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HEALTHY PEOPLE

HEALTHY PEOPLE. Aims. Interpret evidence about a screening programme and decide whether it is worthwhile – for individuals or groups Demonstrate an understanding of the concept of risk and be able to communicate risk effectively to the patient and his or her family

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HEALTHY PEOPLE

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  1. HEALTHY PEOPLE

  2. Aims • Interpret evidence about a screening programme and decide whether it is worthwhile – for individuals or groups • Demonstrate an understanding of the concept of risk and be able to communicate risk effectively to the patient and his or her family • Assess your own knowledge of immunisation with a Quiz.

  3. criteria for screening    • THE WHO CRITERIA IS AS FOLLOWS • The condition screened for should be an important one • There should be an acceptable treatment for the disease • The facilities for diagnosis and treatment should be available

  4. SCREENING CRITERIA • there should be a suitable test or examination which has few false positives - specifity - and few false negatives - sensitivity • there should be a recognised latent or early symptomatic stage • the test or examination should be acceptable to the population • the cost, including diagnosis and subsequent treatment, should be economically balanced in relation to expenditure on medical care as a whole

  5. Clinical Scenario's • A 50 year old female consults you asking for screening for ovarian cancer as she had a step sister who died of this disease when she was 45. What information would you want from her and what would you tell her about screening for ovarian cancer ?

  6. CLINICAL Scenario's • A 60 year old male attends asking if he can be entered into a screening programme for prostate cancer as he has heard that it is common in men as they grow older. What information would you ask for and what would you want to communicate to him about prostate screening ?

  7. CLINICAL SENARIO • A 50 year old female with newly diagnosed type 2 DM asks you if she really has to go for diabetic retinal screening as she has not got time. How do you answer this and does this screening programme fulfil the WHO criteria ?

  8. screening (for ovarian cancer) • There is little information concerning the nature of the precursor to a malignant ovarian tumour and there is, as yet, no proven role for screening for ovarian cancer . • The common epithelial cancers may develop from ovarian inclusion cysts. Unfortunately screening by ultrasonography does not reduce mortality from ovarian cancer. • Carcino-embryonic antigen is insufficiciently sensitive or specific to be used as a screening test

  9. prostate cancer screening • interim results from a large European random controlled trial (1) and a large US study show that screening with prostate-specific antigen (PSA) testing (combined with digital rectal examination [DRE] in the US study) (2) detects many more cancers than usual care

  10. PROSTATE CA SCREENING • however a review notes caution and states • "..the value of prostate cancer screening is still unclear.... whether or not this (results of the studies mentioned) translates into a survival benefit from prostate cancer remains uncertain.."(3) interim results from the European study (n=162,243) suggest that, over nine years, 1,410 men would need to be screened with PSA testing (and 48 additional men with cancer would need to be treated) to prevent one death from prostate cancer

  11. References • 1. MeReC Extra No 40 July 2009 • 2. Schröder FH, Hugosson J, Roobol MJ, et al, for the ERSPC investigators. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med 2009;360:132-8 • 3. Andriole GL, Crawford ED, Grubb RL, et al, for the PLCO Project Team. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med 2009;360:1310-9

  12. screening for diabetic retinopathy • Screening guidance for diabetic retinopathy has been outlined by NICE (1): • examine the eyes of people with type 2 diabetes at the time of diagnosis and at least annually thereafter (including those registered blind and partially sighted). • use tests that have been demonstrated to achieve: sensitivity of 80% or higher; specificity of 95% or higher; and technical failure rate of 5% or lower • Retinal photography, which is currently the most practical method, when conducted and evaluated by trained personnel, or slit-lamp indirect ophthalmoscopy, which is effective in trained hands.

  13. COMMUNICATING RISK TO HEALTHY PATIENTS • A 50 year old man comes to see you and as a final passing comment he asks should he get his cholesterol checked ? • What do you need to know to answer this and how do you communicate his risk ?

  14. primary prevention - high cholesterol • with respect to primary prevention of CVD in primary care: • a systematic strategy should be used to identify people aged 40-74 who are likely to be at high risk • people should be prioritised on the basis of an estimate of their CVD risk before a full formal risk assessment. Their CVD risk should be estimated using CVD risk factors already recorded in primary care electronic medical records

  15. HIGH RISK PATIENTS H • The following patients have higher risks: • Significant family history (Men <55 and women <65 years) increases risk by a factor of 1.5; as does impaired fasting glucose and South Asian origin.6 • Obesity (BMI ≥30 kg/m2 (especially central obesity men with waists ≥102 in white caucasians (≥90 cm in asians). Corresponding waist values for women are ≥88cm and ≥80 cm). Obesity increases risk by a factor of 1.3.

  16. HIGH RISK PATIENTS • Serum triglyceride of 1.7mmol/l or more increases CVD risk by 1.3 times • A low HDL cholesterol (< 1.0 mmol/l in men and <1.2 mmol/l in women) also increases risk.

