CVIM s Cancer Screening Practices

Transcription

1 Professional Practice Minutes CVIM s Cancer Screening Practices At CVIM, preventative health care is very important! In these minutes you will find a review of our recommendations for cancer screening based on evidencebased medicine. At every visit: Take a moment at the end to address if any of the following are needed: Cancer screening Vaccinations Hep C or HIV screening Put Preventative Healthcare as an Impression and document that they were addressed. Our QA results are presented below, compared to national data. CDC Hispanics CVIM Colon* 59% 46% 57% Cervical** Breast** * >50 had a FIT or Colonoscopy ** Last two years where women have had at least 1 PAP or 1 mammogram This is improved but we can always do better!!

2 1. Cervical Cancer Screening CVIM Cervical Cancer Screening Guidelines: o PAPs start at 21 years old o Ages 21-29: Cervical cytology alone every 3 years, with reflex to HPV genotype o Ages 30-64: PAP & HPV If both negative, no test is required for 5 years OR Cytology every 3 years o At 65 years old, it is ok to stop if: 3 consecutive negative cytologies or 2 negative ones in the last 10 years No hx of CIN 2 or higher o In women with a hysterectomy for benign disease that also has no history of CIN 2 or higher cytology, no further PAP smears needed. Thin Prep PAP Procedure 1. Spatula first to collect samples of cervix 2. Swirl 10x in solution 3. Endocervical brush: insert until only bottom fibers are exposed. Turn ¼ to ½ in one direction. 4. Put in solution and swirl 10x against wall Make sure patient name and DOB are on vial. We have the ability to do HPV testing for free! Free HPV vaccinations for our patients at the Health Department! o Women 9-26 years old o Men 9-26 years old CVIM s policy and standard of care for GYN exams o Wash hands before and after all exams! o Wear gloves on BOTH hands!

3 2. Lung Cancer Screening CVIM Lung Cancer Screening Guidelines: Yearly screening low dose CAT scans are now recommended for two groups: Group 1 (meet all criteria) years of age Currently a smoker or has quit within the past 15 years Smoked a pack or more a day for 30+ years Group 2 (meet all criteria) years of age Smoked a pack or more a day for 20+ years Has one additional risk factor for lung cancer, not including second hand smoke

4 3. Colon Cancer Screenings CVIM Process: Each morning Cristina gives Sarah a list of all patients above 50 y/o who need colon cancer screening. Sarah puts a lab slip/note in the chart. The nurse/medical team needs to see these and give the FIT kit to the patient. The patient must bring the FIT back and the nurse must record this on the Facesheet. Our team puts it in the digital record (and also enters the results when they arrive) so we can retrieve it. **Thank you Sarah and Cristina for your wonderful work!!** Epidemiology: Incidence/Mortality Incidence and mortality varies greatly globally (over 10-fold) In US incidence and mortality Mortality 50k/year 2 nd leading cause of CA death Dx most frequently at y/o Median age of death 73 y/o 28% of eligible adults not screened Risk Factors Hereditary CRC Adenomatous polyposis syndromes (Lynch, FAP, MAP) Previous CRC/adenomatous polyp Family Hx (20% of cases; 3-10% have FH) Male sex/black race IBD

5 Stool Based Screening: Method Frequency Evidence of Efficacy Considerations gfobt q1yr RCT w/ mortality enpdoints (SENSA>Hemoccult II) FIT q1yr Test characteristic studies (accuracy > gfobt) * * FIT-DNA q1-3yr Test characteristic studies (false-positives > FIT) Insufficient evidence about longitudinal F/u abnormality w/ neg colonoscopy *All stool-based do not require bowel prep, or anesthesia, and test can be performed at home SEPT9 DNA Serology test also considered but not enough quality evidence to make recommendations about use (1 study fit criteria w/ sensitivity <50%) Benefits Annual FIT is similar in life-years gained and deaths averted to 5-year colonoscopy

