Transcript Module 3 - 14.36 MB

HEALTH
MAINTENANCE
&
PREVENTION
IN ELDERS
Module #3
Ed Vandenberg, MD, CMD
Geriatric Section OVAMC
&
Section of Geriatrics
981320 UNMC
Omaha, NE 68198-1320
[email protected]
Web: geriatrics.unmc.edu
402-559-7512
• A healthy, physically active, cognitively intact
79-year-old man is referred to you after
serum prostate-specific antigen (PSA) is
found to be 6.5 ng/mL. The patient has not
seen a physician in 15 years and underwent
PSA testing at a health fair, after prompting by
his wife. He reports nocturia once or twice per
night, and physical examination reveals an
enlarged, smooth prostate gland. The patient
is aware of the controversies surrounding
screening for and treatment of prostate
cancer and he suggests that he would like to
ignore the test result and “just get on with
life.”
Which of the following is the most appropriate
approach to this patient?
( choose on answer)
Answer:
1) Recommend
(2) Tell him that doing
transrectal
nothing is a
ultrasound
reasonable option
2) Tell him that doing
but tell him about
nothing is a
more active
reasonable option
treatment, and the
but tell him about
pro’s and cons of
more active
screening
treatment
Medicare covers PSA?
3) Recommend PSA
Annually
testing in 6 months
Case based Geriatric Review AGS 2002
4) Refer him to a
urologist for a
Recommendations
 DRE/PSA annually for:
 Age 50-70 y.o. ALL MEN
(ACP & ACS)
(C-D)
 Age 40-70 y.o. (Afr. Am. or 1st degree relative with Prostate Ca.)
(USPSTF) says:
evidence is insufficient to recommend for or against routine
screening for prostate cancer with (PSA) or (DRE).
(USPSTF)
)
 Counsel patients about risk/benefits of testing
US Preventive Services Task Force ( USPSTF) http://www.ahrq.gov/clinic accessed 2-2005
(I
Why the confusion?
•
•
•
•
Most common
malignancy in older
men & mortality rises
with age
Occult prostate ca
(Autopsy study)
-~30% age 70 y.o.
~ 50% ninth decade,
Men ( all races) at Age
65 will expect to live to
80 y.o.
Localized prostate cancer
(T 0-2) followed without
intervention:,
5 year survival
98%
10 year survival 87%
Extra prostatic disease
(T 3-4)
5 year survival
51%
10 year survival
0%
Doubling time of early
prostate ca. ~ 3 years
Johannson JE,. N Eng J Med 1994;330:242-
Data we have to date
Randomized controlled trials
1) Labrie et al:[i]
- age 50-80 (N= 46,000)with 8 years of follow-up,
-screened annually, all with PSA > 3.O received TRUS and biopsy,
Prostate cancer death rates did not differ between
groups (4.6 vs. 4.8 deaths per 1,000 people,
respectively).
Help is on the way!!
2) U.S. National Cancer Institute "Prostate, Lung, Colorectal, and
Ovary" Trial
3) The European Randomized Study of Screening for Prostate
Cancer
both initiated in 1994, are ongoing, . Neither study will have data on
mortality for several more years.
4) Case controlled study Concato J, ( under way) [ii]
[i]Labrie F, first analysis of the 1988 Quebec prospective randomized controlled trial. Prostate 1999;38:83-91.
•
[ii]Concato J,. J Clin Epidemiol 2001;54:558-564.
PSA, DRE & Prostate Cancer Screening
Two groups based on treatment options :
(Age < 70 or with > 10 years life expectancy)
• Localized disease(T 0-2)
Treatment:-- Surgical, Anti-androgens,
Radiation therapy
• Metastatic disease(T3-4)
Treatment---Surgical, Anti-androgens,
Radiation
(Age > 70) or( age <70 with < l0 years life
expectancy)
localized disease-----no treatment. (individualize based on health
status)
metastatic disease—anti-androgen or chemotherapy
What PSA number to use?
More confusion
Yield of Large Screening Programs [i], [ii]
•
Six studies ( meta-analysis) , large, previously unscreened samples
•
Screening with a single PSA or PSA and DRE and % that were abnormal:
Age
PSA > 4 ng/ml
PSA>4 &/or +DRE # Prostate Ca
50-60
4 % [iii]
15%
1.5% [iv]
70-80
27% [v]
40%
10% [vi]
POSSIBLE CHOICES
1) PSA > 4 ng/ml in ALL
or
2) Age adjusted ranges and velocity of change
•
•
•
•
•
[i] RTI-University of North Carolina Evidence-based Practice Center meta-analysis for the U.S. Preventive Services Task Force (USPSTF)
[ii] U.S. Preventive Services Task Force (USPSTF)
[iii] Maattanen L, Auvinen A, Stenman UH, et al. European randomized study of prostate cancer screening: first-year results of the Finnish trial. Br J Cancer 1999;79:12101214.
