Prevention/Screening

    Most of these came from Canadian Task Force on Preventative Care http://www.canadiantaskforce.ca

    Introduction

    • Guidelines for screening.

     

    Levels of Evidence:

    • I - Evicence from randomized control trial(s)
    • II-1 - Evidence from controlled trial(s) without randomization
    • II-2 - Evidence from cohort or case control analytic studies (prefer more than one center/group)
    • II-3 - Evidence from comparisons btwn times or places with/without intervention. (dramatic results from uncontrolled experiments can be included here.
    • III - Opinions, based on clinical experience or reports of committees.

    Canadian Task Force - Grades of recommendations

    • A  - Good evidence to recommend the clinical preventive action.
    • B  - Fair evidence to recommend the clinical preventive action.
    • C  - The existing evidence is conflicting and does not allow making a recommendation
    • D -  Fair evidence to recommend AGAINST the clinical preventive action.
    • E  - Good evidence to recommend AGAINST the clinical preventive action.  
    • I  - The CTF concludes that there is INSUFFICIENT evidence (in quantity and/or quality) to make a recommendation

     

    Breast Cancer

    Mammography

    • Age 50-74 --> Mammogram q2yrs
      • (equivalent to 5 weeks of background radiation)
    • Source: Cancer Care Ontario (based on Swedish Two-Country Trial - screen 414 over 7 years to prevent death)
    • Screening ages 40-49 --> 2007 Meta analysis --> not effective.

     

    • Ages 40 – 49 not routinely screening with mammography.

    (Weak recommendation; moderate quality evidence)

    • Ages 50-69 routinely screening with mammography every 2 to 3 years
      (Weak recommendation; moderate quality evidence)
    • Ages 70 - 74 routinely screening with mammography every 2 to 3 years.
      (Weak recommendation; low quality evidence).

     

    Magnetic Resonance Imaging

    • not routinely screening with magnetic resonance imaging
      (Weak recommendation; no evidence)

     

    Clinical Breast Exam

    • We recommend not routinely performing clinical breast exam alone or in conjunction with mammography to screen for breast cancer.
      (Weak recommendation; low quality evidence).

     

    Self Breast Exam

    • We recommend not advising women to routinely practice breast self exam (D recommendation)
    • Fair evidence no benefit, good evidence of harm (Increased physician visits, increased rates of benign biopsy)

     

    • Any new breast lumps/masses must be investigated to rule out malignancy:
      • Ultrasound for women < 35yo (due to higher breast density)
      • Mammography if ≥ 35yo
      • Some sources have age cutoff of 30 (ESMO guidelines 2013)

    Colon Cancer

    Canadian guidelines for Colorectal Cancer (Cancer Care Ontario) - CMAJ
    Average Risk: 
    • Ages 50-74yeras
      • FOBT q2yrs  
        • (NNS: 2655 (age<60), 492 (age > 60)
      • OR Flex Sig q10yr
        • NNS: 1854 (age< 60), 343 (age > 60)
    • No screening colonoscopy in guidelines because no RCT has shown mortality benefit
      • Also higher complication rate for Colonoscopies compared with Sigmoidoscopy (perforation 3 vs 19 in 100,000 of perforation, 3 vs 159 in 100,000 risk bleeding requiring transfusion, 2 vs 23 in 100,000 diverticulitis).
      • If 10,000 colonoscopies done on <60yo:  >5 cancers detected, 20 complications
     
    Moderate Risk
        Family Hx --> 1st degree relative diagnosed <60 OR two 1st degree relatives
        Start: 40y or 10 years before diagnosis (whichever earlier)
        - Colonoscopy q5y

    High Risk
        FAP
                -  Flex sig/colonoscopy yearly starting teens until advised to have surgery
        HNPCC
                - Colonoscopy at age 20-25 q2y until age 40, then yearly after 40.
        IBD (Ulcerative Colitis or Crohn's Disease)
                - Colonoscopy q1-2y after max 8y of colitis
                - Multiple biopsies to r/o dysplasia even if no lesions found
                - No screening if only proctitis

    Prostate Cancer

    PSA

    • No routine screening!
    • D - recommendation
    • Evidence that PSA increases detection rate, but no evidence that reduces mortality (gold standard to evaluate screening).  It is generally used to monitor disease progress.
    • Can offer to fit men 50-70yo with 10+yr life expectancy, but generally don't have to do.
    • Not covered by OHIP
    • Two studies:
      • PLCO (US) 
      • ERSPC (Large European Study)
        • NNS 781 over 13yrs. (twice needed to screen in twice time period)

    Cervical Cancer

    Routine PAP

    • Once sexually active and age 21-69 (if not sexually active, can wait)
      • PAP smear q3y

     

    • Stop if >60yo and 3 paps normal.
    • Very little mortality data, but shown that screening decreased cervical cancer by 60%.  Seems that NNT is >100,000.
    • If HPV negative, risk of CIN 3+ after 6y is 0.27%

    Gardasil

    • Give 3 doses: now, in 2mo, and in 6mo.
    • Covered by OHIP only for girls in Grade 8 (as of summer 2012)