6 Harms Annual FIT is similar in GI or cardiovascular complications to 5-year colonoscopy Guidelines for Colon Cancer Screening - from different organizations USPSTF: (w/o risk factors) Screen individuals 50*-75 y/o A Recommendation Colonoscopy q10year gold standard FIT q1year Clinical judgement for screening y/o C Recommendation Previous screening? Comorbidities/ability to f/u on + test No screening for >85 y/o MSTFCRC: Same age guidelines for AA) Colonoscopy q10 or FIT q1 ACA: Same age guidelines Colonoscopy q10, flex q5 ACP: Same age guidelines Colonoscopy q10, FIT or gfobt q1, Flex q5 + FIT or gfobt q3 AAFP: Same age guidelines FIT, flex, or colonoscopy

7 CVIM Colon Cancer Screening Guidelines: Annual FIT test for low risk patients age those with no symptoms, personal or family history Colonoscopy if positive result, or if patient has symptoms o Clinical judgement for screening y/o o No screening for >85 y/o Recommendations with a Family History of Colon Cancer: Individuals should undergo screening starting at 40 y/o or 10 years before age of relative s dx Colonoscopy every 5 years Family history includes a 1st degree relative with a diagnosis at <60 or multiple 1st degree relatives with diagnosis

8 4. Breast Cancer Screening Epidemiology: Incidence/Mortality 2 nd leading cause of CA death for women in U.S. Incidence 232k Mortality 40k Age of diagnosis Median age of death 68 <15% lifetime risk for average-risk women 5-10% who develop have 1 st degree relative with breast CA AA have greater mortality unclear reason Risk Factors Advancing Age Dense breasts (40% pop ~1.2x RR) Personal history of ovarian, peritoneal, or breast CA Family history of breast, ovarian, or peritoneal CA (2x risk) Genetic predisposition (BRCA, PALB2, CHEK2, ATM) Radiotherapy to chest at age RISK assessed using predictive models (Gail Model - risk of development by age 90) Screening Strategies Mammography Film o Sens 84.4%; Spec 90.8%; Recall rat 9.6%; PPV 4.3% o 15-20% reduction in CA mortality on systematic review (advances in imaging technology and treatment strategies call into question the applicability of this information) Full-Field Digital o Electronic detector o More accurate for women <50 o Increased FP rate MRI Requires IV contrast; $$$ Sens 0.77 vs 0.39 (mam); Spec 0.86 vs 0.95 (mam) in review of direct comparison studies

9 Thermography Elevated breast skin temp 25% FP, 60% FN Not recommended Ultrasound Not clinically evaluated Adjunct to mammography Tomosynthesis (DBT) Moving x-ray w/ digital detector Modest increase detection rates and decreased recall for FP; mortality not assessed Increased PPV 4.3% to 6.4% when combined with mam Clinical Breast Exam Estimated Sens 0.54; Spec 0.94 Lower Sensitivity in community setting (0.36) 2009 Lit review: Unproven Self-Examination No shown benefit Higher biopsy rate of benign disease *It is recommended that we discuss breast self-awareness with women Harms from Screening: False positives (prompts a workup without CA finding within a year after + mammogram) More common in younger women with dense breasts Combined (CBE*: 13.4%; and mammogram: 23.8%) FP rate of 31.7% for retrospective cohort of 2400 aged Anxiety 47% mamm related 3 months, effect might 1 year Over-diagnosis (detection of disease by screening that would not have caused morbidity or mortality if not detected) Estimated based on random screening comparisons and longitudinal analysis of incidence Meta-analysis showed of 19% Ideal screening includes ability to differentiate CA that will progress

