Preventive Medicine (Case 1)
Cynthia D. Smith MD and Brian Wojciechowski MD
Case: A 60-year-old female kindergarten teacher presents for a checkup. She has no complaints and has not seen a physician for over 10 years. She has no significant past medical history, takes no medications, and has no allergies. She lives with her husband and has two grown children who are married and six grandchildren who live nearby. She occasionally drinks alcohol (one to two drinks per week) and has smoked one pack of cigarettes per day for 30 years. She has a younger sister who was recently diagnosed with breast cancer at the age of 53 years. She comes today because she is worried that she might have breast cancer.
Screening and Prevention Options
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Breast cancer screening |
Aspirin for prevention of ischemic strokes |
Immunizations |
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Colon cancer screening |
Blood tests: total cholesterol/high-density lipoprotein (HDL) cholesterol or fasting lipid profile, HIV Fasting glucose, hemoglobin A1C (HgA1C), thyroid-stimulating hormone (TSH) |
Tobacco use and alcohol misuse counseling |
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Cervical cancer screening |
Healthy diet and exercise |
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Hypertension/obesity |
Depression screening |
When asked to perform a routine physical exam on a middle-aged female smoker, it is best to first try to choose the highest impact areas to focus on in the time allotted. It helps to find out right away the patient’s greatest concern and if there is a particular area of prevention on which he or she would most like to focus. This can help in maximizing impact and outcomes during the visit. In this patient, high-impact areas would be breast cancer screening, colon cancer screening, and tobacco cessation.
PATIENT CARE
Clinical Thinking
History
• Inquire about over-the-counter medications and herbal supplements.
• Family history has a large impact on timing and strength of recommendation of screening tests. Focus particularly on family history of cancer, including age at diagnosis, and family history of heart disease in the 40s or 50s. Focus only on first-degree relatives (parents, siblings).
• Don’t forget to do a complete ROS.
Physical Examination
• Check blood pressure, weight, and height, then calculate a body mass index (BMI).
• Carefully examine lymph nodes and lungs, given the smoking history.
• Examine breast and axillary lymph nodes.
• Do a pelvic exam and Papanicolaou (Pap) smear.
Tests for Consideration
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$655 |
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$5 |
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$15 |
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$19 |
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$14 |
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$24 |
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$13 |
| Screening and Prevention Strategies | Medical Knowledge |
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Breast Cancer Screening |
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Estimating risk |
Large, well-conducted trials have shown reduction in mortality from breast cancer from screening mammography with the greatest benefit in women aged 50–74 years. |
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Determine a patient’s risk of developing breast cancer using a detailed history and a risk prediction tool such as the Gail model (www.cancer.gov/bcrisktool/). An average-risk woman has a less than 15% lifetime risk for developing invasive breast cancer. |
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Mammography |
For an average-risk woman, screening should be discussed beginning at age 40 years. The risks and benefits should be reviewed, and a decision should be made based on the patient’s values and her level of risk. Women aged 50–74 years should undergo screening mammography every 1 to 2 years. For women over age 74 years (this age group not included in randomized trials so no data are available), screening should be based on individual discussions regarding risk vs. benefit with the patient and life expectancy. |
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Clinical breast exam |
Clinical breast exam may be used as an adjunct to mammographic screening (insufficient evidence of additional benefit above mammography). |
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Breast self-exam |
The benefit of breast self-exam (BSE) has not been proven, and the United States Preventive Services Task Force (USPSTF) recommends against teaching BSE, citing the lack of proven benefit. Women who express interest may be instructed in how to differentiate normal from abnormal tissue. BSE should not substitute for mammography. High-risk women, with Gail model risk scores above 20%, should be referred for genetic counseling. They may choose an intensified surveillance strategy with annual magnetic resonance imaging and mammogram, clinical breast exams every 3–6 months, and breast self-exams every month starting at age 25 years. |
