2-yr-old twins • 3. Nurse who works in the emergency department • 4. 60-yr-old diabetic • (D) 1, 2, 3, 4

  23. The risk for pneumococcal invasive disease is higher for:(A) Smokers, but not for diabetics or asthmatics (C) Smokers and asthmatics, but not for diabetics(B) Diabetics, but not for smokers or asthmatics (D) Smokers, diabetics, and asthmatics

  24. Answer • (D) Smokers, diabetics, and asthmatics

  25. The USPSTF Updated: December 2009 • Summary of Recommendations • The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.Grade: B recommendation. • The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. Grade: C recommendation. "So, what does this mean if you are a woman in your 40s? You should talk to your doctor and make an informed decision about whether mammography is right for you based on your family history, general health, and personal values." • Diana Petitti, MD, MPH Vice Chair, U.S. Preventive Services Task ForceNovember 19, 2009 • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.Grade: I Statement. • The USPSTF recommends against teaching breast self-examination (BSE).Grade: D recommendation. • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.Grade: I Statement. • The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer.Grade: I Statement. • On December 4, 2009, the USPSTF unanimously voted to update the language of their recommendation regarding women under 50 years of age to clarify their original and continued intent.

  26. Studies suggest that clinicians would need to perform mammography on _______ women 40 to 49 yr of age to avert asingle death from breast cancer.(A) 25 (B) 250 (C) 2500 (D) 25,000

  27. Answer • (C) 2500

  28. Benefits of screening mammography • Women 40-49 yr of age • trial in United Kingdom (2006)— 11-yr follow-up • 16% decrease in breast cancer mortality among screened vs nonscreened women at 10 to 11 yr • Canadian trial (1980s)—showed no effect • Takehome message—modest benefit observable only with long follow-up; number needed to screen (NNS)—2500 women 40 to 49 yr of age to avert 1 death (25,000 annual mammograms) • most studies done in United Kingdom • US case-control studies (Elmore 2005 and Norman 2007)—no difference in mortality • case-control studies usually overestimate benefit • Women 50 yr of age: 30% reduction in mortality in screened women • benefit seen in 5 yr • tighter confidence intervals and benefit persists over long period • 270 women every 2 yr for 20 yr to avert 1 death (ie, 2700 mammograms) • Women 70 yr of age and older little data is available on mortality in randomized controlled trials (RCTs) • population-based data—better detection in screened group, but no significant difference in mortality

  29. Question: How often should women 50 to 69 yr of age undergomammography? A) every year; B) every 1 to 2 yr;C) every 2 yr; D) every 3 yr

  30. Answer • C) every 2 yr

  31. RCTs comparing annual vs biennial screening • — no difference in breast cancer mortality • population-based data (Breast Cancer Surveillance Consortium)—from United States • looked for increase in late-stage disease with biennial vs annual screening • Proportion of advanced-stage disease decreases with age (tumors not as aggressive in older women) • in women over 50 yr of age the proportion of advanced-stage cancer was the same with annual and biennial screening • for younger women (40-49 yr of age), 21% of cancers late-stage disease in annual group vs 28% in biennial • 7% difference may warrant annual • Screening • Canadian study—annual vs biennial screening in women 50 to 69 yr of age the 10-yr survival was the same

  32. Recommendations to reduce the frequency of mammography from once per year to once every 2 yr for women 50 to 69yr of age are based on:(A) Data showing no increase in breast cancer mortality with biennial vs annual screening(B) Data showing no increase in late-stage breast cancer with biennial vs annual screening(C) Data showing no difference in 10-year breast cancer survival rates with biennial vs annual screening(D) All the above

  33. Answer • (D) All the above

  34. Patient characteristics and breast cancer • Hormone therapy (HT): taking estrogen and progestin for >5 yr increases rate of cancer and advanced disease • explanations—estrogen and progestin promote tumor growth, increase breast density, and mask tumors • Only 15% of postmenopausal women now using hormone therapy • decreased use associated with lower incidence of breast cancer (particularly estrogen receptor–positive disease [13% per year])

  35. Use of estrogen and progestin therapy for 5 yr increases the risk for breast cancer and for late-stage disease due to thehormones’ potential to:(A) Promote tumor growth (B) Increase breast density (C) Decrease breast density (D) A and B

  36. Answer • (A) Promote tumor growth • (B) Increase breast density • (D) A and B Answer

  37. Breast density • It is reported with some mammograms (eg, • fatty, scattered fibroglandular densities, heterogeneously dense, very dense) • most women in middle of range • effect of breast density on detection—higher density both increases risk for breast cancer and makes it more difficult to detect • unpublished data—higher density correlates with more advanced disease • consider annual screening, or use of digital mammography

  38. Family history and Obesity • Family history (first-degree relative) • no effect on ability to detect cancer • more abnormalities noted and biopsies performed, possibly due to clinician bias • survival study—no difference with positive family history • screening—not necessary to screen more often than others • Obesity: increases risk for breast cancer and advanced disease • attributed to extra estrogen in adipose tissue, rather than to difficulties with detection

  39. Choose the correct statement about patients with a first-degree relative who has had breast cancer.(A) It is more difficult to detect breast cancer in these patients(B) They are no more likely than other patients to be referred for further investigation of abnormalities found onmammography(C) Studies show no difference in survival rates for these patients(D) They should undergo twice-yearly mammography

  40. Answer • (C) Studies show no difference in survival rates for these patients

  41. Minimizing false positives and negatives • limit hormone use • avoid biopsy by using comparison films • Encourage weight loss (increased breast tissue leads to more false positives) • refer to high-volume facilities (have better specificity) • counsel patients that breast augmentation decreases sensitivity of mammography

  42. To prevent false-positives and false-negatives in breast cancer screening, the patient should do which of the following?(A) Avoid hormone therapy (B) Obtain comparison films (C) Obtain screening at a high-volume facility(D) All the above

  43. Answer • (D) All the above

  44. Sensitivity of digital mammography is higher than that of film mammography for women 40 to 49 yr of age who are both_______ and who have _______.(A) Premenopausal; dense breasts (B) Premenopausal; fatty breasts (C) Postmenopausal; dense breasts(D) Postmenopausal; fatty breasts

  45. Answer • (A) Premenopausal; dense breasts

  46. Cost-effectiveness • compare benefit to harm • women 50 to 69 yr of age • most cost-effective at $21,400/yr of life saved • smoking cessation much more effective way to reduce clinical burden of disease and costs

  47. The sensitivity of digital mammography is higher thanfilm mammography for which groups of women? A) premenopausalB) 40 to 49 yr of age; C) with dense breasts;D) all of these

  48. Answer • D) all of these (must fall into all 3 categories • women >65 yr of age with fatty • breast tissue—film mammography gives better contrast

  49. A women at high risk for breast cancer should undergowhich screening tests? A) mammography; B) clinical breast examination(CBE)C) ultrasonographyD) mammography andultrasonographyE) mammography and magnetic resonanceimaging (MRI)F) mammography, CBE and MRI

  50. Answer • Answer: no correct answer • depends on definition of high risk • mammography and MRI—standard of care for carriers of breast cancer mutation • MRI twice as sensitive as mammography, but less than half as specific • tests usually alternated every 6 mo for mutation carriers

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