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Age Appropriate Screening. Stephen J. Titus MD. 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. USPSTF.

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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 infection’s natural progression suggests it’s 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 RCT’s 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 CBE’s and SBE’s 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 <50 should be done in high risk individuals and those with a family member with colon cancer at an age <60


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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 <10 years are unlikely to benefit


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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 <80

  • 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 AAA’s 4.0-5.4cm periodic surveillance offers equivalent mortality benefit compared with elective repair

  • No benefit has been shown for any intervention on AAA’s 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 < 70kg is single best predictor for 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 “A’s”

    • Chlamydia Screening

    • Tobacco Screening

  • The “D’s”

    • 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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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. 2002;52(1):8-22.

  • American College of Obstetricians and Gynecologists. Guidelines for Women’s Health Care. 2nd ed. Washington, DC: ACOG;2002: 121-134,140-141.

  • Cadarette SM, et al. Evaluation of decision rules for referring women for bone densitometry by dual energry xray absorpitometry. JAMA. 2001;286(1):57-63.