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Preventive Medicine
Dr. Kailash Bajaj
Assistant Professor, Internal Medicine
I have no financial disclosures
Cancer Prevention and Preventive Screening
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Breast cancer screening
Cervical cancer screening
Osteoporosis screening
Colorectal cancer screening
Prostate cancer screening
Lung cancer screening
Triple AAA
1. A 32-year-old nulliparous female with a c/o of a painful lump in her right breast of 4
weeks duration. This lump did become slightly large during menses. No nipple discharge
and no skin changes. No significant PMH and family history. She has a 38yr old sister who
is healthy. O/E exam 1cm mobile, soft, tender mass in her right upper quadrant of her
breast. Normal exam otherwise. No Lymphadenopathy.
What is the next step in management?
A. Reassurance and monthly self breast exam
B. Mammography, followed by Ultrasonography
C. Repeat clinical breast examination in 6 months
D. Ultrasonography now
E. Core needle biopsy
F. MRI of bilateral breast with Gadolinium IV contrast
Answer
D. Ultrasonography now
Breast Cancer Screening-Average Risk
• Screening with Mammogram: Age 50-75 (B)
• Screening between age 40-49 (C): False Positive, unwarranted imaging and biopsy
• Age to discontinue Mammogram is 75 yrs. and life expectancy less than 10 yrs (I)
• Over diagnosis and unnecessary treatment with no survival benefit after age 75yrs
• Annual vs Biennial, In trials screening was performed every 12 to 33 months
• CBE: Insufficient evidence as per USPSTF, ACS every 3 years from age 20 to 39,
and annually thereafter, Timing 1 week after menses in pre-menopausal women
Breast Cancer Screening
• USPSTF recommends against teaching women BSE (D)
• Approximately 10% to 20% of palpable breast cancers can be missed by either
USG or screening mammography, core needle biopsy should be done
BI-RADS (Breast imaging-reporting and data system)
0: Incomplete-Prior imaging for comparison or to call the patient back
1: Negative
2: Benign finding(s)
3: Probably benign-Repeat may be in 6 months
4: Suspicious abnormality
5: Highly suggestive of malignancy
6: Known biopsy – proven malignancy
GAIL MODEL(Breast Cancer Risk Assessment)
• Calculates 5 year risk and lifetime risk of developing breast cancer
• Most widely used method for risk assessment and especially to determine
chemoprevention
• Overestimates: Younger Female, Multiple biopsies for Non Proliferative disease
• Underestimates: Early onset breast Cancer, 2 degree relative, Males with breast
cancer
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1.Does the woman have a history of any breast cancer or of DCIS or LCIS or has she received previous radiation therapy to the chest for Rx of Hodgkin lymphoma?
2.Does the woman have a mutation in either the BRCA1 or BRCA2 gene, or a diagnosis of a genetic syndrome that may be associated with elevated risk of breast cancer?
YES or NO
YES or NO or Unknown
3.What is the woman's age?
This tool only calculates risk for women 35 years of age or older.
4. What was the woman's age at the time of her first menstrual period?
7 to 11 , 12 to 13 , > 14 or Unknown
5. What was the woman's age at the time of her first live birth of a child?
<20, 20 to 24, 25 to 29, > 30 or Unknown or NO BIRTH
6. How many of the woman's first‐degree relatives ‐
mother, sisters, daughters ‐ have had breast cancer?
0 or 1 or > 1 or Unknown
7.Has the woman ever had a breast biopsy?
YES or NO or Unknown
A.How many breast biopsies (+ or ‐) has the woman had?
B. Had at least 1 biopsy with atypical hyperplasia?
8. What is the woman's race/ethnicity?
What is the sub race/ethnicity?
African American or Caucasian or Hispanic or Asian American or American Indian or Unknown
Breast Cancer Screening
• Life time risk < 15% vs. >20-25% based on GAIL MODEL
• Women with lifetime risk ≥20 to 25 % should be referred for genetic counseling to
determine the likelihood of a BRCA mutation
• 5-10% due to inherited gene mutations, 15-20% are familial, AGE is the most important
risk, so majority breast cancers occur sporadic
• 1/3rd hereditary breast cancer due to BRCA-1 & 1/3rd due to BRCA-2 (AD)
BRCA‐1
BRCA‐2
FEMEALE BREAST CANCER
85‐90% (AGE 70)
85‐90% (AGE 70)
MALE BREAST CANCER
1%
6%
2ND BREAST CANCER
40‐60%
OVARIAN CANCER
20‐40%
15‐25%
Breast Cancer Screening
• Women with implants require routine screening mammography with 4 extra pictures (2 on
each breast) called implant displacement (ID) views to evaluate the native breast tissue
• Lumpectomy plus radiation therapy, mammogram of the treated breast about 6 months
after finishing treatment, annually thereafter of both breasts
• No mammogram after mastectomy, but annual mammogram on the remaining breast
• The appropriate timing of clinical breast examinations for the first 3 years is every 3 to 6
months
• For years 4 and 5, examination should be performed every 6 to 12 months
• After 5 years, examinations should be performed annually
2. A 37 year old female came to your office. She is BRCA-1 positive. Her mother had
breast cancer and died from ovarian cancer at age 56, while her grandmother died had
ovarian cancer. Her aunt, who had the same BRCA1 defect, died from breast cancer
couple of months ago. She has 3 kids and not planning in future pregnancy. Normal
exam and vitals. What would you strongly recommend her ?
