Preventive Medicine

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Preventive Medicine

• John B. Waits, MD

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Maimonides, A.D. 11351204

•  "Live sensiblyamong a thousand people, only one
  dies a natural death, the rest succumb to
  irrational modes of living.

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Reality

• "Why do I have to get a Pap smear again this
  year, Doctor?"
• "My neighbor gets a chest x-ray every year. Why
  aren't you ordering one for me?"
• "I saw an ad for a total body MRI in the
  newspaper. Do you think I should get one?"

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Types of Clinical Prevention

• Immunization
• Screening
• Behavioral counseling (lifestyle changes)
• Chemoprevention

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Levels of Prevention

• Primary prevention
• Immunizations, Folic acid, Healthy Lifestyles
• Secondary prevention
• PAP, Mammo, FOBT
• Tertiary prevention
• Beta-blockers after MI, ACE inhibitors in DM

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Criteria for a Good Screening Test

• High sensitivity and specificity
• High positive predictive value
• Simplicity and low cost
• Safety
• Acceptable to patients and clinicians
• Labeling
• Frequency of condition
• Effectiveness of intervention

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Possible adverse effects from screening

• Risk of false-positive result
• Risk of pseudodisease (overdiagnosis)

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Prioritizing Preventive Services

• Start with the condition
• not the test
• not the intervention
• with the largest burden of suffering
• Demonstrated effectiveness
• Test
• Intervention

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Priority Conditions

Cervical Cancer

Depression

Injuries (Motor vehicle collisions, Domestic
violence)

Lifestyle (Obesity, Physical Inactivity)

Sexually-transmitted infections (GC/Chlam/HIV)

Substance abuse (Tobacco, Alcohol)

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Priority Conditions 50yo

• Cardiovascular (MI, CVA, AAA)
• Cancer (Lung, CRC, BrCA, Prostate, Cervical)
• Depression
• Immunization (Flu 50, Pneumo 65)
• Injuries (Falls, Bone Fcx, MVA, Domestic
  violence)
• 65yo Falls and Bone Fractures
• Lifestyle (Obesity, Physical Inactivity)
• Substance abuse (Tobacco, Alcohol)
• Vision Hearing (65yo)

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Cardiovascular Disease

• Global CVD Risk
• High ( 20 10-yr risk)
• Moderate (10-19 10-yr risk)
• BP, dyslipidemia, low-dose ASA
• Low (

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Framingham CAD Risk Calculator

• http//www.intmed.mcw.edu/clincalc/heartrisk.html

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Blood Pressure Screening

• Every 2 years

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Cholesterol Screening
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Screening for Diabetes
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Aspirin Case

• ST is a 55-year-old man who you see regularly for
  hypertension and depression. He is overweight and
  sedentary, and his elder sister recently had a
  heart attack. He asks you whether he should take
  a daily aspirin, "just in case."

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Aspirin Case, cont.

• Which one of the following statements best
  reflects the new U.S. Preventive Services Task
  Force (USPSTF) recommendations regarding aspirin
  for the primary prevention of cardiovascular
  events?
• A daily aspirin is recommended only for men over
  age 40.
• Aspirin is recommended for both men and women
  ages 50 to 75.
• Physicians should discuss benefits and harms of
  aspirin chemoprevention with adults who are at
  increased risk of heart disease.
• Aspirin is recommended for all men and women with
  at least one cardiovascular risk factor.

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Cancer

• Lung
• Colorectal
• Breast
• Prostate
• Cervical

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Lung Cancer

• U.S. Preventive Services Task Force (USPSTF)
  concluded in 2004 that "the evidence is
  insufficient to recommend for or against
  screening asymptomatic persons for lung cancer
  with either low dose computed tomography, plain
  chest radiographs, sputum cytology, or a
  combination of these tests"

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Stay Tuned 2008.

• National Lung Screening Trial The National Lung
  Screening Trial (NLST) is a lung cancer screening
  study launched in late 2002. The trial seeks to
  randomly assign 50,000 current or former smokers
  at 30 sites throughout the United States to
  either lung cancer screening with CT or screening
  with chest radiographs, and is powered to detect
  a 20 percent reduction in lung cancer mortality
  due to differences in screening methods.
  Enrollment of new patients has closed and
  participants have just completed their third
  screening exam. The final analysis of survival
  and mortality is planned for 2008. Information
  for physicians and patients regarding this trial
  is available online at www.cancer.gov/nlst.

