CURRENT SCREENING RECOMMENDATIONS

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CURRENT SCREENING RECOMMENDATIONS

• Marie Denise Gervais, M.D.
• Department of Family Medicine
• Assistant Clinical Professor
• UM/Miller School of Medicine

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"The superior physician helps before the early
budding of the disease..."

• Chinese Emperor Huang Ti 2600 BC

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Aims and Objectives

• Define prevention and its role in clinical
  practice
• Review the 5 criteria of a screening test
• Discuss current screening recommendations
• Overview of the ressources available to
  facilitate access to screening in underserved
  population

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What is Prevention?

• 1 True Prevention
• Healthy Patients
• Lifestyle, Immunization
• 2 Early Detection
• Asymptomatic Patients
• Screening
• Pap, Mammography
• 3 Minimize Complications / Disability
• Disease already present
• Stroke Rehab, DM/ACE-I Post-MI Statin

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Why Practice Prevention?

• Increase quality and years of healthy life
• Eliminate health disparities
• Utilize the team approach to patient care
• Improve clinician, staff and patient satisfaction
• In keeping with Healthy People 2010

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Definition of a Screening Test

• A test or standardized procedure used to detect a
  disease or condition in an asymptomatic person
• Accurate
• Effective

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5 Criteria for Screening Tests

• 1. Does it involve a disease that affects length
  or quality of life?
• 2. Is there an available treatment that is
  effective acceptable to the patient?
• 3. Does early detection treatment improve
  morbidity/mortality?
• 4. Is the screening procedure effective,
  acceptable to patients and reasonably
  inexpensive?
• 5. Is the disease common enough to justify
  screening large populations?

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Challenge of Implementation

• Linking clinical practice to the quality of the
  evidence
• Selecting screening guidelines
• Keeping up to date
• The 15 minute office visit

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United States Preventive Service Task Force

• USPSTF guidelines
• Evidence-Based
• Formal Methodology
• Reliable Conclusions
• Best Evidence Available
• Continually Updated
• http//www.ahcpr.gov/clinic/uspstfix.htm
• http//www.ahrq.gov/clinic/cps3dix.htm
• I-phone application AHRQ ePSS

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A Recommendation

• Strongly recommends that clinicians routinely
  provide the service
• High certainty of substantial benefits in
  important health outcomes
• Benefits substantially outweigh harms

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B Recommendation

• Recommends that clinicians routinely provide the
  service
• High certainty of moderate benefits in important
  health outcomes
• Benefits outweigh harms

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C Recommendation

• Recommends against routinely providing the
  service
• At least fair evidence of improved health
  outcomes for individual patients
• Moderate certainty that the net benefits are
  small

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D Recommendation

• Recommends against providing the service to
  asymptomatic patients
• At least fair evidence that the service is
  ineffective or that harms outweigh benefits

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I Insufficient Evidence

• Evidence of effectiveness is lacking, of poor
  quality, or conflicting
• balance of benefits and harms cannot be
  determined
• Discuss it with the patient

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In SummaryUSPSTF Recommendations

• A- outreach
• B- inreach/ case finding
• C- shared decision making
• D- should not promote
• I do not promote

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CURRENT SCREENING RECOMMENDATIONS

• 2010

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BREAST CANCER

• Screening Test
• Mammogram C S CBE
• B Female gt40 yrs every 1-2 yearC
• Nov 2009gt50
• I for CBE
• I for teaching CBE D

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BREAST CANCER CHEMOPREVENTION

• Chemoprevention
• Tamoxifen, Raloxifene
• B in high risk for BRCA and low risk for adverse
  effects
• D in women at low risk

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BRCA TESTING FOR BREAST AND OVARIAN CANCER

• D routine testing for low risk females
• B in women with positive family history BRCA 1
  and BRCA2 mutations

