Routine Health Screening

1. Routine Health Screening Chief Rounds Meghna Trivedi, MD Daniel Hyman, DO October 18, 2010

2. What is screening? • Screening is defined as an evaluation to detect a disease in an asymptomatic stage. • Screening is appropriate when population is willing to undergo testing, the disease causes significant burden of illness to patient and society, the test has adequate sensitivity and specificity to detect disease without excessive false-positive results and treatment is effective in asymptomatic phase than after appearance of symptoms • The gold standard for efficacy of screening is decrease in mortality as evidenced by clinical trials

3. Health screening and maintenance guidelines • United States Preventive Services Task Force (USPSTF) in collaboration with Agency for Healthcare research and Quality (AHRQ) and Centers for Disease Control and Prevention (CDC) are lead authorities in health screening and prevention

4. USPSTF • USPSTF is an independent panel of private-sector experts in prevention and primary care • USPSTF conducts rigorous reviews of research evidence to create evidence-based recommendations for preventive services that should be provided in the primary care setting • It consists of a panel of primary care physicians and epidemiologists and is funded, staffed, and appointed by the U.S. Department of Health and Human Services

5. CASE 1 • Ms. J is a 69 years old Caucasian female who comes for new patient visit. • Medical history is significant for DM, HTN, dyslipidemia, PVD s/p bilateral lower extremity stents in 2000, anxiety/depression and hypothyroidism. • She takes aspirin 81mg/day, atorvastatin 10 mg/day, glipizide 10 mg bid, atenolol 50 mg daily, zoloft 50 mg daily, Levothyroxine 112 mcg/day and lisinopril 5 mg/day • Family history: Dad had MI at age 53 • She complains of diarrhea on and off for one month. Diarrhea is watery, non-bloody. Denies use of recent antibiotics, travel and does not have pets. Noticed that she is unable to tolerate milk and milk products secondary to flatulence and diarrhea.

6. Case 1 continued... • Reports blurry vision at times and says it goes away after drinking soda. Not seen ophthalmologist yet. • She checks her fasting blood glucose at home and it is usually in low 100s. Last HbA1C was checked more than an year ago and it was “normal” • Her last gynecological exam was in February this year and so far Pap smears have been negative • She smokes 1-2 cigs/week, drinks socially and does not use drugs. Works at Wal-Mart • Vitals: afebrile, HR-88 bpm, BP- 172/78, RR-16, BMI- 22 • Physical exam was within normal limits except that pt looked anxious. Contributes it to seeing a new doctor and says BP is usually “good”

7. 1. How would you manage this patient? • 2. What important health maintenance services should be offered to this patient?

8. What applies to our patient • She is 69 and has DM, HTN,HPL, PVD, Hypothyroidism and mood disorder • She needs a complete physical including ht, wt and vitals. Reasonable to check lipids, TSH, HbA1C and metabolic panel • Ophthalmology and podiatry evaluation • Screening mammography • Osteoporosis screening with DEXA scan • Colorectal cancer screening • She DOES NOT need cervical cancer screening • Due for pneumococcal vaccine and flu shot

9. Pt was managed as follows: • 1. Diarrhea- check stool studies. Avoid milk and milk products. • 2. DM- check basic metabolic profile, HbA1C, continue glipizide. Maintain blood sugar diary. Needs ophthalmology and podiatry visits • 3. HTN- BP elevated. Schedule for BP check with RN in one week, continue current BP meds. • 4. PVD- s/p b/l LE stents. Check lipid profile. Currently no complains • 5. Dyslipidemia- check lipid profile (as above). Continue statin. LDL goal less than 100 mg/dL • 6. Hypothyroidism- check TSH, continue synthroid at current dose

10. Recommended Interventions for Prevention • Screen for the following: • Height, weight and blood pressure check • Alcohol and tobacco use • Depression • Diabetes mellitus • Dyslipidemia • Colorectal cancer screening • Breast cancer screening • Pap smear for cervical cancer screening • Routine voluntary HIV screening • Bone mineral density test for osteoporosis • AAA screening

11. Breast cancer facts • So far in 2010- • 207,090 women (new cases) were diagnosed with breast cancer • 39,840 women died from breast cancer • # 1 cause of cancer deaths in Hispanic women • Among women, breast cancer is the most commonly diagnosed cancer after non-melanoma skin cancer, and is the second leading cause of cancer deaths after lung cancer National Cancer Institute (NCI)