A. Bilateral salpingo-oophorectomy and bilateral mastectomy
B. Annual mammogram and pap and pelvic exam
C. CA-125 monitoring and pelvic examination every 6 months
D. D/C oral contraceptive pills
E. Annual breast MRI screening as an adjunct to mammography
Answer
A. Bilateral salpingo-oophorectomy and bilateral mastectomy
Genetic counseling and testing
• Breast cancer before age 50 yrs, bilateral, both breast and ovarian cancers, male
breast cancer, Ashkenazi Jewish ethnicity, 2 first degree relatives
• Twice yearly ovarian cancer screening with transvaginal ultrasound and serum
CA-125 levels beginning at age 30 if BRCA gene is positive
• Recommend annual MRI screening at age 25
1. BRCA mutation not opting for bilateral mastectomy
2. First-degree relative of BRCA carrier, but untested
3. Lifetime risk >20-25 percent or greater as per Gail Model
4. Radiation to chest between age 10 and 30 years
5. Li-Fraumeni and Cowden Syndrome
3.A 65 year old female came to establish relationship with her PCP. She has 2
children in her 20s. She is fairly healthy with no significant PMH. She does not take
any medications. Her last pap and pelvic exam was 20 years ago which was normal.
She never had any abnormal pap and pelvic in her life. She wants to discuss
screening strategy for cervical cancer prevention with you.
What would you recommend her?
A. She should be screened (by either cytology every two to three years or co-testing
every five years) until age of 75 years
B. She does not any kind of screening as her risk is very low
C. She should have yearly screening with pap and pelvic for next 10 years
D. She would need Pelvic USG
Answer
A. She should be screened (by either cytology every two to three years or co-testing
every five years) until age of 75 years
Cervical Cancer Screening
• The USPSTF recommends screening within 3 years of onset of sexual activity or
age 21 (whichever comes first) and screening at least every 3 years (A)
• The USPSTF recommends against routinely screening women older than age 65
for cervical cancer if they have had adequate recent screening (D)
• Adequate screening is defined as 3 negative cytology tests or 2 consecutive
negative HPV/Pap co-tests in the 10 yrs prior to stopping, recent test within 5 yrs
• For women age 30 to 65 years who want to lengthen the screening interval,
screening with a combination of cytology and HPV testing every 5 years (A)
• HPV testing is not recommended in women younger than age 30 years (D)
Evaluation of atypical squamous cells (ASC-US & ASC-H)
ASC-US (Atypical squamous cells of undetermined significance):
-25 or older with ASC-US is testing for high-risk types of HPV testing with triage of women who test
positive to colposcopy or repeat at 1 year
-Colposcopy : cytology shows ASC-US or a more severe cervical abnormality
-21 to 24 years, repeating cytology at 12 months rather than reflex HPV testing
-Pregnant women are managed in the same way as nonpregnant, Colposcopy 6 weeks postpartum
ASC-H (A high-grade squamous intraepithelial lesion (HSIL) cannot be excluded):
-21 and above should have colposcopy regardless of HPV status
-Pregnant women with ASC-H need colposcopy, and this should not be deferred until the patient is
postpartum
Human Papilloma Virus (HPV)
• Persistent high risk HPV causes almost 100% of cervical cancer
• Infection is transient: 90% clears within 2 years, most do not develop cancer
• The carcinogenic types, HPV 16 and HPV 18, which are targeted by the current
HPV vaccines (age 9 to 26), cause approximately 70 percent of all cervical
cancers worldwide and 72 percent of anal cancers.
