Case 1: Female Annual Exam Flashcards
Patient has increased risk of breast cancer if
first degree relative has had breast cancer
Does the USPSTF recommend breast self exams?
No
Does the USPSTF recommend clinical breast exams?
No
Does the ACS recommend clinical breast exams?
Yes - every 3 years for women 20-39 and every year for women > 40
Risk factors for HPV transmission (requires sexual contact) and results in squamous cell carcinoma (except DES)
- Early age of intercourse
- multiple sexual partners
- DES exposure in utero
- cigarette smoking
- immunosuppression
DES exposure in utero
Given to women until 1971 to prevent miscarriage - caused clear cell adenocarcinoma of vagina
Guidelines for cervical cancer screening
- 21 to 29: pap q 3 years
- 30 to 65 pap+co HPV test q 5 years or pap q 3 years
- > 65 stop screening if past 10 years have been normal (2 consecutive negative cotests or 3 consecutive negative pap smears)
Women who have undergone total hysterectomy for benign reasons do not require cervical cancer screening
Groups that need more frequent cervical cancer screening (4)
- immunocompromised
- HIV +
- history of CIN 2, 3, cancer
- DES exposure
Characteristics of good screening test (6)
- accurate (high sensitivity and specificity)
- detects disease in asymptomatic phase
- minimal associated risk
- reasonable cost
- acceptable to patient
- available treatment of disease
Lung cancer screening recommendation
Annual low dose CT scan for 30 pack year history ages 55-80
Must be current smoker or have quit within prior 15 yrs
Sensitivity
Higher sensitivity = fewer false negatives
Specificity
Higher specificity = fewer false positives
Recommendation for ovarian cancer in asymptomatic women
Do not do it!
There is ______ evidence regarding whether or not to recommend skin cancer screening
Insufficient
*Skin cancer is most common type of cancer but no screening test is in place
ACS breast cancer screening recommendations
40-44: patient’s choice to start annual mammograms
45-54: annual mammograms
>55: switch to 2 years or continue annual
USPSTF breast cancer screening recommendations
50-74: biennial mammograms
<50: practice shared decision making with patient
If there are differences in recommendations, it is important to get
patient’s input
Breast lump workup
- History
- Breast exam (suspicious if hard, immobile, > 2 cm, irregular borders)
3a. if cystic: FNA
3b. if solid: mammography
Use ultrasound to differentiate between cystic and solid if unsure
Medications that cause nipple discharge (4)
- antidepressants
- antipsychotics
- some antiHTN
- some opiates
If nipple discharge is present, must have further imaging studies (4)
Mammogram or
Ultrasound or
Ductogram or
Biopsy
Non modifiable breast cancer risk factors (6)
- increased exposure to breast cancer (menarche before 12, menopause before 65)
- first degree relative with breast cancer
- BRCA1/2
- Advanced age
- Female sex
- Dense breasts
Modifiable breast cancer risk factors (5)
- Age at first pregnancy
- DES exposure
- Hormone therapy
- Radiation
- Obesity
Protective factors for breast cancer (5)
- pregnancy at early age
- high parity
- late menses
- early menopause
- SERMs or NSAIDs
Nutritional recommendation to prevent breast cancer
Do not drink alcohol (smoking doesn’t matter)
Tdap vaccination for 19-64
Tdap should replace Td if these pts have not received Tdap previously (<18)
Obesity = excess estrogen
BMI > 30
- at risk for breast cancer
- protective against menopausal Sx + osteoporosis
Menopause
one year without menses
- avg age: 51
between ages 40-60 (earlier in smokers)
Increased risk of cardiovascular disease and osteoporosis (bc of estrogen deficient state)
Perimenopause
2-8 years - irregular menses, can still get pregnant
Perimenopausal Sx (4)
- irregular menses
- hot flashes
- vaginal dryness (water lubricant)
- mood swings
Bone health recommendations