[iv] Horninger W, Reissigl A, Rogatsch H, et al. Prostate cancer screening in the Tyrol, Austria: experience and results. Eur J Cancer 2000;36:1322-1335.
[v] Richie JP, Catalona WJ, Ahmann FR, et al. Effect of patient age on early detection of prostate cancer with serum prostate specific cancer with serum prostate specific
antigen and digital rectal examination. Urology 1993;42:365-374.
[vi] Schroder FH, van der Cruijsen-Koeter I, de Koning HJ, Vis AN, Hoedemaeker RF, Kranse R. Prostate cancer detection at low prostate specific antigen. J Urol
2000;163:806-812.
PSA LEVELS :
SUGGESTED RANGES: FOR AGE AND RATE OF INCREASE (VELOCITY)
PSA
AGE
PSA1
PSA2
VELOCITY
40-49
0.0-2.5
0.0-2.2
0.75 ng/ml/yr36 over 2 years
50-59
0.0-3.5
0.0-3.5
“
60-69
0.0-4.5
0.0-4.9
“
70-79
0.0-6.5
0.0-5.8
“
1.Data from Mayo Clinic
2.Data from Prostate Cancer Awareness Week
36. Small EJ, Prostate Cancer Incidence, Management, and Outcomes; Drugs and Aging 1998
Jul; 13 (1) 71-81
Skin Cancer Screening and prevention
What do you recommend?
( choose one answer)
Answer
For High risk:
1) Avoid sun exposure,
use sun block and
protective clothing
when outdoors.
2) Move to Polar
regions
3) “Bake away” and pay
me later for care
1) Avoid sun exposure, use sun
block and protective clothing
when outdoors.
Screening Recommendations
• USPSTF
No recommendation
Prudent advice
……screen annual during exams
and (keep your eyes open
during clinic visits!!)
US Preventive Services Task Force ( USPSTF)
http://www.ahrq.gov/clinic accessed 2-2005
• A 65-year-old man has type 2 diabetes
mellitus, systolic hypertension, and
hypercholesterolemia but no evidence of
target organ damage. He smokes cigarettes.
Current medications are a statin,
chlorthalidone, and metformin. The patient
walks at a brisk pace for 30 minutes every
day. Findings of physical examination are
normal except for peripheral neuropathy.
Electrocardiogram shows normal sinus
rhythm without evidence of myocardial
infarction. The patient tells you that his
neighbor takes aspirin to prevent strokes, and
he asks whether he should take it too.
Case based Geriatric Review AGS 2002
Which of the following should you advise?
( choose one answer)
1) There is no evidence
that ASA will help him
2) The potential benefits
out weight the potential
harm
3) The potential harms out
weight the potential
benefits.
4) The potential benefits of
dipyridamole are
greater than those of
aspirin.
• Answer
2) The potential
benefits out weight
the potential harm
Discussion
Benefits
• Four randomized trials in
men without a history of
myocardial infarction or
stroke have shown that
aspirin chemoprophylaxis
prevents fatal and nonfatal
cardiac events.
• The magnitude of potential
benefit is related to
underlying risk of coronary
artery disease.
• This patient is at high (> 5%)
risk for a cardiovascular
event in the next 5 years.
• 15 cardiovascular events
could be prevented by
treating 1000 such persons
for 5 years.
• Adverse effects of aspirin
include hemorrhagic strokes
and major gastrointestinal
(GI) bleeding.
• Daily low-dose (≤ 325 mg)
aspirin would precipitate one
to two hemorrhagic strokes
and five to ten GI bleeds in
1000 persons taking aspirin
for 5 years.
• Thus, if patient is low-risk for
cardiovascular disease,
aspirin is more likely to
precipitate a stroke or major
GI bleed than to prevent a
cardiovascular event.
USPHTF http://www.ahrq.gov/clinic 2-2005
IMMUNIZATIONS
• Influenza.
• Who and when?
• All > 65 and annual (fall)
Pneumococcal
What age?
• Age 65
• When to repeat and in
who?
• 5 years in high risk
•
•
•
•
•
•
Tetanus
What to give?
dT 0.5 cc IM
How often?
q 10 yrs.
What to do in unimmunized?
• dT: initial, 1-2 months
and 6 months
SMOKING CESSATION
• When to discuss?