• A history of an abnormal Papanicolaou test, genital warts, or HPV infection is
NOT a contraindication to HPV immunization
• However, immunization is less beneficial for females who have already been
infected with one of more of the HPV vaccine types
Cervical Cancer Screening
• The USPSTF recommends against screening for cervical cancer in women who have had
a hysterectomy with removal of the cervix for a benign disease (No h/o CIN2-3, AIS in
past 20 years or cervical cancer ever)
• ACS specifies certain risk groups that may require more frequent screening: HIV
infection, immunosuppression, or in utero DES exposure.
• CIN 2-3 S/P Excision/LEEP treatment need routine (3 yr cytology or Co-testing every 5
yr) for at least 20 yrs post treatment & completion of “initial intense surveillance” defined
as defined as co-test at 1, 2 and 5 yrs post excision/LEEP
• Cervical cancer screening twice in the first year after diagnosis of HIV infection and then
annual exam include a thorough visual inspection of the anus, vulva, and vagina, as well
as the cervix
Screening for uterine tumors-Tamoxifen
• Premenopausal women have no known increased risk of uterine cancer with tamoxifen
and require no additional monitoring beyond routine gynecologic care
• For postmenopausal women, an annual gynecologic examination
• Monitor for symptoms of endometrial hyperplasia or cancer and investigate any abnormal
vaginal symptoms
• Limit tamoxifen use to 5 years duration
• If atypical endometrial hyperplasia develops, the use of tamoxifen should be reassessed
and appropriate gynecologic management should be initiated
• Hysterectomy should be considered for women with atypical endometrial hyperplasia in
whom tamoxifen therapy must be continued
Pelvic exam‐ACP Jan 2014 Statement
“Routine pelvic examination has not been shown to benefit asymptomatic, average risk, non‐pregnant women. It rarely detects important disease and does not reduce mortality and is associated with discomfort for many women, false positive and negative examinations, and extra cost”
‐For women with symptoms such as vaginal discharge, abnormal bleeding, pain, urinary problems, or sexual dysfunction
‐Postmenopausal women with an adnexal mass on pelvic exam need further work up 4. A 62-year-old Caucasian woman comes to you regarding her concerns about “thin bones.” She
denies any significant PMH. She went through menopause eight years ago. She smokes half a pack
per day.
Her vitals include: height 5’8”, weight 125 lbs, BMI 19. Her 10-year probability of a major
osteoporotic fracture is 12% and of hip fracture is 3.9% based on her Fracture Risk Assessment Tool
(FRAX) assessment. what would you recommend her?
a. DEXA scan is not indicated as she is less than 65
b. Since her 10‐year probability of any osteoporotic fracture of ≥9.3%, DEXA Scan is indicated
c. The spine is metabolically more active in younger postmenopausal women than is the hip and may provide lower measurements compared to the hip d. Hip measurements are the best predictors for monitoring intervention measures in near future
e. Both b and c
ANSWER E
b. Since her 10‐year probability of any osteoporotic fracture of ≥9.3%, dexa scan is indicated
c. The spine is metabolically more active in younger postmenopausal women than is the hip and may provide lower measurements compared to the hip Screening for Osteoporosis
• BMD assessment in all women 65 years of age and older (B)
• The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men (I)
• Younger women whose 10‐year risk of fracture is ≥9.3% than that of a 65‐year‐old woman without any other risk factors • Major independent risk factors for osteoporosis are: Caucasian race, Low body weight, Current smoking, Excessive alcohol use, Family history, Personal history of a fragility fracture, Long‐term oral glucocorticoid therapy, RA, Secondary osteoporosis (eg, hypogonadism or premature menopause, malabsorption, chronic liver disease, inflammatory bowel disease)
Follow up DEXA scan
• In the presence of low bone mass (T‐score ‐2.00 to ‐2.49) at any site or risk factors that may cause ongoing bone loss (eg, glucocorticoid use, hyperparathyroidism), repeat DEXA scan every 2 years
• In the presence of normal or slightly low bone mass (T‐score ‐1.01 to ‐
1.49), and with no risk factors for accelerated bone loss, a follow‐up DXA in 10 to 15 years. 5. A 60 yr old healthy male had last screening colonoscopy 10 years ago which was
normal. Repeat Colonoscopy discloses a 1.5-cm polyp in the ascending colon
(villous adenoma, low-grade dysplasia) and a 6-mm polyp in the sigmoid colon
(tubular adenoma, low-grade dysplasia). The polyps are completely removed.
What would you recommend him?
A. Colonoscopy every 1 to 2 years
B. Colonoscopy every 3 years
C. Colonoscopy every 5-10 years
D. Colonoscopy every 10 years
E. Referral for to a surgeon for colectomy
Answer
B. Colonoscopy every 3 years
Colorectal Cancer Screening
• The USPSTF recommends screening for average risk pts using FOBT,
sigmoidoscopy, or colonoscopy in adults beginning at age 50 years and continuing
until age 75 years.