    Osteoporosis

    DEXA

    • At ≥65 Screen Everyone (males + females)
    • 50-64 if risk factors:
      • Fragility fracture >40yo
      • Prolonged use of glucocorticoids (>3mo cumulative in previous year at dose of ≥7.5mg daily)
      • Use of other high risk medications (i.e. aromatase inhibitors or androgen deprivation therapy)
      • Parental hip fracture
      • Vertebral fracture or osteopenia identified on Xrays
      • Current Smoker
      • High Alcohol Intake (>2 drinks/day)
      • Low body weight (<60kg) or major weight loss (>10% of body weight since 25yr)
      • Rheumatoid Arthritis
      • Other disorders associated with osteoporosis
    • <50yo if SEVERE risk factors such as:
      • Fragility Fracture
      • Prolongued glucocorticoids (>3mo cumulative in previous year at dose ≥7.5mg daily)
      • Hypogonadism or premature menopause (age < 45yr)
      • Malabsorption Syndrome
      • Primary hyperparathyroidism
      • Other disorders ass'd with rapid bone loss/fracture. 
    • Screen q 1-3 years (usually 3)

     

    Ca / Vitamin D

    • Calcium: 1200mg (Concern over artery calcification if too much)
    • Vitamin D:
      • Cancer Guideline: 1000
      • Osteoporosis Guideline: 800

    Cardiovascular Disease

    Lipid Profile

    • men 40-75
    • Women 50-75
    • Every 3-5 years
    • Age to screen varies based on:
      • Smoking, Diabetes, HTN, Obesity
    • Screen earlier if:
      • Rheumatic: SLE, RA, Psoriatic arthritis, Ank Spond, IBD
      • Chronic: COPD, CKD, HIV
      • Genetic: SE Asian, First Nations
      • Other: Abdominal Aneurism, Erectile Dysfunction.

    Fasting Glucose

    • ≥40, q3y

    Framingham Risk Score

    • Components:
      • Age
      • LDL-C
      • Total Cholesterol
      • HDL-C
      • Blood Pressure
      • Diabetes
      • Smoker
    • Set lipid targets based on risk (see Lipids)
    • Double risk if positive family hx (First degree relatives):
      • < 55 y for Men
      • < 65 y for Women
    • Young individuals: Poorly represented.
      • Use Calculated Cardiovascular Age to motivate young people to achieve risk targets (exercise, diet, quit smoking).
    • >75yo --> not well validated.  Studies underway as of 2014

     

    Abdominal AAA

    • USPSTF Task Force (US) Guidelines:
      • Screen men 65-75yo who have ever smoked (one-time screen)
      • Abdominal U/S for AAA
      • Repair if ≥5.5cm in diameter

    Lung Cancer

    • Age 55-74 with > 30pkyr smoking hx in those who have smoked within 15y
      • --> Low Dose CT q1yr for 3 years
      • --> Should only be recommended in centers with expertise
    • Source: Canadian Task Force of Preventative Medicine
    • Source: Cancer Care Ontario did not put out a recommendation (pilot project in 2017)

     

    • Chest Xray
      • NNS to prevent lung cancer death 320
      • CXR: 7% positive screen (95% false positive, 0.6% diagnosed with cancer, 309 deaths per 100,000 patient years)
        • LR+ 3.5, LR- 0.08 (NEJM 2011)
      • CT: 24% positive screen (95% false positive, 0.6% diagnosed with cancer, 247 deaths per 100,000 patient years)
        • LR+ 8.4 LR- 0.29 (NEJM 2011)

     

    Mostly for smokers

    • Chest Xray - D recommendation

    Low Dose CT (aka spiral CT)

    • US Guidelines: (cancer.org 2015) with Low Dose CT - US Preentative Services Task Force USPSTF
      • Screen patients 55-80yo
      • In fairly good health (life expectancy reasonable & willing to undergo curative treatment for lung ca)
      • ≥ 30pkyr smoking hx
      • Are still smoking OR quit in last 15y
    • Canadian Guidelines
      • Canadian Task Force for Preventative Care --> No guideline released yet (in the works! as of Aug 2015).
    • Main recommendation is 7 portions of leafy green vegetables or fruit (B recommendation)
    • Smoking Cessation (B recommendation)
    • NOTE: USPSTF recommends one-time AAA screening with abdo U/S 65-75y who smoked >100 cigarettes in lifetime, or men with "high risk" (first degree relatives).  
    • Ruotine spirometry is not recommended as COPD screen for asymptomatic patients.

    Bladder Cancer

    • Generally do not screen
    • Urine dipstick or cytology in general population to screen for bladder CA (D recommendation)

    Other Recommendations

    • Flossing (A)
    • Tooth brusing (B), tooth scaling for prophylaxis (B)
    • STI prevention through counsel + education materials (B)
    • Weight reduction (B)
    • Past Hx of varicella? if no --> vaccination (B)


    Periodic Health Exam

    • CTPC Recommendation: Maybe abandon
    • Costs $2billion, outdated, 
    • Only part of the PHE that is useful is blood pressure check (B recommendation)
    • Less available appointments, increased ER visits for other issues
    • On the other hand improved PAP delivery, cholesterol and FOBT screening, decreases patient worry.

     

    Other Screening

    Endometrial Ca

    • An endometrial biopsy must be obtained to exclude hyperplasia or malignancy in all women over 40.
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