EXAM 1- SCREENING Flashcards
Most effective form of health care
primary prevention
primary prevention
health screening for risk factors
types of primary prevention
- immunizations
- health risk assessment
- education
secondary prevention
ID and treat pts that are asymptomatic who have risk factors for disease
types of secondary prevention
- CA- mammogram, PAP, PSA, Cscope
2. HTN- BP checks
tertiary prevention
part of management of a given established disease aimed at decreasing complications
tertiary prevention types
- lifestyle modifications
- education about disease
- meds
what to consider for if screening is worthwhile
- prevelance rates
- disease associated with disability and death
- high risk populations
- individual risk factors
- economics
sensitivity- true positive
% of pts that test positive who have the disease
specificity- true negative
% of pts that test negative who do not have the disease
USPSTF
US Preventive Services Task Force
breast CA
most freq dx CA in women
overall lifetime risk of breast CA for all women
12%
breast ca risk
family hx of breast ca
other high risk factors for breast ca
- BRCA1/BRCA2 mutation
2. Ashkenazi Jew
CBE
USPSTF recommended that there is not enough evidence to suggest adding CBE to mammogram for early detection of breast CA
clinician has to use their judgement
mammogram digital vs film
Sensitivity/digital: 70%
Sensitivity/ Film: 66%
Specificity Both: 92%
mammogram
x ray examination of breast
mammogram CI
pregnanct women
woman younger than 25 (bc radiation)
USPSTF - breast CA
Recommends against routine screening 40-49 years: Grade C
Screen women age 50-74 every 2 years: Grade B
Recommends against teaching SBE
Insufficient evidence grade D with grade I statement
American CA Society- breast CA
Annual mammography age 40 years
Clinical breast exam every 3 years age 20-39
Annually after age 40years
American college of obstetrics
Mammography every 1-2 years beginning age 40
Clinical breast exam annually beginning age 20 years
cervical ca burden of disease
12,200 new cases and 4210 deaths annually (2010)
Incidence varies by ethnicity/race
Worldwide: second most common cancer in women
Most common cause of mortality from GYN cancer
cervical CA risk factors
early onset intercourse < 17 y/o, # of sex partners, smoking, DES exposure in-utero, HPV
Papanicolaou Smear aka Pap test Uses
Screening for cancer of the cervix
Detects neoplastic cells in cervical secretions
pap test
Can be done by GYN or PCP, done by swabbing cervix and using under screen to check for active bacteria or infections and sent and read to see if there are neoplastic cells that indicate risk or CA
USPSTF Recommendations of cervical CA
Age 21-65 years
PAP every 3 years
Age 30-65 years
Combination of cytology and HPV testing Grade A recommendation
Over age 65: no screening Grade D
Total Hysterectomy
No screening grade D when no h/o prior abnormality
USPSTF cervical CA age 21-29
pap with cervical cytology q 3 yr
no HPV testing
USPSTF cervical CA age 30-65
Screen with cervical cytology every 3 yearsorin women who want to lengthen screening interval, screen with cervical cytology and HPV testing every 5 years.
USPSTF cervical CA > 65 y/o
Recommend against screening if adequate prior screening and not at high risk for cervical cancer.
USPSTF recommendations against screening for cervical ca with HPV screening alone or in combination with cytology
women < 30 y/o
Recommendations by The American Cancer Society (ACS), The American Society for Colposcopy and Cervical Pathology (ASCCP), and The American Society for Clinical Pathology (ASCP) for cervical CA
Begin Pap smears at age 21, regardless of when sexual activity began.
Age 21-29: Screen with cervical cytology alone every 3 years.
Age 30-65: Screen with cervical cytology and HPV testing (co-testing) every 5 years (preferred)orscreen with cervical cytology alone every 3 years (acceptable).
Women >65 years of age with a history of CIN 2, 3, or adenocarcinoma in situ: Continue routine screening for at least 20 years after treatment or regression. In some women, this may mean screening past age 65.
HPV testing alone should not be used as cervical cancer screening.