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Colorectal Cancer Screening |
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Colonoscopy |
Screening with colonoscopy has been shown to decrease mortality from colorectal cancer; screening should be performed in average-risk patients starting at age 50 years and continuing at least until age 75 years. |
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Biannual home FOBT screening, followed by colonoscopy for positive results, has also been shown to decrease mortality from colorectal cancer. This should be done with three cards mailed in and rehydrated. No mortality benefit has been found for a single test in the office. |
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Computed tomography (CT) colonography |
Screening options that directly visualize the entire colon are preferred (colonoscopy). If a patient opts for flexible sigmoidoscopy, CT colonography, or double-contrast barium enema, the interval is every 5 years. Please note that women are more likely to have right-sided lesions that may be missed on these studies. |
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High-risk patients |
Patients with a first-degree relative with colorectal cancer should be screened 10 years before the age at which the relative was diagnosed. |
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Cervical Cancer Screening |
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Pap smear |
Risk factors for cervical cancer include history of abnormal Pap smears, cervical cancer, in utero exposure to DES (diethylstilbestrol), immunocompromise, early onset of sexual activity, and multiple sexual partners. Cervical cytologic examination via the Pap smear has been shown to decrease mortality from cervical cancer. Immunocompetent, average-risk women should begin screening at age 21 years, whether or not they are sexually active. Screening should occur every 2 years, and women over 30 years with three consecutive normal Pap smears may undergo screening every 3 years. For patients after total hysterectomy for benign disease, there is no evidence for benefits of obtaining vaginal smears. |
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Aspirin for Prevention of Ischemic Strokes in Women and Coronary Artery Disease (CAD) in Men |
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Calculate 10-year stroke risk for patient and if above net benefit threshold, start ASA 81 mg daily |
Use a calculator to input the patient’s data and calculate the 10-year risk of ischemic stroke; compare this with threshold value and decide if the net benefit is positive for your patient. http://www.westernstroke.org Our patient’s 10-year stroke risk is 10%. Because this is above the net benefit threshold of 8% for her age group, she may benefit from empiric aspirin (ASA) therapy (81 mg daily). |
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Screening Tests to Consider |
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DXA |
A DXA scan is recommended for women age 65 years and older every 2 years and for women aged 60–64 years who are at high risk (weight under 70 kg or 154 pounds, tobacco use, prior fracture) for osteoporosis and pathologic fractures. |
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Lipids |
A lipid panel should be obtained in all males 35 years or older and all women 20 years or older who are at increased risk for cardiovascular disease. Nonfasting total cholesterol/HDL levels can be obtained as an initial screening test. If total cholesterol is >200 mg/dL and HDL is <40 mg/dL, patient will need a fasting lipid profile. Fasting lipid profile is obtained after a 12-hour fast, if nonfasting screen is elevated, or as first screening test. Repeat every 5 years if normal. |
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HIV |
Voluntary HIV testing for all persons aged 13–64 years |
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Diabetes |
Should consider fasting glucose or HgA1C in patients with blood pressure (BP) > 135/80 mm Hg or patients with hyperlipidemia. |
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Thyroid |
Insufficient evidence to recommend for or against routine screening for thyroid disease |
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BP |
Check BP every 2 years if <120/80 mm Hg, yearly if 120–139/80–89 mm Hg. This recommendation is based on the reduction in all-cause mortality for patients who are diagnosed and treated for hypertension (decreased death due to stroke and heart failure). |
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BMI |
Measure height and weight, and calculate the BMI. BMI = body weight (in kg)/height (in meters) squared. Underweight: BMI < 18.5 kg/m2; normal weight: BMI ≥ 18.5–24.9 kg/m2; overweight: BMI ≥ 25.0–29.9 kg/m2; obesity: BMI ≥ 30 kg/m2. For patients who are overweight or obese, discuss their eating habits and activity level, and find out if they are open to meeting with a nutritionist. Identify high-calorie foods they can cut out easily (juices, sugar sodas, sweets), and ask them to start walking. Starting a food diary is also helpful for them before seeing the nutritionist. |
