Transcript 6.15.09 Colford GenMedBoard REview

Board Review
Clinical Epi and Prevention
Cristin Colford, MD
June 15th, 2008
Cervical Cancer Screening
• USPSTF strongly recommends screening for cervical cancer in
women who have been sexually active and have a cervix
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Start within 3 years of the onset of sexual activity or age 21;
Screen at least every 3 years
Insufficient evidence to recommend for or against liquid based cytology
Insufficient evidence to recommend for or against HPV testing for
primary prevention
• Recommends against routinely screening women over age 65 if they
have had adequate recent screening with normal pap smears and
are not otherwise at high risk for cervical cancer
• Recommends against routine PAP smear screening in women who
have a total hysterectomy for benign disease
Options for Management of ASCUS
(atypical squamous cells of undetermined significance)
• Repeat cytology
• Immediate colposcopy
• Reflexive HPV DNA testing
Refer for immediate colpo
• LGSIL (Low Grade Squamous Intraepitheliel Lesion)
• HGSIL (High Grade Squamous Intraepitheliel Lesion)
Breast Cancer Screening
• Annual screening begins at age 40 to 50
• Mammography
• Most agree that an annual breast exam by
a clinician is also warranted, but USPSTF
is a bit equivocal
Colon Cancer Screening
• Start at age 50
• This year USPSTF put upper age limit of 75
– Probably won’t make it to your test
• Many options
– Colonoscopy every 10 years
– FOBT annually
– Sigmoidoscopy every 5 years with or without annual
FOBT
– Barium enema
Prostate Cancer Screening
• Insufficient evidence to recommend
uniformly
• Shared decision process starting at age 50
– Inform of risks and benefits
– Annual PSA with or without DRE
• If screening, may start earlier in high risk
men. African Americans or family history
of first degree relative start age 45
• Update 2008: Do not screen men > 75
Cancers we don’t screen for
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Ovarian
Endometrial
Gastric cancer
Pancreatic cancer
Lung cancer
Renal cell cancer
Thyroid cancer
AAA Screening
• USPSTF Recommends one time
abdominal ultrasound in men aged 65-75
who have EVER smoked
• DO NOT screen women (harms outweigh
benefits)
Heart Disease Prevention
• Know ATP III Guidelines for cholesterol
targets
• JNC Guidelines for blood pressure targets
• We should calculate overall risk and adjust
our treatment based on that, but I’m
guessing that will not be on boards
• A healthy 43 y/o woman presents as a new patient. Her only
chronic medical problem is hypertension. She works as a flight
attendant and lives with a roommate. She does not smoke; she
drinks alcohol in moderation. She has never been sexually active
and has not been assaulted. Her father developed colon cancer at
age 75, and a maternal aunt developed ovarian cancer in her 60s.
The patient has never had a Pap test and wonders whether she is at
risk for ovarian cancer. Her most recent mammogram was 2 years
ago.
• What is the most appropriate screening test to recommend to this
patient?
• A) Pap smear
• B) Mammograhy
• C) colonoscopy
• D) CA-125 testing
• E) Pelvic ultrasonography
B) Mammography
• Current recommendations suggest
screening between 40-50 is reasonable
• Pap smear is optional. She as extremely
low risk if she has never had sex.
• Colon—begin age 50 unless family history
• Ovarian cancer—no screening program
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A 37 y/o white woman presents as a new patient. She is in good health.
She wonders, however, whether she should be tested for the breast cancer
gene because her 45 y/o sister was just diagnosed with invasive breast
cancer. She has no personal history of breast problems, and has not yet
had a mammogram. She has menarche at age 13 years, and has no
children.
Which of the following statements about genetic susceptibility testing for
BRCA1 or BRCA2 in this patient is most accurate?
A) She has a 50% chance of testing positive for a BRCA1 or a BRCA2
mutation and should be tested.
B) This patient's risk of breast cancer by age 40 years is 30%;
mammography is indicated regardless of testing results
C) A positive test for BRCA1 or BRCA2 would have no impact on decision
making about screening mammography, so testing is not indicated
D) Knowing the result of BRCA1/BRCA2 testing on her sister would be
helpful in decision making for this patient
D) Get the sister’s result
• 52 y/o man is a new patient. Wants annual physical and PSA
testing. He exercises, doesn’t smoke, rare etoh. Old records show
well controlled BP, negative ETT 4 years ago, various lab tests all of
which are normal. Only medicine is atenolol.
• Previously had colonoscopy 2 yrs ago and PSA values of 4.2 1 yr
ago and 3.8 2 yrs ago. Previous doctor told him level was borderline
and waited for repeat measurement.
• DRE exam is normal, PSA is 5.0
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A) prescribe tamsulosin therapy
B) perform serial PSA measurements
C) Order free PSA assay
D) Refer for urologic evaluation
E) prescribe finasteride
D) Off to urology for biopsy
• The cut point is 4. If over 4, kind of need to go
to urology
• Some recommend “velocity”. If PSA rise greater
than 0.75/year. However, already over 4, so
send him.
• Of course, the patient can refuse to go. But the
guidelines tell us you should recommend he
have a biopsy…..
• 55y/o white man inquires about PSA screening during
routine visit. Generally healthy and no urinary symptoms
and no family history of cancer. In this age group,
prevalence is 10% -42%. Positive predictive value of
PSA exceeding 4 for carcinoma of the prostate is 28%35% and the negative predictive value is approximately
75%
• What should you tell the patient?
• A) His risk of prostate cancer is between 10% and 42%
and screening is warranted
• B) Because an elevated PSA would likely be falsely
positive, screening is unwarranted
• C) A PSA less than 4 would mean prostate cancer is
highly unlikely
• D) False-positive PSA results are approximately twice as
common as true positives
D) False positives are twice as
likely as true positives
• Interpret the PPV.
• PPV probability of disease given a positive
test. PPV of 28-35% is about 1/3. Thus,
false positive rate is 65-72% or about
twice the true positive rate (PPV)
• 65 year old pt here for routine visit has a loud, harsh
systolic murmur hear loudest at 2nd intercostal space,
heard at apex and radiates to carotids. Otherwise
normal cardiac exam. No hx of CP, SOB, syncope,
dizziness. No hx of CAD. Never had an echo. Textbook
tells you the positive LR for such a murmur is 1.8.
• What do you tell the patient?
• A) He has an innocent flow murmur and needs no further
evaluation
• B) He likely has severe narrowing of the aortic valve
• C) He has a narrowing of his aortic vavle with a 40%
chance that it is severe
• D) He may have a narrowing of his aortic valve but the
chance that it is severe is low.
Positive LR
• Probability of that finding in patients with
that condition (ie severe AS) in relation to
probablity of the finding in patients without
the condition
• LR 1.8 is above 1, but not that high to
change your pretest prob much
• An echo is warranted to exclude severe
AS