ACS- cervical CA begin
age 21, regardless of sexual activity beginning
ACS- cervical CA age 21-29
screen with cervical cytology alone q 3 yr
acs- cervical CA age 30-65
Screen with cervical cytology and HPV testing (co-testing) every 5 years (preferred)orscreen with cervical cytology alone every 3 years (acceptable).
ACS - cervical ca, > 65 yr with hx of CIN 2,3, or adenocarcinoma in situ
Continue routine screening for at least 20 years after treatment or regression. In some women, this may mean screening past age 65.
HPV testing alone
should not be done as cervical CA screening
Adequate negative prior screening for cervical CA definition
three consecutive negative cytology results or two consecutive negative co-tests within the last 10 years before stopping with the most recent test within the last 5 years.
discontinuation of PAP- USPTF
Discontinue after age 65 with adequate prior screening*and not at high risk of cervical cancer (ie, history of high-grade precancerous lesion or cervical cancer, in utero DES exposure, or immunocompromised).
ACS/ASCCP/ASCP discontinuation of PAP
Discontinue after age 65 with adequate negative prior screening*and no history of CIN 2 or higher within the last 20 years.
Women with HIV screening for cervical CA
continue for HIV
D/C PAP post total hysterectomy (uterus and cervix) ACS/ASCCP/ASCP
Discontinue after hysterectomy in women with no prior history of CIN 2 or higher in the past 20 years, or cervical cancer ever.
evidence of adequate negative screening not required.
D/C PAP after total hysterectomy
Recommends against screening in women who do not have a history of a high-grade precancerous lesion (CIN 2-3) or cervical cancer
clinical information needed for pap
- age
- date of last menstrual period
- pregnancy status
- postpartum or postmenopausal
- hx of abnormal pap smears
- surgery
- hx of carcinoma
- any forms of treatment
pap smear liquid based cervical cytology (LBCC) vs conventional pap
LBCC more satisfacotry
CI for PAP
- menstruating
- vaginal infection
specimen should not be allowed to dry on slide
other altering factors- lubricating jelly on speculum, douching, tub bathing, drugs like digoxin and tetracycline
pap - CA result
Patients with suspicious pap must have colposcopy cone biopsy, and/or dilation and curettage
diagnosis made only with biopsy of tumor
pap- STI result
Fungal, parasite, and herpes infections can cause cellular changes on pap- must culture for these specifically
PSA
Prostate specific antigen
Screening for early detection of prostatic cancer
Burden of disease- prostate CA
2nd leading cause of CA death in men lifetime risk 15.9% risk of death 2.8% 70% men > 70 yrs have occult prostate CA that does not effect health status, more likely to die from something else 22-23% mortality <70 yrs
prostate CA risks
AA (increased incidence)
family hx- relative risk of 2 with 1st degree relative, 5 when 2 affected
DRE
Sensitivity 59%
Specificity is unknown but suggested to be as high as 94%
Poor reproducibility
May add to CA detection when combined with PSA
PSA >/= 4.0
68-80% sensitivity
60-70% specificity
USPSTF 2012 conclusion for PSA screening
Recommend against PSA screening for prostate cancer
Grade D recommendation = little clinical benefit
colon CA screening
Third most common cancer in the US
Second leading cause of cancer death in US
5% life time risk for developing colon cancer
20%of colon cancer diagnoses are in individuals with specific risk factors
Colon CA risks
personal or family h/o colorectal cancer/adenomatous polyps in 1st degree relative
UC
Familial polyposis or hereditary nonpolyposis colorectal cancer
guaiac based FOBT
2 samples of 3 different stools to six test card panels
Positive Hgb or blood: turns blue
False negative with Vitamin C
False positive with ASA, NSAIDS, red meat (within past week)
DRE single panel test sensitivity 9% should not be used
hemoccult II
Sensitivity 25-38% & specificity 98%
hemoccult SENSA
Sensitivity 64-80% & specificity 87-90%
tier 1 colon ca screening
Colonoscopy every 10 years
Annual FIT
tier 2 colon ca screening
CT colonography every 5 years
FIT–fecal DNA every 3 years
Flexible sigmoidoscopy every 5–10 years
tier 3 colon ca screening
capsule colonoscopy every 5 years
Septin 9 testing is not recommended.