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Immunization |
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Influenza vaccine |
Recommended for all adults. This vaccine is given every year in the autumn. (Avoid if egg allergy or a history of Guillain-Barré syndrome within 6 weeks of having received an influenza vaccine.) |
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Pneumococcal vaccine |
For adults 65 years and older give pneumococcal polysaccharide vaccine once to prevent 60% of bacteremic disease from pneumococcal infection. Administer to adults < 65 years of age with chronic conditions. One-time revaccination at 5 years. The 13-valent pneumococcal conjugate vaccine has recently been approved by the FDA for use in adults 50 years of age and older. |
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Meningococcal vaccine |
Meningococcal conjugate vaccine is preferred for adults ≤ 55 years of age and in those with risk factors; meningococcal polysaccharide vaccine is preferred for adults > 55 years of age. Revaccinate with conjugate vaccine after 5 years for those at increased risk of infection. |
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Tetanus-diphtheria-pertussis (Tdap) vaccine |
Td vaccine should be administered every 10 years; substitute a one-time dose of Tdap for the Td booster for adults 19–64 years of age. |
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Live attenuated vaccine. Use in patients ≥60 years to prevent shingles and postherpetic neuralgia whether or not they report a prior episode of herpes zoster. |
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Tobacco Use and Alcohol Misuse |
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Tobacco |
All patients must be screened for tobacco use. Two simple questions: “Do you smoke?” “Do you want to quit?” Patients who want to quit smoking should be offered pharmacologic therapy in addition to counseling, as this increases cessation rates from 50% to 70%. |
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Alcohol |
Routine screening in all patients is recommended by USPSTF. One single question: “How many times in the past have you had four (women)/five (men) or more drinks in a day?” |
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Diet and Exercise |
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Healthy diet |
Adults with hyperlipidemia and other risk factors for CAD should be counseled about a healthy diet. |
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Physical inactivity |
Insufficient evidence for routinely discussing this with every patient. Need to know that asymptomatic adults who are interested in being physically active do not need to be cleared before starting. Recommendations should include 30 minutes of moderate aerobic exercise 5 days per week. Keep it simple! |
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Depression |
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Depression |
All adults over the age of 18 years should be screened for depression provided staff-assisted depression care supports are in place. Use the quick two-question screen: “Over the past 2 weeks have you felt down, depressed, or hopeless?” and “Over the past 2 weeks, have you felt little interest or pleasure in doing things?” |
a. Prostate cancer screening: Controversy exists regarding the role of prostate-specific antigen (PSA) screening, chiefly because prostate cancer can be a very indolent, not clinically relevant problem, and most men who are diagnosed with prostate cancer will live to die of another disease. Men may suffer the burden of additional testing, unnecessary treatment, and anxiety for a problem that may never have become clinically relevant. Unnecessary testing and treatments are expensive, may have severe side effects, and may also be ultimately unnecessary. On the other hand, a very large European trial showed a 20% decrease in prostate cancer mortality from screening; however, to save one life, you would need to screen 1410 men and treat 48 of them.1 Men in high-risk groups (African American or positive family history) may have the most to gain from PSA screening.
Practice-Based Learning and Improvement: Evidence-Based Medicine
Title
An analysis of the effectiveness of interventions intended to help people stop smoking
Institution
Department of Environmental and Preventive Medicine, Wolfson Institute of Preventive Medicine, London, UK
Reference
Arch Intern Med 1995;155:1933–1941
Problem
It takes time to counsel a patient about stopping smoking. What is the cost of this per life saved?
Intervention
Personal advice and encouragement to stop smoking should require less than or equal to 5 minutes given by physicians during a single routine consultation.
Quality of evidence
Systematic review of 20 studies in primary-care settings
Outcome/effect
An estimated 2% (95% confidence limits, 1%, 3%; P < 0.001) of all smokers stopped smoking and did not relapse for up to 1 year as a direct consequence of the advice. The effect is modest but cost-effective: the cost of saving a life is about $1500.