12. Breast Cancer Screening • Breast self exam (BSE), clinical breast exam (CBE) and mammography are the three modalities used for breast cancer screening • CBE and BSE have not been found to decrease risk of dying from breast cancer • USPSTF recommends screening mammography every two years for women aged 50-74 yrs • Current evidence is insufficient to assess the additional benefits and harms of mammography in women older than 75 yrs • National Cancer Institute (NCI) recommends breast cancer screening from ages 40-75 years

13. Breast self exam- No study has been able to show a statistically significant reduction in detection of breast cancer. Women are no longer aggressively encouraged to perform BSE. • Clinical Breast Exam- It is the physical exam of breast done by health professional. In clinical studies where CBE was performed along with mammography, the reduction in deaths from breast cancer was similar to the reduction in those women who had received mammography alone. • MRI- Recent studies of women with an inherited risk of breast cancer have shown that MRI has a higher sensitivity in detecting breast cancers than other screening methods. However, there are no study data showing that MRI screening reduces the number of breast cancer deaths.

14. Factors associated with increased risk of breast cancer: • HRT: 24% increase in incidence of invasive breast cancer • Ionizing radiations: 6 fold increase in incidence • Obesity: in postmenopausal women not on HRT • Alcohol consumption: in dose- dependant fashion • Genetic susceptibility: autosomal dominant inheritance • Although the risk of inheriting the predisposition is 50%, not everyone with the predisposition will develop cancer because of incomplete penetrance and/or gender-restricted or gender-related expression. • Factors associated with decreased risk of breast cancer: • Exercise • Early pregnancy: 50% decrease in incidence compared to nulliparous or those giving birth after age 35 years • Breast feeding

15. Benefits of Mammography • Early detection of breast cancer with screening mammography means that treatment can be started earlier in the course of the disease

16. Potential harms of screening mammography • False negative results- screening mammograms miss up to 20% of breast cancers that are present at time of screening. The main cause of false-negative results is high breast density seen in younger women. • False positive results- common in younger women, those with previous breast biopsies, women with family h/o breast cancer, women taking estrogen. False positive results cause anxiety, extra tests and physical discomfort • Over diagnosis and overtreatment- Screening mammograms find cancers and DCIS that do not cause symptoms or are not life threatening and treating them leads to “overtreatment” • Radiation exposure- low dose of radiation but repeated exposures have a potential to cause cancer

17. Screening for Osteoporosis • USPSTF recommends women older than 65 years should be screened for osteoporosis. Routine screening should begin at 60 years for women with increased risk for osteoporotic features • Body weight <60 kg is the single best predictor of low bone mineral density (BMD) • Low body weight, age and no current use of estrogen are incorporated in 3 item Osteoporosis Risk Assessment Instrument (ORAI) • BMD measurement at femoral neck using dual energy X-ray absorptiometry (DEXA) is commonly used tool for osteoporosis • 2 years screening interval is appropriate. • There is no data to determine age to stop screening.

18. Screening for Type II DM • USPSTF recommends screening for Type 2 DM in asymptomatic adults with sustained BP>135/80. Persons with symptoms of polyuria, polyphagia, polydipsia, nonhealing ulcers, recurrent infections, established vascular diseases should be tested for DM • American Diabetes Association (ADA) recommends using fasting plasma glucose test for screening (easy, fast, convenient, reproducible and less expensive) • ADA defines diabetes as fasting plasma glucose level 126mg/dL or greater and confirmation with repeated screening test on a separate day for people with borderline results • ADA suggests an optimal screening interval of 3 years

19. CASE 2 • Ms. D is an 45 year female who comes for new patient visit. Her c/c is weight loss. • She lost 17 pounds in 4 months • She has history of Hodgkin's lymphoma diagnosed 8-10 years ago, s/p splenectomy and radiation • She is a single mom and is under stress at work and home. She works in healthcare. Smokes 1.5 ppd for 20 years. Drinks “too much” alcohol when she is stressed out. She consumes app. 8 cups of tea daily and lot of soda. • Her father was diagnosed with colon cancer at 52 and died at age 58, mom has diabetes and thyroid disorder. Siblings are healthy • Review of systems is positive for myalgia, weight loss and fatigue.

