Health Care Maintenance
Molood Hadi, DO
Internal Medicine
University of California, Irvine
Objectives
• Learn about guidelines for cancer screening in
the setting of primary care
– Cervical Cancer Screening
– Breast Cancer Screening
– Colon Cancer Screening
– Prostate Cancer Screening
• Learn about preventative immunization
guidelines
Preventative Care
Primary Prevention
• Targets individuals who may be at risk to
develop a medical condition and intervenes to
prevent the onset of that condition (eg,
childhood vaccination programs, water
fluoridation, smoking prevention programs,
clean water, and sanitation).
• The disease does not exist. The goal is to
prevent development of disease.
Preventative Care
Secondary Prevention
• Targets individuals who have developed an
asymptomatic disease and institutes
treatment to prevent complications (eg,
routine pap-smears, and screening for
hypertension, diabetes, or hyperlipidemia).
• The disease does exist, but the person is
unaware (asymptomatic). The goal is to
identify and treat people with disease.
Preventative Care
Tertiary Prevention
• Targets individuals with a known disease, with
the goal of limiting or preventing future
complications (eg, rigorous treatment of
diabetes mellitus, and post–myocardial
infarction treatment with β-blockers and ASA).
• The disease exists and there are symptoms.
The goal is to prevent complications.
Cancer Prevention
Cervical Cancer Screening
Cervical Cancer Screening
• The Pap test aims to identify abnormal cells
sampled from the transformation zone, the
junction of the ecto- and endocervix, where
cervical dysplasia and cancers arise
Cervical Cancer Screening
• Sexually active adolescents are more likely
than adult women to become infected with
HPV and to have abnormal cervical cytology
screening
• Most of these abnormalities are transient and
cervical cancer is exceedingly rare in young
women.
Who to Screen
• USPSTF recommends screening for:
– women ages 21 to 65 years with cytology (Pap smear)
every 3 years
– women ages 30 to 65 years who want to lengthen the
screening interval, screening with a combination of
cytology and human papillomavirus (HPV) testing
every 5 years.
• Women aged less than 21 years should not be
screened, regardless of the age of sexual
initiation or the risk factors. (ACS, USPSTF, ACOG)
Whom Not to Screen
• The USPSTF recommends against screening for cervical
cancer in women older than age 65 years who have
had adequate prior screening and are not otherwise at
high risk for cervical cancer.
• The USPSTF recommends against screening for cervical
cancer in women who have had a hysterectomy with
removal of the cervix and who do not have a history of
a high-grade precancerous lesion (i.e., cervical
intraepithelial neoplasia [CIN] grade 2 or 3) or cervical
cancer.
More on Guidelines
• The USPSTF recommends against screening for cervical
cancer with HPV testing, alone or in combination with
cytology, in women younger than age 30 years.
• Need for a bimanual pelvic exam
– Age less than 21 years: no evidence supports the routine
internal examination of the healthy, asymptomatic patient.
– Age more than 21 years: no evidence supports or refutes
the annual pelvic exam or speculum and bimanual
examination. Annual examination of the external genitalia
should continue.
– ** ACOG recommends annual pelvic exam in all patients aged 21 or older
Screening HPV-Immunized Patients
• The possibility that vaccination might reduce
the need for screening with cytology alone or
in combination with HPV testing is not
established.
• Women who have been vaccinated should
continue to be screened.
Breast Cancer Screening
Breast Cancer Screening
• Benefits and harms of breast cancer screening
vary by age.
• Sensitivity of mammography and clinical
breast examination is higher in older,
compared with younger, women.
• Performance characteristics of mammography
are poor for women younger than 40.
Age to Initiate
• All major North American groups recommend
routine screening with mammography with or
without clinical breast examination for women
age 50 and older.
• There is controversy about routine screening for
women in their 40s.
– ACS, ACR, NCI, ACOG, NCCN recommend starting
routine screening at age 40.
– USPSTF, ACP, ACFP recommend beginning routine
screening at age 50.
Age to Discontinue
• Several groups do not explicitly state at what
age to stop.
• USPSTF recommends screening at age 74.
There is insufficient evidence beyond age 74.
• ACOG recommend that women age 75years
and older should consult with their clinician to
decide whether to continue screening.
Frequency of Screening
• USPSTF recommend biennial mammography.
• Most other North American groups tend to
shift towards annual examination.
– “Yearly mammograms are recommended starting
at age 40 and continuing for as long as a woman is
in good health”. (ACS)
• WHO for women 50-69 recommends every 12 years.
Clinical Breast Exam
• American Cancer Society recommends CBE
every three years from age 20-39 and annually
thereafter.
• USPSTF concludes that evidence is insufficient
to assess additional benefits of CBE beyond
mammography.
• WHO does NOT recommend CBE.
Breast Self Exam?!
• ACS changed its previous recommendations in
favor of monthly BSE to that women be
educated about the benefits and limitations of
BSE.
• Women should know how their breasts
normally look and feel and report any breast
change promptly to their health care provider.