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Intuitive Protocol CT PET

• Am J Respir Crit Care Med. 2005 Jun
  15171(12)1378-83. Epub 2005 Mar 24.
• annual spiral CT if high-risk
• noncalcified nodules 5 mm or greater repeat CT
• FDG-PET for 7 mm growing nodules
• FDG-PET for nodules 10 mm or larger
• Results
• All NSCLC Dx in stage I
• FDG-PET correctly diagnosed 19 of 25
  indeterminate nodules.
• FDG-PET (Sensitivity 69 / Specificity 91 / PPV
  90 / NPV 71)
• When a negative FDG-PET was followed three months
  later with a repeat CT, the negative predictive
  value was 100 percent.
• Lancet 2003 Aug 23362(9384)593-7.
• Combined use of low-dose spiral CT and selective
  PET effectively detects early lung cancer.
  Lesions up to 5 mm can be checked again at 12
  months without major risks of progression.

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Colorectal Cancer ask at age 30

• Have you ever had colorectal cancer or an
  adenomatous polyp?
• Have you had inflammatory bowel disease
  (ulcerative colitis or Crohn's disease)?
• Has a family member had colorectal cancer or an
  adenomatous polyp? If so, how many, was it a
  first-degree relative (parent, sibling, or
  child), and at what age was the cancer or polyp
  first diagnosed?

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Colorectal Cancer Average risk 50yrs

• FOBT (annual)
• sigmoidoscopy (every 5 yrs)
• FOBT sigmoidoscopy (annual / q5yrs)
• double contrast barium enema (q5yrs)
• colonoscopy (q5-10yrs)
• ? virtual colonoscopy
• NOT DRE or hemoccult during DRE

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Colorectal Cancer High risk

• A personal history of CRC or adenomatous polyp
• A genetic syndrome predisposing to CRC (ie,
  HNPCC, FAP)
• One or more first degree relative with CRC or
  adenomatous polyp
• Two or more second degree relatives with CRC
• IBD causing pancolitis or longstanding (8 to 10
  years) active disease

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Breast Cancer Case

• GK is a 46-year-old woman who presents to your
  office for a well-woman examination. She informs
  you that her 51-year-old friend was diagnosed
  with breast cancer one month ago and that she is
  worried about getting breast cancer. On further
  inquiry, you learn that she delivered her only
  child when she was 32 years of age and has no
  family history for breast cancer. She does not
  perform breast self-examinations and has never
  had a mammogram. GK asks for your advice on
  breast cancer screening.

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Breast Cancer Question 1

• According to recommendations from the U.S.
  Preventive Services Task Force (USPSTF), which
  one of the following options is best for this
  patient?
• Discuss the harms and benefits of screening, and
  offer screening because she is older than age 40.
• Do not offer screening because she is younger
  than age 50.
• Offer screening to obtain a baseline examination,
  and begin routine screening at age 50.
• Discuss the harms and benefits of screening, and
  offer screening because she is older than age 40
  continue screening every one to two years until
  age 70.
• Screening is not indicated because she is at low
  risk for developing breast cancer.

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Breast Cancer Question 2

• According to recommendations from the USPSTF,
  which one of the following strategies is best to
  screen for breast cancer?
• Monthly breast self-examinations combined with an
  annual clinical breast examination.
• Monthly breast self-examinations and mammography
  every one to two years.
• Clinical breast examination every one to two
  years.
• Mammography with or without clinical breast
  examination every one to two years.
• Routine breast self-examinations and mammography
  with or without clinical breast examinations
  every one to two years.

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Breast Cancer Question 3

• Which of the following statements regarding the
  benefits and harms of screening for breast cancer
  is/are correct?
• The majority (80 to 90 percent) of patients with
  abnormal screening mammograms are diagnosed with
  breast cancer.
• In general, the benefits of screening for breast
  cancer increase as a woman becomes older.
• In general, the harms of screening for breast
  cancer increase as a woman becomes older.
• The balance of benefits and harms and the
  decision about when to initiate screening vary
  from patient to patient.

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Breast Cancer Summary

• Mammography q1-2yrs age 40
• significantly reduces mortality
• more benefit with increased age
• best age 50-69
• age 70 unless life expectancy lower from
  co-morbidities
• insufficient evidence to recommend for or against
  the teaching or performing of routine breast
  self-examination

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Prostate Cancer

• Many more men are diagnosed with prostate cancer
  than die of it however
• 15 lifetime risk of diagnosis / 3 lifetime risk
  of mortality
• 2nd leading cause of cancer-related death among
  U.S. men (30,200 men in year 2002)
• The risk of developing prostate cancer increases
  beginning at age 40
• African-American men (start age 40-45)
• 60 higher incidence / twofold higher mortality
  rate c/w whites
• Non-white Hispanics 35 lower mortality rate
  than white
• Asian-Americans and Pacific Islanders 40 lower
  rate
• 50yo annually (?), stopping at age 65 (?)
• Do NOT order PSA without counseling