Historical significance/comments
This systematic review showed that a one time, 5-minute intervention could save lives.
Interpersonal and Communication Skills
Educate Patients about HIV Testing
The Centers for Disease Control and Prevention now recommends routinely screening for HIV at least once for everyone between the ages of 13 and 64 years. There is no need to identify risk factors for HIV before screening, but you must counsel and obtain consent from patients before obtaining the test. Laws vary by state regarding the amount of pre- and post-test counseling required. The key message is that HIV is a treatable disease, and the sooner it is diagnosed and treated, the better the outcomes. Additionally, early identification diminishes the likelihood that the virus will be spread to others. If patients have multiple risk factors or new high-risk exposures, they may require repeated HIV testing. Be sure to schedule a follow-up appointment to give patients their results in person. You do not want to inform patients that they are HIV positive over the telephone.
Professionalism
Professionalism Challenges in the Electronic Age
The modern era of communication has changed the way doctors communicate with each other and the way doctors can communicate with their patients, and has given patients potential access to their doctors as never before. In so doing, numerous issues of professionalism are raised.
Although many physicians still use beepers, especially in the hospital, cell phones make it possible for doctors to be reached around the clock. E-mail and social media (such as Facebook, Twitter, and Linked-in) add additional ways for physicians to be accessed at all hours. Whereas telephone access outside of the hospital has traditionally been left to physician preference, many physicians now share their private cell phone numbers with patients for after-hours emergencies, particularly for very sick patients; other physicians, however, still feel strongly that the patient should contact the answering service to reach them or the doctor on call. Regardless of the choice, it is important for doctors to set professional boundaries and to practice self-care with respect to time off and maintenance of a personal life outside of their practice. Such guidelines are preferably established at the onset of the doctor-patient relationship.
The Internet not only gives patients access to incredible amounts of current medical information (of varying reliability!), it also gives the physician and patient a new way to communicate: many physicians now use e-mail as an easy way to communicate with patients and their families when questions arise, or to follow up issues discussed during an office visit. Most doctors who prefer this approach use a professional or office-based e-mail address for these communications. It is important to note that all such written communications need to respect Health Insurance Portability and Accountability Act (HIPAA) regulations and should be encrypted and password protected.
Using social media to directly contact and interact with patients and their families is generally not recommended. Privacy issues are a problem, as well as the crossover and exposure that occur between the doctor’s professional life and personal life. The posting of private information about your day at work, even to a friend list that does not include patients or families, is a clear HIPAA violation. Note, however, that from an advertising perspective, many practices and hospitals can be “followed” on Facebook or Twitter by the general public. These interactions are generally informational (e.g., listing of new programs and office services) and do not contain specific patient data or one-to-one doctor-patient interactions.
Systems-Based Practice
A difficult decision is when to stop screening patients for preventable diseases; guidelines often do not address an upper limit. A good standard is that if the patient’s life expectancy is not greater than 10 years, there is probably little or no benefit to screening. A recent study published in The Journal of the American Medical Association used Medicare databases in conjunction with a tumor registry to compare cancer screening rates and found that up to 15% of patients with advanced cancer who did not have a meaningful likelihood of benefit continued to undergo screening tests.2
References
1. Schröder FH, Hugosson J, Roobol MJ, et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med 2009;360:1320–1328.
2. Sima CS, Panageas KS, Schrag D. Cancer screening among patients with advanced cancer. JAMA 2010;304:1584–1591.
Suggested Readings
Boulware LE, Marinopoulos S, Phillips KA, et al. Systematic review: the value of the periodic health evaluation. Ann Intern Med 2007;146:289–300.
Elwood JM, Cox B, Richardson AK. The effectiveness of breast cancer screening by mammography in younger women. Online J Curr Clin Trials 1993;Feb 25; Doc No. 32.
Fenton JJ, Cai Y, Weiss NS, et al. Delivery of cancer screening: How important is the preventive health examination? Arch Intern Med 2007;167:580–585.