Colon Cancer Screening
• Stool-Based Tests
• Colon Imaging and Direct Visualization
FOBT
• Guaiac-based fecal occult blood test
– Identifies hemoglobin by the presence of a
peroxidase reaction which turns the guaiacimpregnanted paper blue
– Non-invasive and easy to perform
– Not a good test for detection of polyps, which
usually do not bleed
– False positive results require follow up workup
iFOBT (FIT)
• Immunochemical-based fecal occult blood
(iFOBT) a.k.a. Immunochemical test (FIT)
– Not widely available yet
– More expensive that quaiac-based test
– More specific than FOBT
• Mot cost effective if fewer colonoscopies are needed
for follow-up.
– Higher sensitivity for cancer
– Low sensitivity for advanced adenocarcinoma
Fecal DNA Test
• Cologuard (Fecal DNA test)
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Detects DNA of colorectal neoplasms
More sensitive and specific than FOBT
Expensive!
Large amount of specimen required (entire bowel
movement collection)
– Less cost-effective over all
Colon Imaging and Direct
Visualization
Endoscopic and Radiologic Testing
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Flexible Sigmoidoscopy (FS, FSIG)
Optical Colonoscopy
Double-contrast barium enema (DCBE)
CT colonoscopy (CTC, formerly referred to as
“virtual colonoscopy”)
• Capsule Endopscopy
Flexible Sigmoidoscopy
• Can only identify lesions in the distal 60cm of
the bowel
• Minimal patient preparation
• Does not require sedation
• Can be performed by trained clinicians who
are not specialized in gastroenterology
• Abnormal findings will require colonoscopy for
visualization of the entire bowel
Colonoscopy
• High sensitivity and specificity
• Lesion can be removed during the procedure
• Requires conscious sedation and vigorous bowel
preparation
• Carries risk of perforation and bleeding
• Some polyps and cancer may be difficult to detect
because of their location
• Randomized trials comparing the effectiveness of
FIT with colonoscopy are ongoing.
Double-Contrast Barium Enema
• Double-contrast barium enema
– Visualizes the entire large bowel
– Detects one-half of large (>1cm) polyps
– Abnormalities must be followed by colonoscopy
– Procedural expertise required
– Use has declined with increasing use of
endoscopic and CY procedures
CT Colonography
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Nearly as sensitive as optical colonoscopy
Requires aggressive bowel prep
Does not require sedation
No risk of bowel perforation
Positive findings require colonoscopy
– All polyps >10mm and three or more >6mm
• Cumulative dose of radiation, with repeated
screenings, may increase cancer risk
Capsule Endoscopy
• Obtains images of the colon using small video
cameras embedded in the two ends of an
ingested capsule (takes images as the capsule
traverses the colon)
– Less invasive than optical colonoscopy
– Requires more rigorous bowel preparation
– Does not allow for biopsy or polyp removal
What Test to Choose…
No single test is of unequivocal superiority
• Cost and cost-effectiveness
• Patient preference
• Test availability
• First-round screening vs. interval screening
following an initial negative screen
Screening Average-Risk Patients
• Screening beginning at age 50 yrs for average
risk patients
• Discontinue screening when he individual’s
estimated life expectancy is less than 10 years
• Screening should be supported by a program
that assures proper follow-up of abnormal
findings.
USPSTF Guidelines
– Annual FOBT with a sensitive test
– Flex Sigmoidoscopy every 5 year, with sensitive
FOBT every 3 years
– Colonoscopy every 10 years
– CTC every 5 years
– DCBE every 5 years
Screening Increased-Risk Patients
• Risk for earlier onset of CRC
– Begin earlier
• Risk for more rapid progression
– Screen more frequently
• Risk of more proximal lesions (HNPCC) or risk
for greatly increased incidence (HNPCC, FAP)
– Screen with colonoscopy
Prostate Cancer Screening
Prostate Cancer Screening
•The positive predictive value for a PSA level >4.0
ng/mL is approximately 30%.
•PSA–based screening results in small or no
reduction in prostate cancer–specific mortality and
is associated with harms related to subsequent
evaluation and treatments, some of which may be
unnecessary.
Review of the Evidence for USPSTF: By Roger Chou, MD; Jennifer M. Croswell, MD, MPH;
Benign Causes of Elevated PSA
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Benign Prostatic Hyperplasia
Acute Prostatitis
Subclinical inflammation
Prostate Biopsy
Cystoscopy
TURP
Urinary Retention
Ejaculation
DRE
Perineal Trauma
Prostatic Infarction
Prostate Cancer Screening
• Men to make an informed decision with their
doctor about whether to be tested for prostate
cancer.
• Starting at age 50, men should talk to a doctor
about the pros and cons of testing so they can
decide if testing is the right choice for them.
Immunizations
Influenza vaccine
• all individuals six months of age and older
• Individuals who report egg allergy should
receive an inactivated influenza vaccine that
was not produced in eggs
Pneumococcal Vaccine
• Pneumococcal Polysaccharide Vaccine (PPSV23;
Pneumovax or Pnu-Immune) consists of capsular
material from 23 pneumococcal types
– Has been used in adults for decades but not in infants or
toddlers under age two
– All adults aged >=65 should receive a dose of PPSC23 even
if there were vaccinated when they were < 65 years of age.