1000 mg of calcium for pre menopausal
1200 mg of calcium for post menopausal
Dietary = 3 to 4 servings of dairy
However, increased Ca puts pt at risk for CV disease and kidney stones - currently USPSTF recommends against Ca and Vit D supplementation in healthy pre or post menopausal women
Recommendation to avoid osteoporosis
- increase dairy intake
- include weight bearing exercises such as walking into daily routine
Osteoporosis screening
> 65: DEXA scan
<65: DEXA scan if risk of fracture is = to 65 year old without risk factors (9.3% in 10 years)
RFs for osteoporosis (8)
- Low estrogen state
- Decreased calcium in diet
- Lack of physical activity
- Dementia
- Family Hx of osteoporotic fracture
- Personal hx of previous fracture as an adult
- Smoking
- Weight
Elevated BMI at risk for (6)
- hypertension
- coronary artery disease
- stroke
- osteoarthritis
- type 2 diabetes
- some cancer
Dietary guidelines on exercise
75 minutes of vigorous intensity or 150 minutes of moderate intensity/week
+ muscle strengthening 2x/week
Double for more extensive benefits
Smoking cessation strategies (9)
- Setting a quit date
- nicotine replacement
- support group
- 1-800-QUIT-NOW
- Choosing an activity to substitute for smoking (e.g., taking a walk or chewing sugarless gum when the urge to smoke occurs)
- Making a list of the reasons why it is important to quit smoking and keeping it handy to refer to
- Keeping track of where, when, and why you smoke (identify triggers)
- Throwing away all tobacco and smoking paraphernalia
- Medication
One in __ women will have breast cancer before they are __ years old
8, 80
Mammography can identify breast cancer ___ to ___ years before detectable on exam
1 to 2 years
Adequate cervical specimen
Contains 5000 squamous cells
Has sufficient endocervical cells (columnar epithelial cells just proximal to squamo columnar junction at site of beginning dysplastic changes)
Bethesda cytology categories for cervical cancer
ASC: atypical squamous cells
LSIL: low grade squamous intra epithelial lesion
HSIL: high grade squamous intra epithelial lesion
Squamous cell carcinoma
3 vaccines for HPV - give all before sexual debut or shortly thereafter. All are 3 doses
- Gardasil: quadravalent recombinant DNA (HPV4)
- Cervarix: bivalent vaccine (HPV2)
- Gardasil 9
Gardasil
6, 11 (genital warts)
16, 18 (most cervical cancer)
females & males 9-26
Cervarix
16, 18 (most cervical cancers)
31, 45
females 9-25
Gardasil 9
6, 11 (genital warts)
16, 18 (most cervical cancer)
31, 33, 45, 52, 58 (15% of cervical cancer)
females & males 9-26
Only screen for ovarian cancer in symptomatic patient:
Bimanual exam
Place non gloved hand on abdomen superior to symphysis pubis and feel for uterus between two hands, then move pelvic hand to each lateral fornix and try to capture each between the hands
Ovaries are usually palpable in slender women and not palpable in obese women
Mammography benefits
Good screening test that can detect asymptomatic early stage disease
Sensitivity of mammography
60-90%
Low sensitivity = mroe false negative results
False negative mammography results are more common in
younger women because they have denser breast tissue
Radiation exposure in mammography
is negligible
Breast MRI
Not recommended for screening in general population of asymptomatic, average risk women
Breast MRI indications
- surveillance of women more than 20% lifetime risk of breast cancer (genetic predisposition, mantle radiation for Hodgkin’s disease)
- diagnostic tool to identify more completely extent of disease in pt w recent breast cancer diagnosis
- contrast enhanced breast MRI in evaluation of women with breast augmentation in whom mammography is difficult
Breast ultrasound
Not recommended for screening purposes
- used for evaluation of suspected abnormalities
ASC + but HPV negative
Recommend cotest every 3 years
