PREVENTION CARE IN ADULTS Hong Xiao, M.D. Department of Family & Community Medicine Weight and BMI Abdominal Aortic Aneurysm (AAA) Blood Pressure Breast Exam Breast Cancer Mammogram Breast Cancer BRCA Mutation Genetic Counseling All Adults weight annually for all patients seen for health care services. Screen for obesity using BMI (Body Mass Index). USPSTF 2006 (B). Men aged 65 to 75 who have ever smoked: Order a onetime AAA screening ultrasonography. USPSTF 2006 (B). Annually for all adults seen for health care services. There is insufficient evidence to support clinical breast examination alone for breast cancer screening. There are good randomized controlled studies showing mortality benefit with clinical breast exam combined with mammography versus neither. There is conflicting data on the potential benefits and harms from encouraging self breast examination. Women ages 40-69: Mammogram every one to two years, earlier if + family history of pre-menopausal breast cancer. Continue >69 depending on risks and life expectancy. Women ages 40-49: Review risks and benefits with provider and mutually decide about mammograms. USPSTF 2006 (B). NOTE: Clinical breast exams annually for women 40 years of age. Women with family history associated with high risk for BRCA 1 or BRCA 2 genes: breast cancer diagnosed at an early age bilateral breast cancer history of both breast and ovarian cancer presence of breast cancer in one or more male family members multiple cases of breast cancer in the family both breast and ovarian cancer in the family one or more family members with two primary cancers Ashkenazi Jewish background Refer for genetic counseling and evaluation for BRCA testing. 2009
Cervical Cancer Colon Cancer Prostate Cancer Testicular Cancer Screening Pap Smear Women 3 years after the onset of sexual activity or 21: Pap smears annually. After two normal annual Pap smears, repeat every 2-3 years. May stop in women with 3 consecutive normal results > age 65 or after hysterectomy for benign indications. All Average Risk (no Family History of first degree relative with colon cancer before age 60, or two first degree relatives with colon cancer at any age ) patients > 50: Screening modalities that may be used include fecal occult blood cards, flexible sigmoidoscopy, air-contrast barium enemas, or colonoscopy. CT colonoscopy is too new to determine the efficacy at this time, and thus cannot be recommended for or against. Fecal DNA testing is a new modality of occult blood evaluation. It offers benefit of high sensitivity. However, there is insufficient evidence to recommend for or against use of the modality at this time. A discussion with the patient regarding the different testing methods including the pros and cons of each is suggested. There is evidence of little benefit in terms of life years gained in screening individual between ages of 76-85, unless other special considerations. Screening patients older than 85 years of age is not recommended. No recommendation. Evidence insufficient that screening or treatment benefits men with prostate cancer. Consensus opinion recommends discussion with the patient regarding prostate examination and testing (the pros and cons). If one decides to screen, it should begin at age 50, and in men who have at least a 10-year life expectancy or age 45 in those who are at increased risk. The increased risk group includes African American men and men with a family history of a first-degree relative diagnosed with prostate cancer. Screening of men older than 75 years of age is not recommended. Currently there is a recommendation against testicular cancer screening. 2
Cholesterol Chlamydia Gonorrhea Men: age >35, Women: >45: Screen cholesterol. High Risk Men ages 20-34; High Risk Women ages 20-44: Screen cholesterol. USPSTF 2006 (B). Screening interval depends on Coronary Heart Disease (CHD) Risk. The National Cholesterol Education Program (NCEP) defines CHD Risk equivalent patients as those with the following conditions: Clinical CHD Abdominal aortic aneurysm Diabetes Symptomatic carotid artery disease Peripheral arterial disease Calculate CHD Risk based on Framingham tables in all other patients with 2+ of the following Major Risk Factors: Cigarette smoking Hypertension (BP 140/90 mmhg or on antihypertensive medication) Family history of premature CHD (CHD in male first degree relative <55 years; CHD in female first degree relative <65 years) Age (men 45 years; women 55 years) Low HDL cholesterol (<40 mg/dl)* * HDL cholesterol 60 mg/dl counts as a "negative" risk factor; its presence removes one risk factor from the total count. Screen High risk every 1 year, Moderate risk every 2 years, Low risk q 5 years. NCEP 2002 (expert opinion). All sexually active women age <25: Screen for Chlamydia. Use urine testing if the patient is not scheduled for pelvic examination. USPSTF 2006 (A), CDC - STD 2006. There is general consensus of expert opinions that favors screening for gonorrhea in high risk women. These individuals should likewise be screened when pregnant. There is insufficient evidence to recommend routine screening for gonorrhea in otherwise asymptomatic women (pregnant or not), and in men (high risk or not). 3
