ACS 2003 Monthly Optional [D] USPSTF Previous Guideline. Breast Self-Examination (BSE) Clinical Breast Exam (CBE) [I] > 40: yearly

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Michael Jonah Campbell
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Health Care Screening for Women Michael S. Policar, MD, MPH UCSF School of Medicine policarm@obgyn.ucsf.

1 Health Care Screening for Women Michael S. Policar, MD, MPH UCSF School of Medicine There are no relevant financial relationships to disclose GUIDELINE SHOCK New guidelines released before older ones fully implemented May be the opposite of traditional practice Organizations may differ in content and timing Rationale often not well explained No one tells the consumer!! USPSTF: Age Band Anticipatory Guidance (counseling) Substance abuse; tobacco; avoid alcohol while driving Diet, exercise: limit fat and cholesterol; adequate Ca Injury prevention: seat belts, helmets, smoke detector Sexual behavior: contraception, STDs Dental health Immunizations TDaP booster; Rubella vaccine (childbearing age) Influenza vaccine (annually) Chemoprophylaxis Multivitamin with folate (women planning pregnancy) USPSTF: Age Band Physical exam, lab, and imaging tests Height and weight Physical Blood pressure exam Pap smear (at least every 3 years) Clinical breast exam (starting at 40 yo) Mammography (starting at 40 yo) Lipid screening (starting at 45) Bowel cancer screening ( starting at 50 yo) Rubella serology or history (childbearing age)

2 ACOG Primary and Preventive Care PHS visit should be done annually Physical examination Height, wt, BMI, BP, neck, breasts, abdomen, pelvic >40 yo: oral cavity, axillae; ; skin if high risk Lab and imaging TSH (Q5 yrs) > 50 yo; ; 19-49: if increased risk FPG (Q 3 45 years old Lipid profile (Q5 45 years old HIV serology (check state laws) Mammography starting at 40 years old Bone density, Q2 65 yo; > 50 increased risk Breast Cancer Screening Breast Self-Examination (BSE) Breast Self Exam (BSE) Clinical Breast Exam (CBE) Previous Guideline ACS 2003 Monthly Optional [D] Yearly Mammogram : Q2 yrs > 50: yearly 20-39: Q3 yrs > 40: yearly USPSTF 2009 [I] > 40: yearly 40-49: [C] 50-74: [B], every 2 years >75: [I] Two very large RCTs (Shanghai, Russia) Breast cancer mortality, survival equal in treatment and control groups SBE no better than coincidental discovery of mass USPSTF 2009:[ D ] recommend against teaching BSE American Cancer Society (ACS) 2003 At > 20 years old, inform of benefits, limitations If BSE chosen, provide instruction in use Acceptable not to do BSE or to do irregularly Goal of BSE is increased breast awareness

3 Clinical Breast Exam (CBE) Most studies evaluate MG + CBE, not CBE alone Accuracy of CBE Sensitivity: 54%, specificity: 93-94% 94% 10% of breast cancers detected on CBE alone, especially in younger women Most recommendations: start CBE at 40; perform annually (concurrent with mammogram) except USPSTF 2009: [ I ] recommendation ACS 2003: every 3 years, then annually ACOG 2003: start at 20, then annually Why Are BSE, CBE Poor Screening Tests? 1895 (Halstead): breast cancer spreads linearly Since 1990: the new conventional wisdom Breast cancer is a systemic disease, with spread to local and distant sites at the same time Once palpated, potential for spread is manifest»leon Speroff: breast cancer best viewed as occultly metastatic at the time of presentation Improved survival for women with small lesions applies mainly to pre-clinical lesions USPSTF: Screening Mammography November 2009 The USPSTF recommends Biennial mammography years [ B ] Against routine mammography years [ C ] Evidence is insufficient to assess benefits, harms of Mammography in women >75 years old [ I ] Digital mammography or MRI (vs film) [ I ] Efficacy of Mammography By Screening Interval in RCTs Screening Interval Mortality Reduction years old 1 year 23% 2 years 23% years old 1 year 11% 2 years 17% Kerlikowske, JAMA 1996, Nelson, Ann Int Med 2009

USPSTF: Screening Mammography December 2009 The USPSTF recommends against routine screening mammography in women aged 40 to 49 years [C] The decision to start regular, biennial screening mammography

categorically reject routine screening for women in their 40s but rather legitimizes the decision to delay it until age 50 Harms of Detection and Early Intervention SAME Meta-analysis analysis of