10 USPSTF Data

11 Guidelines for Breast Cancer Screening - From Different Organizations AAFP: Recommends biennial screening mammography for women aged 50 to 74 years. (2016) The AAFP concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women aged 75 years or older. (2016) ACOG: Annual screening mammography beginning at age 40 Shared decision making Age > 40 on individual basis Benefit increases as age approaches 50 USPTF: Biennial screening mammography aged (B recommendation) Shared decision making Age should be screened on individual basis; 1 st degree relative w/ breast CA may benefit from early screening (C recommendation)* CVIM Breast Cancer Screening Guidelines: Age 40-50: Shared decision making - decide on an individual basis o 1st degree relative w/ breast CA may benefit from early screening Biennial screening mammography aged Encourage breast awareness over systematic self-examination report any changes, discharge, or pain

12 5. Prostate Cancer Screening Epidemiology: Incidence/Prevalence 2 nd most common CA in men worldwide o Incidence increased because of biopsy after elevated PSA For US male: lifetime risk 16%, risk of death 2.9% Risk Factors 1. Age a. Incidence increases with age 2. Ethnicity a. More common in AA, also presents earlier w/ higher PSA 3. Genetic factors (FH) a. BRCA 4. Diet a. Low vegetables b. Low lycopene (tomatoes) c. Low soy d. Omega-3 fatty acids e. Low coffee Screening Strategies Digital Rectal Exam o No evidence of improved morbidity or mortality when detected by DRE at any age o Sen 59%; Spec 94% o PPV - ~28% (5-30%) PSA Elevations in PSA can be from many causes other than cancer BPH DRE transient ng/ml Ejaculation 0.8 ng/ml for 48hrs Bacterial prostatitis elevation for 6-8wks after sx resolve Prostate biopsy elevate by 7.9 ng/ml within 4hrs lasting 2-4wks Acute urinary retention or urethral instrumentation normalize 1-2 days following resolution Finasteride lowers levels ~50%

13 Harms of Screening/ Treatment Men screened q2-4yr 15% false positive risk over 10 years Biopsy related complications o Pain, hematospermia, infection o 1% hospitalization rate Over-diagnosis (20-50%; highest in men >70yo) o Anxiety o Treatment related Impotence (Prostatectomy 2/3; radiation 1/2), incontinence (Prostatectomy 1/5), bowel dysfunction (1/6) USPSTF Screening Effects Table

14 Guidelines for Prostate Cancer Screening - from Different Organizations (new in 2017) USPSTF: Men should be informed of benefits/harms of PSA screening Slightly decreased risk of dying of prostate cancer FPs, Biopsy, Overdiagnosis, Overtreatment, Tx complications (incontinence, impotence) No screening >70yo ACP: Clinicians should have 1-time discussion (more if requested) with average-risk men age of harms/benefits, only screen (PSA q2-4years) after discussion, no screen <50 or >69 or life expectancy <10 years AAFP: refer to USPSTF ACS: men >50 (AA>45) with PSA after discussion q2y w/ baseline <2.5, q1y >2.5 AUA: age 55-69; PSA shared decision making q2+y CVIM Prostate Cancer Screening Guidelines: Men age PSA shared decision making q2+y o Use the PSA Handout (attached) and document your discussions No rectal exam recommended CVIM encourages screening men at risk for prostate cancer: o African American o FH of prostate cancer o Men with a history of BRCA 1 and 2

15 PSA Patient Discussion Guide There are four possible outcomes to a PSA test: 1. Your PSA is normal and you do not have prostate cancer (a true negative). 2. Your PSA is normal but you do have prostate cancer (a false negative). 3. Your PSA is elevated but you do not have prostate cancer (a false positive). 4. Your PSA is elevated and you do have prostate cancer. It is up to you and your doctor to decide whether you should have a PSA. The correct decision is the informed decision. Talk to your doctor and decide what factors are important to you. Here are some Pros & Cons to consider Possible advantages to having a PSA test: It may give reassurance if it s normal It can find many cancers earlier Treatment at early stages may help men live longer and avoid cancer complications Possible disadvantages to having a PSA test: It may miss cancer and give a false reassurance that there is no cancer It may lead to a biopsy and anxiety when a man has no cancer Treatment at early stages may not help men live longer and treatment has risks of side effects, including problems with sexual dysfunction and incontinence