Controversies in Screening

1. Controversies in Screening Hannah Maxfield, MD

2. Objectives Know the definition of a screening test Be able to consider possible adverse effects of screening Know whether screening tests are appropriate for the following conditions: CAD, COPD, various cancers Know the most common D recommendations per the USPSTF Know the most common I recommendations per the USPSTF Know how to discuss these options with patients

3. Screening • Looking for a disease or risk factor in a patient who is otherwise asymptomatic • Can be done through history-taking, physical exam or other testing • Start with the conditions that have the greatest morbidity/mortality – think about patient-centered outcomes

4. You need to know what you’re looking for when you order a screening test

5. What makes a good screening test? • high sensitivity and specificity • high positive predictive value • simplicity and low cost • safety • acceptable to patients and clinicians

6. Consider adverse effects of screening • false positives • overdiagnosis • treatment options available

7. Screening labs • No indication for screening for asymptomatic bacteruria (unless patient is pregnant)

8. CAD • Adults not at increased risk (ECG, ETT, or EBCT)

9. COPD • Don’t use spirometry

10. Cancer • Breast • Ovarian • Cervical • Prostate • Testicular • Colon • Lung

11. Breast Cancer • Don’t use chemoprevention of breast cancer in women who are not at increased risk of breast cancer (D) • BRCA mutation testing for breast and ovarian cancer • Women whose family history is not associated with an increased risk for deleterious mutations in BRCA 1 or BRCA 2 (D) • Screening for breast cancer by teaching BSE (D) • Screening for breast cancer with digital mammography or MRI (I) • Breast cancer screening by CBE with mammography - Women ages 50 to 75 (I)

12. When to start? American Cancer Society, American College of Radiology, AMA, NCI, ACOG and NCCH recommend screening annually starting at 40 AAFP recommends mammography every 1-2 years starting at 40 USPSTF, American College of Physicians and Canadian Task Froce on the Periodic Health Examination recommend starting at 50, with shared decision-making for patients 40-49

13. How often? Every 1-2 years Tumors tend to grow faster in younger women, so if you start early, probably need to do them yearly.

14. Clinical breast exam vs. self breast exam • CBE • ACS, ACOG recommend from age 20-30 • Canadian Task Force recommends against • USPSTF and WHO do not recommend • SBE • Little consensus, some recommendations for “breast self-awareness” and education regarding the benefits/risks/limitations

15. Ovarian cancer • No good screening test • D recommendation

16. Cervical cancer • Women over age 65 who have had previous negative screens; women who have had total hysterectomy for benign disease (D)

17. Current guidelines – almost everyone agrees! Start screening at 21 Cytology only for women 21-20 Cytology and HPV testing for women >30 can be done every 5 years USPSTF also allows for cytology only done every 3 years

18. Prostate cancer • Don’t screen men >75 • Screening for prostate cancer with PSA and/or DRE (I)

19. Prostate cancer • Still struggling with this one. Again, emphasis on shared decision-making. • Important points • Prostate cancer is one of the leading causes of cancer deaths in men • Screening may reduce this but there is no good evidence • A positive test leads to a prostate biopsy • Seems to be a high rate of overdiagnosis, i.e. cancers that would not have caused any issues in the patient’s lifetime • Surgery and radiation can cause problems with urinary, bowel and sexual function

20. Testicular cancer • No appropriate screening test • No studies on the sensitivity or specificity of either clinical or self testicular exam • No useful blood markers

21. Colon cancer • Stop after age 85 • Screening for colorectal cancer with computed tomographic colonography and fecal DNA testing (I)

22. Lung cancer • New recommendations – annual low dose CT scans for high risk populations • This includes adults aged 55-80 with at least a 30 pack year smoking history who are still smoking or who quit within the last 15 years

23. D recommendations (don’t do it!) • All adults – Beta carotene supplements, screening for AAA, pancreatic cancer, hepatitis B, COPD, peripheral artery disease, asymptomatic carotid artery disease • Using aspirin • To prevent colorectal cancer – only in men >45 or women >55 • To prevent CVD – men >45 • To prevent ischemic stroke – women >55 • I for use in adults >80 to prevent CHD

24. I recommendations • (balance of benefits and harms uncertain) • Some of these will surprise you

25. I recommendations • Screening for chlamydia in men, dementia in older adults, family/intimate partner violence, glaucoma, skin cancer, suicide risk, illicit drug use, hearing loss, vision loss • Counseling to promote breast-feeding, promote a healthy diet, prevent low back pain, promote physical activity, prevent skin cancer, avoidance of drinking and driving, wearing seat belts, prevention of STDs • Screening for bladder cancer, breast cancer with CBE/digital mammography/MRI, colorectal cancer with CT colonography, oral cancer

26. Things to remember • know the guidelines so that you can educate your patients and let them participate in shared decision-making • These recommendations are based on population statistics, there may be other individual factors that will sway your decision • It’s only screening if the patient is asymptomatic and has no previous risk factors – otherwise you need to take those symptoms and risks into account too

27. References • Uptodate Overview of preventive medicine in adults. Accessed 3/13/14. • Uptodate Evidence-based approach to prevention. Accessed 3/13/14. • Uptodate. Screening for lung cancer. Accessed 3/13/14. • USPSTF guidelines. http://www.ahrq.gov/clinic/uspstfix.htm • Screening for Cancer: Evaluating the Evidence. THOMAS J. GATES, M.D. Am Fam Physician. 2001 Feb 1;63(3):513-523.