• Each visit in smokers
(A)
What lacks evidence of benefit?
INEFFECTIVE SCREENING TESTS
Screening for:
Strength of
evidence
Lung cancer screening with (CXR or CT)
(I)
Ovarian cancer screening with
(D)
ultrasound
Uterine cancer with ultrasound
(D)
Hematologic malignancies w CBC
(D)
Pancreatic Cancer with CT
(D)
INEFFECTIVE SCREENING TESTS
on whole populations
Screening with Lab/tests
Strength of
evidence
Annual chemistry profile
(D)
Annual CXR
(D)
Annual CBC
(D)
Annual EKG
(D)
ExTT, EBCT for CAD on Asymptomatic
patients
(D)
TERTIARY PREVENTION
1)VISION TEST
2)HEARING
3)UPPER/LOWER EXTREMITY FUNCTION
4)MENTAL STATUS
5)DEPRESSION
6)HOME ENVIRONMENT
7) ADL PERFORMANCE
8) INCONTINENCE
9)NUTRITION
10)SOCIAL SUPPORT
Lachs M.S., Feinstein A.R., et. al.. Annals of Internal Medicine May 1 1990; Vol. 112, No 9
pp 699-705
Keller B.K., Potter J.P. Nebraska Medical Journal, Jan 1994 pp4-10
Summary
Follow evidence based when available
Sources:
• Geriatric Review Syllabus (AGS)
• American College of Physicians ( ACP)
• US Preventive Services Task Force ( USPSTF)
Web site:
http://www.ahrq.gov/clinic
Or downloadable PDA source at
http://www.ahrq.gov/index.html
Please request “Health Care Maintenance” summary card, Geriatric
Depression Scale or the Functional Screening Form from 402.559.3964
[email protected]
• When evidence not available, give advice as if they
were your parents.
or
Post Test
A 75-year-old man comes to your
office for a scheduled visit. He
has no new complaints but has
read about prostate-specific
antigen (PSA) testing, and he
wonders whether he should
have it. The patient has an
ischemic cardiomyopathy
(ejection fraction 20%) that is
moderately well controlled on
furosemide, 40 mg daily;
metoprolol, 100 mg twice daily;
aspirin, 81 mg daily; and
enalapril, 20 mg daily. He also
takes acetaminophen, 1000 mg
three times daily, for knee pain.
He reports nocturia once per
night but no hesitancy,
frequency, urgency, dysuria, or
other urinary problems.
Which of the following
statements regarding PSA
testing for this patient is
based on the best medical
evidence?
1) It should be recommended
because early cancers can
be detected.
2) It should be recommended
because the patient is
symptomatic.
3) It is not indicated because
early cancers cannot be
detected.
4) It is not indicated because
the harms of testing likely
outweigh the potential
benefits.
Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and
Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.
Correct Answer: It is not indicated because the harms of testing likely outweigh
the potential benefits.
Feedback:Although PSA testing can detect asymptomatic prostate cancer, there is
no consensus that early detection improves survival and quality of life. Though
the incidence of prostate cancer increases markedly with age, older men with
the disease usually die of other conditions. Further, abnormal test results almost
inevitably lead to biopsy and treatment if positive. The potential negative effects
of treatment - a small possibility of death and moderately high probabilities of
impotence and incontinence - must be considered in the screening decision.
Total life expectancy for all men at age 75 is 8 to 11 years, with an active life
expectancy of 6 to 7 years. The potential benefits of treatment depend on life
expectancy, and even advocates of screening do not promote PSA testing for
men with a shortened life expectancy. The American Urological Association and
the American Cancer Society recommend that the test be offered to men aged
50 and over who have at least a 10-year life expectancy. Decision analyses
suggest that after about age 70, screening offers at most a very small benefit
and may actually lead to a reduction in quality-adjusted life years. This patient
with ischemic cardiomyopathy almost certainly has a life expectancy of much
less than 10 years.
The American College of Physicians recommends that ?physicians should
describe the potential benefits and known harms of screening, diagnosis and
treatment; listen to the patient?s concerns; and then individualize the decision to
screen.? In this patient, age and comorbidity lower the potential benefits of
treatment, so that watchful waiting might be the preferred approach if cancer is
detected. Therefore, screening is not the preferred option. Patients who are
informed about the potential risks and benefits of PSA screening are less likely
to choose screening; one factor associated with a choice against screening is
older age.
The U.S. Preventive Services Task Force has given PSA testing a grade of D
(i.e., some evidence against performing the service). Nonetheless, the patient
should be informed of the reasons why testing might not be desirable and then