• Insufficient evidence to assess the benefits and harms of computed tomographic
colonography and fecal DNA testing as screening
• Small (<10 mm) hyperplastic polyps in rectum or sigmoid should have next
surveillance colonoscopy in 10 years
• 1 to 2 small (<10 mm) tubular adenomas should have next surveillance
colonoscopy in 5-10 years
• 3 to 10 tubular adenomas, >10 adenomas, One or more tubular adenomas ≥10 mm,
One or more villous adenomas should have next surveillance colonoscopy in 3
years
• If the bowel preparation is inadequate for a screening colonoscopy, the
colonoscopy should be repeated before planning a long-term surveillance
Colorectal Cancer Screening
• If a single FDR was diagnosed before 60 years with CRC or an advanced
adenoma, or two or more FDR had colorectal cancer or advanced adenomas at any
age, screening with colonoscopy is recommended at age 40 or 10 years before the
youngest relative's diagnosis, to be repeated every five years.
• Patients who are candidates for curative treatment of colon or rectal Stage II and
III cancer should have a clearing colonoscopy prior to surgery (if not obstructed)
and a surveillance colonoscopy 1 year after resection, If negative, every 5 years .
• CEA testing and history and physical exam every 3-6months for 5 yrs.
• Abdomen and chest annually for 3 years; pelvis: rectal cancer only, annually for 3
to 5 years
6. A 37-year-old man was diagnosed with UC 9 years ago and is currently
asymptomatic. He was told that his colon was involved beyond rectum. His last
colonoscopy done 9 years ago, showed active colitis extending to the hepatic
flexure. No family of colon cancer. His exam is normal. His labs are normal.
What would you recommend him?
A. Colonoscopy now and every 1 to 2 years
B. Colonoscopy now if negative and every 10 years
C. Colonoscopy every 3-5 years starting at age 40
D. Colonoscopy every 10 years starting at age 50
Answer
A. Colonoscopy now and every 1 to 2 years
Colorectal Cancer Screening-UC
• Annual surveillance colonoscopy beginning after 8 to 10 years of disease in patients with
pancolitis who are surgical candidates.
• Patients with left-sided colitis surveillance should begin surveillance after 15 years of
disease.
• Multiple biopsies should be obtained at regular intervals.
• The finding of definite dysplasia (of any grade) should be confirmed by an expert
pathologist and is an indication for colectomy.
• Patients whose biopsies are indefinite for dysplasia after review by an expert pathologist
should undergo repeat surveillance colonoscopy at a shorter interval.
• Surveillance is not indicated in ulcerative proctitis.
7. A 54-year-old male came for complete physical exam. He has BPH, and his father
died of prostate cancer at the age of 70 years. He takes Flomax for BPH. He has no
urinary symptoms. Vital signs are normal, as is the remainder of the physical
examination.
What would you next for prostate cancer screening?
A. Discuss the risks and benefits of prostate cancer screening
B. Check blood PSA level
C. Do rectal exam
D. Pt needs both DRE and PSA level as he risk of having cancer is more than
average
Answer
A. Discuss the risks and benefits of prostate cancer screening
Prostate Cancer Screening
• The USPSTF recommends against PSA screening for prostate cancer in average
risk patients.
• Screening discussions at age 40-45 in patients at high-risk of developing prostate
cancer e.g, black men and men with a first-degree relative with prostate cancer
diagnosed before age 65, and men likely to have BRCA1 or BRCA2 mutations.
• Frequency every 2-4years if decision is made to screen.
• Stop screening in men with less than a 10-year life expectancy and age 65-75?
Prostate Cancer Screening
• DRE and PSA level before initiating testosterone replacement in men over age 50
years, or over age 40 years if the man has a family history or is African-American
as per Endocrine Society Clinical Guidelines.
• Repeat DRE and PSA three to six months after initiation of treatment, and then
once a year.
• After initial treatment of prostate cancer, patients who are in remission should be
followed with serial digital rectal examinations and serum PSA measurement
every 6 to 12 months.
8. A 57-year-old male came for complete physical exam. He is asymptomatic. He
has 35 pack year history of smoking however, he has quit smoking 20 years. He is
Lisinopril and statin therapy. His vital and physical exam is normal. He wants to
discuss lung cancer screening with you. What would you tell him?