HIV Osteoporosis Thyroid Diseases COUNSELING High risk for HIV infection: Screen annually. All prenatal patients: Screen at entry to prenatal care. Normal risk adults: CDC 2006 recommends and prefers offering HIV screening for all patients 13 in all health-care settings, regardless of risk. NOTE: USPSTF 2007 (C) neither recommends for nor against screening normal risk adults. All women aged 65 and high risk women starting at age 60: Screen using DEXA or bone densitometry testing. USPSTF 2006 (B). Questions remain about how frequently women should be screened, and when to stop offering bone densitometry. The USPSTF makes no recommendation for or against routine osteoporosis screening in postmenopausal women. There is no evidence to recommend for physical examination as a means of screening for thyroid cancer. There is insufficient evidence to recommend for or against routine screening for thyroid disease. Alcohol Use All Adults: Screen and offer behavioral counseling interventions to reduce alcohol misuse. USPSTF 2006 (B). Tobacco Use All Adults: Screen all adults and provide tobacco cessation interventions, especially for pregnant women. Document Tobacco use status. Counsel current and recent tobacco users periodically about quitting. Aspirin Men age 40 years, postmenopausal women, and all with increased coronary heart disease risk. Discuss aspirin chemoprevention. IMMUNIZATION 19-39 40-64 65 Years & Older Td Or Tdap Booster every 10 years Adults aged 19 to 64 years should receive a single dose of Tdap to replace Td for booster immunization against tetanus, diphtheria, and pertussis if they received their last dose of Td more than 10 years earlier and if they have not previously received Tdap. NOTE: Td should be used rather than Tdap if Tdap is not available, and for: Anybody who has already gotten Tdap Adults 65 years of age and older CDC/ACIP 2006 (expert opinion) 4
IMMUNIZATION 19-39 40-64 65 Years & Older MMR Pneumococcal Varicella Persons born after 1956 should have 2 doses measles; additional doses should be given as MMR Immunize high-risk groups once. Re-immunize those at risk of losing immunity after 5 years Persons < 50 with no history of varicella, do titer. If negative, immunize. If > 50, assume they are immune Immunize at 65 if not done previously. Re-immunize if 1 st received >5 years ago and before age 65 Hepatitis B Universal immunization Immunize those at high risk Influenza Hepatitis A Meningococcal Shingles Human Papillomavirus Travel All adults 50 and older, all prenatal patients, and those at high risk: Offer Influenza(Flu) shots annually Immunize those in risk groups (Alaska Native, Pacific Islander, and Native American populations, institutionalized persons and workers in these institutions, men who have sex w/men, users of injection or street drugs, certain laboratory workers, some religious communities, and travelers to countries where Hepatitis A has intermediate or high endemicity) Immunize those in risk groups (Persons with certain medical conditions such as deficiencies in the terminal common complementary pathway and anatomic or functional asplenia; college freshmen who live in dormitories; travelers to endemic or epidemic areas; and persons with occupational risk-laboratory personnel exposed to Neisseria meningitidis) Adult age 60 or older, with or without previous infection. Defer vaccination for at least 3 months following immunosuppressive therapy or chemotherapy. It is not necessary to ask patients about their history of varicella (chickenpox) or to conduct serologic testing for varicella immunity. Zoster vaccine should not be administered to persons with primary or acquired immunodeficiency. Female age 9-26 who has not completed the vaccine series. Optimal time to administer vaccine is prior to the start of sexual activity. Vaccine may be given in special circumstances (e.g., Equivocal or abnormal Pap test, positive HPV DNA test, genital warts, immunosuppression, breastfeeding). Immunize according to travel itinerary Yellow Book 2003-4:CDC Travelers' Health REFERENCE INTERNET CITATIONS U.S. Preventive Services Task Force Ratings: Strength of Recommendations and Quality of Evidence. Guide to Clinical Preventive Services, 2006. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/pocketgd.htm National Institutes of Health. National Heart, Lung, and Blood Institute. National Cholesterol Education Program. Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). 2002. http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3_rpt.htm Centers for Disease Control and Prevention. 2006 Sexually Transmitted Disease Treatment Guidelines. http://www.cdc.gov/std/treatment/2006/toc.htm 5
Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP). Recommended Adult Immunization Schedule 2006-2007. http://www.cdc.gov/nip/recs/adultschedule.htm Staying Healthy Assessment Resources. State of California, Department of Health Services, Office of Clinical Preventive Medicine. http://www.dhs.ca.gov/ps/ocpm/html/staying%20healthy.htm Hong Xiao, M.D. Associate Professor, Family & Community Medicine Last Reviewed: February 2009 6