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CERVICAL CANCER

• Screening Test Pap
• A All sexually active females with a cervix
• ACOG 2009
• start at age 21q2y until30 then q 3y after 3
  neg.
• D recommendation gt65 h/o nl Pap or
• TAH for benign tumor
• I for HPV testing

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COLORECTAL CANCER

• Screening Test
• - Fecal Occult Blood Test yearly
• - Flex Sig Q 5 yrs
• - B.E Q 5 years
• - Colonoscopy Q 10 years
• A for all gt50-75 C 75-85 Dgt85
• C preferred test
• I for fecal DNA and virtual colonoscopy
  

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PROSTATE CANCER

• Screening Test
• Prostatic Serum Antigen (PSA)
• I recommendation menlt75y/o
• D gt75y/o

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LUNG CANCER

• Screening Test CXR, CT, Sputum cytology
• I recommendation

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Screening for Abdominal Aortic Aneurysm

• B recommendation
• One time screening for AAA by ultrasound in men
  aged 65 to 75 who have ever smoked.

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HYPERTENSION

• A recommendation
• Patients gt 18y/o
• I recommendation
• in children

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CHOLESTEROL

• Screening Test Total Cholesterol HDL
• B recommendation
• A recommendation M gt35 F gt45
• B (with risk factors) M 20-35 F 20-45
• C ( without risk factors)

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Screening for Coronary Heart Disease

• Screening Test EKG, ETT, CT
• D in adults at low risk for CHD
• I in adults at increased risk for CHD

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TYPE 2 DM

• Screening Test
• Fasting plasma glucose,
• 2 hour post load plasma glucose,
• Hemoglobin A1C.
• B in adults with hypertension (gt135/80) and
  hyperlipidemia
• I in asymptomatic adults

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Primary Prevention for Coronary Artery Disease

• Chemoprevention Aspirin
• A in adults at increased risk for CHD
• Men gt45-79 for MI. YoungerD
• Women gt55-79 for ischemic stroke. YoungerD

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OBESITY

• Screening Test Body Mass Index (BMI)
• B in adults also Adolescent and Children 2010
• Intensive counseling to promote sustained weight
  loss in obese patients
• I in overweight patients

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Thyroid Disease

• Screening Test TSH
• I recommendation

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OSTEOPOROSIS

• Screening Test Bone Mineral Density
• B gt 65yrs
• or at 60 yrs in those at increased risk of
  osteoporotic fractures

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HEPATITIS

• Screening Test Hep B antigen, Hep C ab
• Hepatitis B
• A in pregnancy at prenatal visit
• D in asymptomatic adults
• Hepatitis C
• D in average risk
• I in high risk

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CHLAMYDIAL INFECTION

• A recommendation
• Screen all sexually active women age 25 years
  or younger and other asymptomatic women at risk
  for infection

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GONORRHEA

• B recommendation
• All sexually active women, including the
  pregnant women if they are at risk for infection.

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HIV

• A recommendation
• All adolescents and adults at increased risk
  for HIV infection

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So How Are We Doing?

• National Health Statistics

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• Life Expectancy up 78.2 yrs
• Infant Mortality down 6.3
• Childhood Immunizations - 76
• Adult Influenza immunization - 65
• Pneumococcal immunization - 53
• Screening MMG - 70

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• Up childhood Obesity
• Up 1st Trimester prenatal care
• Up incidence Chlamydia
• Down incidence GC Syphilis
• Decreased population who Smoke
• Decreased Cancers in men but not women
• No change in Suicide rate
• No change in Drug Use

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Chronic Illness Care

• HTN 27 adequately treated
• DM 54 have HbA1c gt 7.0
• CAD 14 have recommended LDL level
• TOBACCO 50 counseled on cessation

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So How Are We Doing?

• Access to screening and follow up remain a
  challenge for minority groups
• Burden of disease is not shared equally
• Incidence and mortality rates differ by cancer
  among racial groups

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So How Are We Doing?