4 USPSTF: Screening Mammography December 2009 The USPSTF recommends against routine screening mammography in women aged 40 to 49 years [C] The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms The Task Force does not categorically reject routine screening for women in their 40s but rather legitimizes the decision to delay it until age 50 Harms of Detection and Early Intervention SAME Meta-analysis analysis of RCTs of screening mammography Ann of Intern Med 2009; 151:716 Harms more likely in younger women Physical and psychological harms of over-diagnosis Unnecessary diagnostic imaging tests Biopsies in women without cancer Inconvenience due to false-positive screening results Harms of over-treatment of a breast cancer that would Not become apparent during a woman s lifetime Have become apparent but wouldn t shorten life Radiation exposure (minor concern)

Breast Cancer Screening USPSTF Rationale Breast Cancer Screening USPSTF Summary Age Relative reduction in Br Ca deaths Number needed to invite Relative Harms 39-49 15% 1904 More (more false

5 Breast Cancer Screening USPSTF Rationale Breast Cancer Screening USPSTF Summary Age Relative reduction in Br Ca deaths Number needed to invite Relative Harms % 1904 More (more false positives) % 1339 Less (fewer false positives) Grade C B Age (years) Recommendation Screen if specified high risk factors Discuss pros and cons of screening Encourage screening Strongly encourage screening Discuss pros and cons of screening >75 Little data Mammography Screening Guidelines American College of Radiology 2010 American Cancer Society 2003 Annually starting at 40 American College of Ob-Gyn 2003 Every 1-2 years Annually starting at 50 American College of Physicians based on individual risks Every 1-2 years starting at 50 World Health Organization 2009 Every 1-2 yrs between National Breast Cancer Coalition (NBCC) Supports USPSTF findings Evidence for benefit of mammography before 50 years of age is not strong When screening started at 40, 60% more false- positives than if started at age 50 BSE is ineffective and potentially harmful

6 Routine STI Screening Cervical Chlamydia (in women) Annually in sexually active women thru 25 years old Cervical gonorrhea (in women) Annually in sexually active women thru 25 years old Only if practice-site prevalence is at least 1% HIV serology (CDC 2006) ; USPSTF (2007): [C] recomm dn Screen once 13-64; repeat < annually if known risk Only if practice site prevalence is at least 0.1% Pregnant women Syphilis, HIV, Chlamydia (under 26 years old) Hepatitis B antigen (newborn treatment) Strategies for Improving Chlamydia Screening Screening procedures clear to all office staff Unlink Chlamydia screening from pelvic exam With NAAT, urine or vaginal samples are preferred Practice opportunistic prevention Screen at problem-oriented oriented visits if necessary Automate office work flow Kit on chart or exam room prep table in advance Practice performance is compared to peer group Reward above average performance Remediate below average performance Are the Wrong Women Screened for Ct? 20-50% of women under 25 are not being screened Ct screening rate in those >25 equal to younger women So what?? Prevalence in women over 25 is <1%; less with aging Ct infects columnar epithelium; recedes with aging As prevalence decreases, positive predictive value declines, making incorrect diagnoses more likely Targeted STI Screening: Risk Factors GC + Ct screening History of GC, chlamydia, or PID in the past 2 years More than 1 sexual partner in the past year New sexual partner within 90 days Reason to believe that a sex partner has had other partners in the past year Syphilis, HIV screening Sexual history, partner behaviors, local prevalence

7 Contact Testing for STI Exposure Test asymptomatic persons with high risk sexual exposure (new or multiple sexual partners) for Gonorrhea Chlamydia Syphilis HIV Maybe: HSV-2 serology No contact testing for HSV (culture), HPV (DNA) HBV, HBC (strategy for HBV is vaccination) CDC 2006: Screening for Hepatitis B Have you previously been vaccinated for Hepatitis B? Yes no further evaluation No consider being vaccinated if HB risk factors If HB vaccine is offered, pre-vaccination HB serology Is not cost effective in low prevalence groups, teens Is cost effective in high prevalence adult populations»idu, MSM, sexual contacts of chronic carriers, persons from endemic countries If screened, also give the first dose of vaccine CDC 2006: Screening for Hepatitis C Sexual transmission is very uncommon Candidates for targeted screening Transfusion from a donor who later tested positive Injected illegal drugs, even a few times years ago Transfusion or organ transplant before 7/1992 Recipient of clotting factor(s) made before 1987 Ever been on long-term kidney dialysis Evidence of liver disease (e.g., abnormal LFTs) If positive for Chlamydia GC Syphilis Primary herpes Recurrent herpes Trichomoniasis Ext genital warts BV, candida Testing for STI Co-Infection Test for GC, syphilis, HIV Chlamydia, syphilis, HIV Chlamydia, GC, HIV Chlamydia, GC, syphilis, HIV (?) may be long standing (?) may be long standing (?) may be long standing Not STIs, therefore don t screen