20. Case 2 continued... • Her only medication is birth control pill. She had a gyn exam • Vitals: Temp-98.4. HR-66, BP-140/80, RR-16, BMI- 21, Wt-53 kg, Ht- 5'8” • Physical exam reveals thin lady in no apparent distress. Rest of the exam within normal limits

21. How would you manage this patient?

22. Differential diagnosis of weight loss is broad. In her, I would • think of following possibilities: • Recurrence of Hodgkin's lymphoma • Stress related/depression • Smoking • Malignancy (particularly colon cancer given history in father) • Hyperthyroidism

23. Work up • Important to get old records of lymphoma management • Refer to oncologist • CT scan of chest/abdomen and pelvis • Check comprehensive metabolic panel, CBC with differential (r/o anemia), TSH, HIV test • Needs screening colonoscopy • Depression screening • Smoking cessation counseling • Avoid too much tea as it also contains caffeine • She needs annual flu shot in addition to pneumococcal, meningococcal vaccine repeated every 5 years

24. Colorectal Cancer (CRC) Facts • Estimated new cases and deaths from colon and rectal cancer in the United States in 2010: • New cases: 102,900 (colon); 39,670 (rectal) • Deaths: 51,370 (combined) • Colorectal cancer is the third most commonly diagnosed cancer in both men and women. National Cancer Institute (NCI)

25. Risk factors for CRC: • Increased age, polyps, family history, diet high in total fat, cigarette smoking, IBD, sedentary lifestyle, history of other primary cancers • Some but not all studies have shown that aspirin use decreased the risk of development of adenomatous polyps and thereby the incidence of colon cancer • Many studies have also suggested a decreased risk of colon cancer amongst users of postmenopausal female hormone supplements

26. Modalities used to detect CRC 1. Fecal occult blood testing (FOBT)- guaiac and immunochemical. FOBT performed every 1-2 years in age group 50-80 reduces the number of deaths from CRC by 15-33% 2. Sigmoidoscopy- any polyp in upper part of colon may be missed and colonoscopy is required if any abnormality is noticed. 3. Colonoscopy- rectum and entire colon can be viewed; one of the most sensitive tests available. Although uncommon, complications like bleeding and perforation may occur. 4. Virtual Colonoscopy- Uninvasive procedure, may not detect all small polyps and cancers. If a polyp or a non polypoid lesion 6-9 mm or larger is detected, a standard colonoscopy is warranted. 5. Double contrast barium enema (DCBE)-False positive results, inability to perform biopsy /polypectomy 6. Digital rectal exam (DRE)- Often a part of routine physical exam. Can detect abnormalities only in the lower part of rectum. Genetic studies of stool samples to detect CRC are being studied in many clinical trials. More studies are needed to determine whether this type of test can accurately detect colorectal cancer or precancerous polyps in people who do not have symptoms.

27. Screening for Thyroid disorders • USPSTF concludes that evidence in insufficient to recommend for or against routine screening for thyroid disorders in adults. • TSH has high sensitivity (98%) and specificity(92%) • People at high risk for thyroid disorders include the elderly, postpartum women, those with high levels of radiation exposure, and people with Down's syndrome.

28. Screening for alcohol related problems in primary care setting • “Risky” or “hazardous” drinking is defined as >7 drinks/week or >3 drinks/occasion for women; and >14 drinks/week or >4 drinks/ occasion for men. • Alcohol abuse and dependence are associated with repeated negative physical, psychological and social effects from alcohol • CAGE questionnaire (feeling the need to cut down, annoyed by criticism, guilty about drinking and need for an Eye opener in the morning) is the most popular screening test for detecting alcohol abuse/dependence. • AUDIT (Alcohol Use Disorders Identification Test) is also well studies screening test for alcohol misuse.

29. Screening for depression in adults • Who should be screened? • People with other psychiatric disorders, substance misuse, persons with chronic medical conditions, unemployed, lower socioeconomic status and elderly. Women are at increased risk than men. • Asking two simple questions about mood and anhedonia (“Over past two weeks have you felt down, depressed or hopeless?" and “have you felt little interest or pleasure in doing things?”) is as effective as other formal tools. • A positive screening test should trigger a full diagnostic interview • A multidisciplinary team approach is required for treatment of depression

30. CASE 3 • Mr. K is a 67 year old male who comes for his routine annual examination. He does not have any complains • He is in pretty good shape, only has history of hyperlipidemia for which he takes lipitor 20 mg/day • He used to smoke 1 ppd for15 years and quit12 years ago. Drinks alcohol socially • There is no significant family history of cancers, CAD or other medical problems. Screening colonoscopy performed at age 60 was normal. • His BP is 130/80, HR-68, BMI- 24. Physical exam is within normal limits • Latest lipid panel reveals total cholesterol=213mg/dl, HDL= 48mg/dl

31. Which of the following should be offered to him at this time? • 1. Colonoscopy • 2. Fasting blood sugar • 3. CT of the chest • 4. Abdominal ultrasonography

32. You are about to leave the room when he asks if he needs the test for prostate cancer screening. His friend was recently diagnosed with prostate cancer and he is concerned. What would you tell him?