USPSTF 2008 colon ca screening recommendations
start average risk patients at age 50 years and continue until age 75 years
FOBT, sigmoidoscopy or colonoscopy
aged 76 to 85 years and less than 10 yrs of life expectancy
Recommend against routine screening Grade C recommendation
USPSTF does not recommend colorectal cancer screening for adults older than 85 years
USPSTF stool based screening tests and intervals
Guaiac-based fecal occult blood test (FOBT), every year
Fecal immunochemical test (FIT), every year
FIT-DNA, every 1 or 3 years
USPSTF direct visualization screening tests and intervals
Colonoscopy, every 10 years Computed tomographic (CT) colonography, every 5 years Flexible sigmoidoscopy, every 5 years Flexible sigmoidoscopy with FIT; sigmoidoscopy every 10 years, with FIT every year
average risk for colon CA recommendations
testing with a tier 1 test should begin at age 45 years for African Americans and at age 50 for patients of all other races
family history of colorectal cancer or advanced adenoma diagnosed
colonoscopy at age10 years younger than the youngest age at diagnosis of a first-degree relative, or age 40, to be repeated every 5 years.
one first-degree relative with colorectal cancer, advanced adenoma, or an advanced serrated lesion diagnosed at age 60 or older,
tier 1 test age 40, continue same intervals as average-risk patients.
colonoscopy
a fiber optic tube to directly inspect the entire colon
approximately 5 feet long
has two fiber optic bundles: one provides a light source inside the colon and the other transmits the image from the colon to a high definition monitor and recording device
third channel can be connected to a suction apparatus to remove debris blocking the view
fourth channel can be used to insert a biopsy device
colonoscopy
must cleanse their bowel prior to a colonoscopy
usually given conscious sedation for the procedure
done by a gastroenterologist
can biopsy suspicious lesions and remove polyps at the time of the procedure without the need for another preparation and a separate sedation and procedure
flexible sigmoid
about two feet long: examines first 60 CM of colon
If h/o polyps need full colonoscopy
If polyps are seen cscope is needed
Detects 66% of men if a polyp is found and triggers full colonoscopy
55% of lesions in women as cancers are more proximal
can be done with the patient awake and on an examining table in the primary care provider’s office
Discomfort often limits the examination to the first foot of the colon (sigmoid colon)
lung ca burden of disease
Leading cause of death men and women (combined)
2012 > 160,000 deaths
This is more than breast, prostate and colon cancer combined
high risk population for lung CA
85% lung cancers caused by smoking
65 y/o 1ppd 50yr smoker: 10% risk of developing lung cancer over next 10 years
75 y/o 2ppd/50 yr smoker: 15% risk
USPSTF recommendations for screening for lung CA
annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years (2013 update) for at risk pts
CT scan for lung ca
sensitivity 94% specificity 73%
indications for lung CA screening
have a 30 pack-year smoking history and currently smoke
or have quit within the past 15 years
Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery
ACS recommendations for lung CA screening
clinicians with access to high-volume, high-quality lung cancer screening and treatment centers should initiate a discussion about lung cancer screening with patients aged 55 to 74 years who have at least a 30-pack-year smoking history, currently smoke or have quit within the past 15 years, and who are in relatively good health
30 pack yr hx
1 pack/day for 30 years = 30 pack yr hx
2 packs/day for 15 years = 30 pack yr hx
ACS
CAD burden of disease
CAD/CHD leading cause of death in the US
1/3 CHD events are related to a TC> 200mg/dL
Age 40years: 49% lifetime risk Men & 32% women
quality of screening tests for cholesterol
TC and HDL not affected by eating TG: affected by eating May be 20-30% higher must be fasting TC can vary by 6% a day HDL can vary by 7.5% a day Recommend two measurements prior to initiating therapy
USPSTF screening for cholesterol
Grade A
Screen all men age 35
Screen all women age 45
uspstf grade b recommendations for cholestserol
Screen men age 20-35 and women age 20-45
WITH Family history of CAD prior to age 50 Diabetes HTN Smoking