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PSA

• Elevated by Bx, retention, prostatitis
• NOT by DRE
• 4.0 ng/mL (sensitivity 70-80 / specificity
  60-70 / PPV 30 /
• 10.0 ng/mL (PPV 42 to 64), but
• nearly 75 percent of cancers detected within the
  "gray zone" of PSA values between 4.0 to 10.0
  ng/mL are organ confined and potentially curable

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PSA plus

• PSA velocity (change in PSA over time)
• PSA density (PSA per unit volume of prostate)
• free-to-total PSA (reduced with prostate CA)
• complexed PSA (marginal increase in specificity)
• age- and race-specific reference ranges

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Digital Rectal Examination

• Sensitivity 59
• Specificity 94
• Positive predictive value of an abnormal DRE for
  prostate cancer varies from 5 to 30 percent

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Cervical Cancer

• sexually active women with an intact cervix,
  starting three years from age of onset of sexual
  activity or at age 21 (whichever is earlier)
• Negative x3? Screen every 3 years.
• No cervix? No PAP, IF
• No GYN cancer
• No CIN III
• No DES exposure
• 70 years, repeat neg.PAP, and are not at
  increased risk (more than one sexual partner in
  past five years, immunosuppression) no more PAP
• Mortality from cervical cancer is greatest among
  women who have not had prior adequate screening

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Depression

• 5-15 prevalence in primary care
• 50 not diagnosed
• Screening
• "Over the past two weeks, have you felt down,
  depressed, or hopeless?"
• "Over the past two weeks, have you felt little
  interest or pleasure in doing things?"

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Influenza Vaccination

• high risk for influenza-related complications and
  severe disease
• children aged 6--59 months,
• pregnant women,
• persons aged 50 years,
• persons of any age with certain chronic medical
  conditions
• persons who live with or care for persons at high
  risk, including
• household contacts who have frequent contact with
  persons at high risk and who can transmit
  influenza to those persons at high risk
• health-care workers
• FluMist can be used on all non-pregnant,
  non-high-risk 5-49yo
• efficacy 60-90 instead of 30-70 from shot

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Pneumococcal Vaccination

• Benefits limited minimal to no harm
• Given only once, except
• Revaccinate after age 65 (5-year interval) if 1st
  dose before age 65
• Repeat dose _at_5yrs asplenia, chronic renal
  disease, or immunocompromised
• Research question does increased antibody titres
  equal in vivo improved clinical outcomes?

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Falls / Fractures

• "Get Up and Go" test
• Functional Reach
• Home assessment
• Bone-mineral density

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DXA (Bone Mineral Density)

• 65 (high-risk age 60)
• Risk-factors Caucasian, Asian, family history,
  advanced age, female, postmenopausal, small
  stature (
• Age-independent high-risk criteria (symptoms /
  history) loss of height, postmenopausal,
  premature menopause, estrogen deficiency,
  cigarette smoker, fragility fracture, X-ray
  evidence of low BMD (osteopenia), vitamin D
  deficiency, hyperthyroidism, malabsorption,
  gastrectomy, organ transplantation, long term
  glucocorticoid therapy, anticonvulsant therapy,
  gonadotropin releasing hormone agonist therapy,
  and long term heparin use
• Repeat adult non-traumatic fracture (or,
  fracture out-of-proportion to mechanism of injury)

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Injuries

• Motor Vehicle Collisions
• Domestic Abuse

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Sexually-transmitted Infections

• Chlamydia
• Common, often asymptomatic, highly treatable
• Serious complications including pelvic
  inflammatory disease, ectopic pregnancy,
  infertility, and chronic pelvic pain.
• Urine-based nucleic acid amplification tests make
  screening simple and accurate.
• Sexually active women ages 15 to 25 years
• Older women who have new or multiple sexual
  partners, or inconsistent use of barrier methods
• NO Doxy during pregnancy!
• Gonorrhea
• can be asymptomatic
• sexually active women ages 15 to 29 years who
  live in high risk areas
• HIV

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Vision and hearing problems

• Questioning inadequate
• Snellen chart (refractive errors, cataracts)
• Glaucoma
• Macular degeneration
• "whispered voice test
• small hand-held combination audiometer and
  otoscope
• 10-item self-administered questionnaire (the
  Hearing Handicap Inventory for the Elderly,
  Screening HHIE-S)

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Healthy Diet
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Exercise
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Tobacco
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Alcohol