• African American males have higher incidence
  rates than all other racial and ethnic groups for
  cancers of the colon and rectum, lung and
  prostate (ACS 2004)
• Breast, lung and colon cancer are the most
  commonly diagnosed cancers in African American
  women (ACS 2004)

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Breast cancer screening

• In 2003, prevalence of mammography screening was
  40.2 in women with no health insurance and 52.3
  in immigrant women who had lived in the US for
  less than 10 years.
• Black women are dying more frequently from this
  disease (34 versus 27)
• Women of Hispanic origin has the lowest
  mammography use reported at every age category

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Cervical cancer screening

• Lowest prevalence of screening among women with
  no health insurance (61.0).
• Invasive cervical cancer is diagnosed in more
  advanced stages in Haitian and English-Speaking
  Caribbean immigrants than in US born black women

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Colorectal cancer screening

• Is underutilized
• 42.2 of adults 50 and older had either a home
  test FOBT within the past year or an endoscopic
  procedure within the past 5 years
• Utilization is lowest among minority groups, no
  health insurance

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FOR AN EFFECTIVE PREVENTIVE SYSTEM

• Establish preventive protocols
• Define roles of staff
• Audit delivery of preventive services
• Readjust SYSTEM

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RESOURCE MATERIALS

• FLOW SHEETS
• Reminders on charts
• Reminder postcards
• Patient education materials
• EMHR

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Affordable Care Act

• Always consider all A and B ratings
• All are relevant for implementing the affordable
  care act

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A Ratings in adults
Cervical Cancer Screening All women sexually active with a cervix New ACOG recommendations 2009 2 0 0 3
Syphillis Screening All adults at inc risk of Syphilis 2 0 0 7
HIV Screening All gt13 at incr risk 2 0 0 7
Blood Pressure All adultsgt18y/o 2 0 0 7
Colorectal Cancer Screening All adults gt50-75 2 0 0 8
Cholesterol Screening -All mengt35 -Women gt45 at risk for CHD 2 0 0 8
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A Ratings in adults
Chlamydia infection screening - All women lt24 sexually active - Older women at higher risk 2 0 0 7
Folic Acid Supplementation All women capable of pregnancy (0.4 to 0.8 mg daily) 2 0 0 9
Tobacco use counseling All adults and smoking cessation interventions for smokers 2 0 0 9
ASA CVD -Men 45 to 79 to prevent MI -Women 55 to 79 to prevent ischemic stokes 2 0 0 9
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B Ratings in adults
Screening MMG All womengt40 y/o Q1-2 years new in 2009 gt50 y/o 2 0 0 2
Breast Ca ChemoPrevention Women at high risk 2 0 0 2
BRCA Screening and counselling Women with family history at high risk 2 0 0 5
Osteoporosis Screening Women gt65y/o Women gt60y/o with incr risk 2 0 0 2
Obesity Screening All adults counseling intervention 2010 all childrengt6 y/o 2 0 0 3
Alcohol misuse and counseling All adults 2 0 0 5
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B Ratings in adults
AA screening by US Men 65-75 who ever smoked 2 0 0 5
Gonnorhea Screening All women at incr risk esp young 2 0 0 5
Diabetes Screening All adults with BP gt130/85 2 0 0 8
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Issues to Consider in Practicing Prevention

• Ethno-cultural population shift
• Increase in elderly population
• Awareness of health disparities
• Efficient utilization of preventive services
• Mortality trends nationally and locally
• Medical Advances
• Expanding Information technology

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Barriers to Access Implementation

• Financial barriers (health insurance)
• Structural barriers (lack of PCP)
• Personal barriers ( cultural or spiritual,
  language,sense of urgency, concerns about
  confidentiality or discrimination).
• PCP and office lack of time, team work, lack of
  motivation, no system in place.

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Time to Put Our House in Order

• Nations with primary care-oriented systems
• have better health outcomes and lower health
  care costs
• Thank You