A. He does qualify for low dose CT chest as has more than 30 pack years h/o
smoking
B. He does not qualify as he quit smoking 20 years ago
C. He does not qualify as he is asymptomatic
D. All of the above
Answer
B. He does not qualify as he quit smoking 20 years ago
Lung Cancer Screening
• The USPSTF recommends annual screening for lung cancer with low-dose
computed tomography in adults ages 55 to 80 years who have a 30 pack-year
smoking history and currently smoke or have quit within the past 15 years. (B
recommendation)
• Screening should be discontinued once a person has not smoked for 15 years or
develops a health problem that substantially limits life expectancy or the ability or
willingness to have curative lung surgery. (B recommendation)
National Lung Screening Trial
• The study looked at 53,454 current or former heavy smokers from 33 medical centers in the US between 2002‐2004
• Participants were randomly assigned to undergo three annual screenings with either low‐dose CT (26,722 participants) or single‐
view poster anterior chest radiography (26,732)
• Persons undergoing three annual screening examinations with low‐
dose computed tomography had a 20% reduction in lung‐cancer mortality as compared with those screened with annual chest radiography
9. A 66-year-old man is referred for abdominal aortic aneurysm (AAA) screening.
He is asymptomatic and takes no medications. He has a 20-pack-year smoking
history. Normal physical exam and normal vitals. Abdominal ultrasound discloses
that he has dilated aorta with a diameter of 2.5cm measured at the level of the renal
arteries
Which of the following is the most appropriate next step in management?
A. Observation with No further testing or screening is recommended
B. Re-test with abdominal ultrasound annually until age 75 as long size of aneurysm
is between 3.0–3.9 cm
C. Re-test with abdominal ultrasound at 6-12 months until age 75 as long as size of
aneurysm is between 4.0-5.5cm
D. Referral to surgery
Answer
A. Observation with No further testing or screening is recommended
Screening for AAA
• An abdominal aortic aneurysm (AAA) is defined as a dilated aorta with a diameter
at least 1.5 times the diameter measured at the level of the renal arteries
• The USPSTF recommends one-time screening for AAA by USG in men aged 65
to 75 who have ever smoked
• Re-test with abdominal ultrasound annually until age 75 as long size of aneurysm
is between 3.0–3.9 cm
• Re-test with abdominal ultrasound at 6-12 months until age 75 as long as size of
aneurysm is between 4.0-5.5cm
• Conservative management for most patients with asymptomatic infra-renal AAA
<5.5 cm
• Vascular surgery referral for asymptomatic AAA <5.5 cm, if size increases >0.5
cm in six months or >1 cm per year
Choose Wisely!!!
http://www.choosingwisely.org/
THANKS
Questions ?
References
- Saslow D, Hannan J, Osuch J, Alciati MH, Baines C, Barton M, et al. Clinical
breast examination: practical recommendations for optimizing performance and
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- American Cancer Society. How Many Women Get Breast Cancer? Overview:
Breast Cancer. Atlanta, GA: American Cancer Society; 2009.
- Baron RC, Rimer BK, Coates RJ, Kerner J, Mullen PD, Chattopadhyay S, et al;
Task Force on Community Preventive Services. Methods for conducting
systematic reviews of evidence on effectiveness and economic efficiency of
interventions to increase screening for breast, cervical, and colorectal cancers. Am
J Prev Med 2008;35:S26-33
- Nelson HD, Tyne K, Naik A, Bougatsos C, Chan BK, Humphrey L. Screening for
breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern
Med 2009;151:727-37
References
- Identification and Management of Women With BRCA Mutations or Hereditary
Predisposition for Breast and Ovarian Cancer, Mayo Clin Proc. Dec 2010; 85(12):
1111–1120.
- http://www.nccn.org/members/profiles/jamesGenetic.asp
- http://www.cancer.gov/cancertopics/factsheet/Risk/BRCA
- http://www.cancer.gov/bcrisktool/
- https://www.endocrine.org/~/media/endosociety/Files/Publications/Clinical%20Pr
actice%20Guidelines/FINAL-Androgens-in-Men-Standalone.pdf
- https://provider.ghc.org/all-sites/guidelines/aaa.pdf
- http://www.patient.co.uk/doctor/abdominal-aortic-aneurysms
References
- http://circ.ahajournals.org/content/early/2013/03/01/CIR.0b013e31828b82aa.full.p
df
- 2011 ACCF/AHA Focused Update of the Guideline for the Management of
Patients With Peripheral Artery Disease, 2011 ACCF/AHA Focused Update of the
Guideline for the Management of Patients With Peripheral Artery Disease
- http://www.ccjm.org/content/79/9/651.full
- http://www.nice.org.uk/nicemedia/live/10978/29981/29981.pdf