33. Prostate cancer screening • USPSTF concludes that current evidence is insufficient to assess the balance of benefits or harms of prostate cancer screening in men younger than 75 years. Recommends against screening for men older than 75 years. • Older men, AA men and men with family history of prostate cancer are at increased risk. Unfortunately, gaps in evidence regarding potential benefits also apply to these men. • PSA is more sensitive than DRE for detecting prostate cancer. PSA screening cut off point is 4.0 microgram/L, however some early cases are missed by this cut-point • Physicians should discuss with men about potential benefits and harms of this test before ordering PSA

34. continued... • If treatment of prostate cancer detected by screening improves outcome, men age 50-74 are most likely to benefit from screening • Length of time required to experience mortality benefit is greater than 10 years. Hence, there is no use screening in men older than 75 years. • American Cancer Society testing be offered to men at risk who are older than 50 years. Again, risks and benefits should be explained

35. Other important USPSTF recommendations….. • Lung cancer screening- Recommends against routine use of CXR, CT scan or sputum cytology • Ovarian cancer screening- CA-125, ultrasound or pelvic exams should not used routinely for ovarian cancer screening • AAA screening- recommends one time screening by ultrasonography in men aged 65-75 years who have ever smoked. Recommends against routine screening of women for AAA • Screening for high blood pressure- USPSTF recommends screening for HTN in adults 18 years and older. JNC-7 recommends screening every 2 years in persons with BP less than 120/80mm Hg and every year with SBP120-139 and DBP 80-90 mm Hg. JNC 8 guidelines will be available early next year.

36. continued.... • Use of aspirin for prevention of cardiovascular diseases: • USPSTF recommends aspirin for men age 45-79 years when potential benefit due to reduction in MI outweighs potential harm due to GI bleeding • Again, it recommends using aspirin in women age 55-79 years when potential benefit of reduction in ischemic strokes outweighs potential harm due to GI bleeding • Screening for Coronary Artery Disease (CAD): • USPSTF recommends against routine screening with EKG, exercise treadmill test or electron beam CT scan for coronary calcium or presence of severe coronary artery stenosis in adults at low risk of CHD events

37. Screening for peripheral arterial disease: • USPSTF recommends against routine screening for PAD • Measuring ankle brachial index (ABI) is the simplest and accurate screening method for PAD. • ABI < 0.90 is strongly suggestive of PAD • Screening for STD/STI (Gonorrhea and Chlamydia) • USPSTF recommends screening for GC infections in all sexually active women 24 and younger, and pregnant women. • Routine screening for Chlamydia is not recommended for women 25 an older if they are not at increased risk.

38. Screening for lipid disorders in adults: • USPSTF strongly recommends screening men aged 35 and older for lipid disorders • Men aged 20-35 should be screened for dyslipidemia if they are at increased risk for coronary heart disease • It is strongly recommended to screen women aged 45 and older for lipid disorders if they are at increased risk for CHD

39. Cervical Cancer Screening • USPSTF recommends screening by gynecologic exam and cytology (Pap smear) for cervical cancer in women who are sexually active and have cervix • USPSTF recommends against routine screening for women older than 65 years if they have recent normal Pap smears • Sensitivity of single Pap smear for high grade lesions is 60-80%, most organizations in U.S. (USPSTF, ACS, ACOG) recommend that annually until 2-3 samples are cytologically normal before lengthening the screening interval • New FDA approved technologies like liquid based cytology (Thin Prep) have improved sensitivity over conventional Pap smear. They have higher cost and lower specificity.

40. Medicare covered preventive services • Abdominal Aortic Aneurysm screening • Bone mass measurement • Cardiovascular screenings • Colon cancer screening • Diabetic screening (2/year if pt has risk factors) • EKG screening • Flu shots • Glaucoma tests

41. continued….. • Hepatitis B shots • HIV • Breast cancer screening (Mammograms) • Gynecological health screening • Welcome to Medicare physical exam (one time complete physical exam) • Pneumococcal shot • Prostate cancer screenings • Smoking cessation

42. USPSTF Electronic Preventive Services selector (EPSS) allows users to download recommendations on PDA or mobile devices and receive updates: • http://epss.ahrq.gov.

43. Adult Immunization Schedule