8 Is A Screening Pelvic Exam Necessary in Adolescents? In sexually active asymptomatic adolescents, physical exam at screening visits should consist of Blood pressure check, BMI, and PNP PNP= Pee, not Pap Pee: Chlamydia NAAT Pelvic exam: not until 21 years old Pap smear: not until 21 years old With or without a contraceptive prescription ACOG Comm on Gyn Practice, #431. OG 2009; 113:1190 Is The Screening Pelvic Exam Outdated? Screen for GC, Ct Cervical cancer Preferred test Use NAAT with urine sample Not before 21 years old Pap every 2-3 yrs afterward None, if total hyst for benign disease Ovarian cancer USPSTF rec. against bimanual exam Vulvar lesions Vaginal infxn Myomas Unnecessary if asymptomatic Unnecessary if asymptomatic Unnecessary if asymptomatic Diabetes Screening Guidelines USPSTF, 2008 Asymptomatic adults with sustained HTN [B] Insufficient to assess the balance of benefits and harms in asymptomatic adults with HTN [ I ] American Diabetes Association, 2010 Screen adults every 3-years beginning at age 45 Screen at an earlier age (and more frequently) if BMI > 25 or risk other factors FPG, Hgb A1C are recommended screening tests ADA 2010: Criteria for the Diagnosis of Diabetes 1. Hemoglobin A1C > 6.5%*, or 2. FPG 126 mg/dl*, or Fasting is defined as no caloric intake for at least 8 hrs 3. 2-hr plasma glucose 200 mg/dl during an OGTT*, or Equivalent of 75 g glucose dissolved in water 4. In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose 200 mg/dl *In the absence of unequivocal hyperglycemia, criteria 1 3 should be confirmed by repeat testing

9 ADA 2010: Criteria for the Diagnosis of Diabetes Fasting plasma glucose (FPG) Normal: plasma glucose < 100 mg/dl IFG*: mg/dl Diabetes: >126 (on two occasions) 2 hour post-load glucose test (PLGT) Preferred test for women with PCOS, GDM Normal: <140 mg/dl IGT**: mg/dl Diabetes: >200 mg/dl (on two separate occasions) * IFG: impaired fasting glucose **IGT: impaired glucose tolerance Screening for Thyroid Disease USPSTF (2004): [ I ] recommendation ATA, AACE, Endocrine Society (JAMA, 2004;291:228) Insufficient evidence to support routine screening Screen women >60, personal or family history of thyroid disease, T1DM, autoimmune disease and atrial fibrillation Screen pregnant women only if above risk factors Obstacles to Adoption Industry Booming market in new screening technologies Most achieve marginal improvements Government Major objective is political expediency, not EBM Health systems NCQA: measure what s measurable Cancer screening as good marketing Consumers Pervasive belief that regarding disease prevention, screening tests are more important than behaviors Obstacles to Clinician Adoption Reasons to continue the screening status quo My patients believe in it The legal system demands it My professional organization expects it Vendors are pressuring me to utilize it Payers still pay for it It keeps my office practice going I believe in it; common sense says that it may help And there s little incentive to do less just that The evidence says it s the right thing to do

10 How Can My Practice Prepare? Ask every patient if she also sees a PCP.if so, avoid duplication of services Meet with your colleagues and determine the screening policies for your practice Make sure that all staff are aware of your policy Inform your patients of changes that apply to them During transition, leave decisions to patient Inform patients with a personal letter or newsletter Keep track of benefit changes made by your payers Few have changed screening benefits yet An Ounce of Prevention is Worth a Pound of Cure But Two Ounces Aren t Necessarily Better Than One If you think that you re really healthy You just haven t had enough tests

20-39: Q3 yrs > 40: annually

20-39: Q3 yrs > 40: annually The Evolving Well Woman Visit Michael Policar, MD, MPH UCSF School of Medicine www.policarlectures.com Why Is This Important To Clinicians? EBM provides an opportunity to impact quality Provide patients