  17. primary prevention - high cholesterol • people older than 40 should have their estimate of CVD risk reviewed on an ongoing basis • people should be prioritised for a full formal risk assessment if their estimated 10-year risk of CVD is 20% or more • the Framingham 1991 10-year risk equations should be used to assess CVD risk

  18. primary prevention - high cholesterol • statin therapy is recommended as part of the management strategy for the primary prevention of CVD for adults who have a 20% or greater 10-year risk of developing CVD • the suggestion is that treatment is initiated with simvastatin 40mg per day and then there is no indication to check lipid levels again. This seems to be based on the findings of the Heart Protection study

  19. COMMUNICATING RISK TO HEALTHY PATIENTS • A 41 year comes to see you about another problem but you notice she has had a BMI recorded recently of 44. In addition she has had an admission to AGH for chest pain where a cardiac cause was excluded but the discharge summery has requested the GP discuss her BMI. • How do you proceed to communicate her risks ?

  20. obesity and cardiovascular disease (CVD) risk • waist circumference is the most practical marker for abdominal obesity • overweight and abdominal obesity are associated with other cardiovascular risk factors including small and dense atherogenic LDL cholesterol, low HDL cholesterol, raised triglycerides, elevated blood pressure, insulin resistance, and impaired glucose regulation including diabetes

  21. obesity and cardiovascular disease (CVD) risk • obese women have four times the risk of CHD than non-obese women. • in men being obese (BMI >30) or overweight is strongly associated with an increase in the risk of atherosclerotic disease. • a cohort study revealed that the adverse effects of overweight on blood pressure and cholesterol levels could account for about 45% of the increased risk of CHD. • NICE state that severe obesity (body mass index greater than 40 kg/m2) affects CVD risk and should be considered when using risk scores to inform treatment decisions.

  22. COMMUNICATING RISK TO HEALTHY PATIENTS • A 36 year old consults you with another problem but mentions that he recognises he is slightly overweight and really should exercise more. He is concerned he will end up with hypertension and worse as his father was the same build and inactive and developed hypertension in his early 40,s. How do you communicate the health benefits of exercise ?

  23. exercise and cardiovascular (CV) risk • people who are physically active reduce their risk of developing coronary heart disease, stroke and type II diabetes by up to 50% • more than two-thirds of the UK population is not sufficiently active to accrue cardiovascular benefits • primary care practitioners should identify and advise inactive adults to aim for 30 minutes of moderate intensity physical activity on 5 or more days of the week

  24. exercise and cardiovascular (CV) risk • healthy adults aged 18 - 65 years are recommended to participate in moderate-intensity aerobic physical activity for a minimum of 30 minutes on five days each week or vigorous intensity aerobic activity for a minimum of 20 minutes on three days each week • Although regular vigorous physical activity confers maximum cardiovascular benefit, it is apparent that this level of activity is unattainable and unlikely to be sustainable for the majority of the population.

  25. exercise and cardiovascular (CV) risk • Regular moderate intensity physical activity: • reduces adiposity, particularly in those with excess upper body and abdominal fat • reduces both systolic and diastolic blood pressure in individuals with elevated blood pressure by approximately 3.8mmHg and 2.6mmHg respectively • reduces elevated plasma triglycerides • increases high density lipoprotein cholesterol level • improves insulin sensitivity and glucose use and reduces the risk of type II diabetes

  26. COMMUNICATING RISKS • A 50 year old lady comes to see you concerned that she should not be on HRT anymore because of the risks of HRT and breast cancer. • She has no personal of FH of breast cancer and has been taking HRT for 6 months to alleviate severe menopausal symptoms. • How do you communicate the risks to her ? What else do you need to know about her ?

  27. BREAST CANCER RISK WITH HRT • HRT used for several years increases the risk of breast cancer but the additional breast cancer risk due to HRT for an individual is relatively small and multiple other risk factors also contribute, e.g. alcohol intake, obesity and lack of exercise • Combined HRT is associated with a higher risk than oestrogen-alone. The MWS suggested a small increase in risk of breast cancer with oestrogen-only HRT compared with combined HRT.3 This increase in breast cancer with unopposed oestrogen was not found in the WHI study when oestrogen-only HRT was used for up to seven years.16

  28. BREAST CANCER RISK WITH HRT • The increased breast cancer risk is proportional to the duration of HRT but not the age at which treatment is started (but the baseline risk of breast cancer also increases with age): • Using combined HRT for five years, in women aged 50-59, there are 6 additional cases of breast cancer per 1,000 women on a baseline incidence of about 10 per 1,000 women. For oestrogen-only HRT, there are about 2 extra cases per 1,000 women

  29. BREAST CANCER RISK WITH HRT • Using combined HRT for five years in women aged 60-69, there are 9 extra cases per 1,000 women on a baseline incidence of 15 per 1,000 women. For oestrogen-only HRT, there are 3 extra cases. • If duration of use increases to 10 years, in women aged 50-59 taking combined HRT, there are 24 additional cases of breast cancer per 1,000 women on a baseline incidence of 20 per 1,000 women. For oestrogen-only HRT, there are 6 extra cases

  30. BREAST CANCER RISK WITH HRT • For women aged 60-69 with 10 years' use, combined HRT increases cases of breast cancer by 36 per 1,000 on a baseline of 30 per 1,000 women and oestrogen-only by 9 cases. • The excess breast cancer risk subsides within five years of stopping. • The invasive breast cancers diagnosed in the combined HRT group of WHI were larger and more advanced than the placebo group.2 Previously it had been thought that breast tumours found in HRT users had a better prognosis.

  31. BREAST CANCER RISK WITH HRT • HRT, especially certain regimes (e.g. conjugated equine oestrogens +/- medroxyprogesterone), can increase mammographic density and may increase the likelihood of having an abnormal mammogram that needs further investigation.

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