Preventive Medicine (Case 1)

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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

Breast cancer screening

Aspirin for prevention of ischemic strokes

Immunizations

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

Cervical cancer screening

Healthy diet and exercise

Hypertension/obesity

Depression screening

 

Speaking Intelligently

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

• Your first task is to figure out why the patient chose to come in to see you for preventative care after 10 years without a physician encounter.

• Your second task is to identify a select number of high-impact screening tests and counseling strategies that have the best evidence to keep this woman healthy.

• As you proceed with the history, review of systems (ROS), and physical exam, try to identify additional items that may motivate the woman to quit smoking (e.g., family history of lung cancer or chronic obstructive pulmonary disease, smoker’s cough, financial strain) or motivate her to get colon/breast cancer screening or vaccinations.

• Use the time to make a personal connection with her and to communicate your desire to work together as a team to keep her healthy.

• Finally, create a prioritized list of recommendations to negotiate with her at the end of the encounter. This list cannot be too long or overwhelming, or it will discourage her from following through with the testing and/or coming back for follow-up.

History

• Take a complete past medical history and past surgical history, and include a history of vaccinations, travel, and possible exposures.

• Inquire about over-the-counter medications and herbal supplements.

• Take a thorough obstetrics-gynecologic history, as this will help you calculate her breast cancer risk score and provide counseling with regard to HIV testing and safe sex. That she is 60 years old doesn’t mean she’s not sexually active!

• Use the time you have to flesh out her social history in detail. The more you know about her as a person, the better prepared you will be to help her make decisions to improve her health. This will also help you decide how to best spend the time counseling her at the end of the visit.

• 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.

• Although there is little evidence that doing a complete physical examination on an asymptomatic person is a valuable screening tool, people who go to the doctor expect to be examined, and this is a good opportunity to do a simultaneous ROS.

Tests for Consideration

• Colonoscopy

$655

• Fecal occult blood testing

$5

• Pap smear

$15

• Fasting lipid profile or nonfasting total cholesterol/HDL

$19

• Fasting glucose/HgA1C

$14

• TSH

$24

• HIV

$13

IMAGING CONSIDERATIONS

→ Mammogram

$130

→ Dual-energy x-ray absorptiometry (DXA) scan

$104
Screening and Prevention Strategies Medical Knowledge
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Breast Cancer Screening

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.

Estimating risk

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.

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.

Clinical breast exam

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