– Minimum of 5 yrs between PPSV23 doses should be
maintained.
Pneumococcal Vaccine
• Pneumococcal Conjugate Vaccine (PCV, initially
marketed as a 7-valent vaccine, PCV7 [Prevnar or
Prevnar 7], now replaced by PCV13 [Prevnar 13])
– consists of capsular polysaccharides from the 13 most
common types that cause disease
– excellent immunogenicity in infants and toddlers,
– since 2010, PCV13 has been recommended for infants and
children
– Starting in 2012, PCV13 is also recommended for use in
selected high-risk adults
Pneumococcal Vaccine
Recommended for many years in the U.S.:
• all adults ≥65 years of age
• younger patients who have a condition that
increases the risk of invasive pneumococcal
disease or pneumococcal pneumonia.
Risk Factors for Infection
• Age >= 65 or <2
• Cigarette smoking
• Chronic cardiovascular disease (eg, CHF,
cardiomyopathy)
• Chronic pulmonary disease (eg, asthma,
emphysema, COPD)
• Chronic liver disease (eg, Cirrhosis)
• Chronic renal failure or nephrotic syndrome
• Diabetes mellitus
• Alcohol abuse
Sequential Dual Vaccination
• Functional of anatomic asplenia
– sickle cell disease, splenectomy
• Immunosuppresive conditions
– HIV, Congenital immunodeficiency, malignancy, B cell defects, multiple
myeloma
• Solid organ or hematopoietic cell transplant recipients
• Patients undergoing treatment with alkylating agents,
antimetabolites, or systemic glucocorticoids
• Cerebrospinal fluid leaks
• Cochlear implant recipients
• Chronic Renal Failure and Nephrotic syndrome
Revaccination
• One single revaccination with PPSV23 at least
5 years after the first dose for:
– Immunocompromised patients
– Functional or anatomic asplenia who are < 65
Zoster Vaccine
• Risk of infection increases with age
• Live attenuated vaccine for herpes zoster was
licensed by the US Food and Drug
Administration in 2006 for use in people age
60 years and older
• Vaccine most beneficial in people ages 65-75.
Advisory Committee on Immunization Practices
Tdap
• DTaP recommended in children
• Single booster dose containing Tetanus toxoid,
reduced Diphtheria toxoid, and acellular
Pertussis (Tdap) recommended for 11-12 yearolds
• Td at 10-year intervals throughout life
• The USPSTF recommends booster doses of
adult-type tetanus and diphtheria toxoid every
10 years
Tdap
• ACIP recommends a single dose of Tdap for all
adults aged 19 years and older, who have not
received Tdap previously to address waning
immunity against pertussis.
• Immunization should be reviewed in the
context of an acute injury or wound and
prophylaxis should be given if indicated.
HPV
• HPV-related disease in females
– Cervical Cancer
– Vulvar and vaginal cancer
• HPV-related disease in males
– Penile Cancer
• HPV-related disease in male and females
– Anal cancer
– Genital warts
– Oropharyngeal cancer
HPV Vaccination in Females
• Most effective among individuals who have
not been infected with HPV
• ACIP recommends the bivalent or
quadrivalent HPV vaccines for females aged 11
to 12
• Catch-up vaccination is recommended for
females aged 13-26 years, who have not been
previously vaccinated or who have not
completed their vaccine series
HPV Vaccination in Males
• Most effective among individuals, who have
not been infected with HPV
• ACIP recommends the quadrivalent vaccine in
males aged 11-12 years
• Recommended for males aged 13 to 21 years,
who have not been vaccinated previously or
who have not completed the three-dose series
• “Permissive use” through age 26 for those not
previously vaccinated.
Screening for Osteoporosis
Bone Density
• Bone Density measurements recommended
in:
– women 65 yeas of age and older
– Postmenopausal women younger than 65 years
with clinical risk factors for fracture
Screening for Osteoporosis
• Risk Factors
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Advanced age
Current cigarette smoking
Previous Fracture
Family history of hip fracture
Low body weight
Excess alcohol consumption
Long-term glucocorticoid Therapy
Rheumatoid Arthritis
Secondary osteoporosis (hypogonadism,
malabsorption, chronic liver disease, IBD)
Screening for Osteoporosis
• All individuals should be counseled about risk
factor reduction
– Smoking cessation, limiting alcohol intake, regular
weight-bearing exercises
• Low bone mass (T-score below -1.0)
– Advise Calcium supplementation
– Vitamin D intake
• Utilize FRAX®!
Follow-Up to Screening
• Low bone mass (T-score -2.00 to -2.49) or risk
factors that may cause ongoing bone loss
– measurements approximately every 2 years
• Low bone mass (T-score -1.50 to -1.99) and with
no risk factors for accelerated bone loss
– follow-up DXA in 3-5 yrs.
• Normal or slightly low bone mass (T-score -1.01
to -1.49) and with no risk factors for accelerated
bone loss
– follow-up DXA in 10 to 15 years.
More Screening…
• Don’t forget screening for:
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DM
Thyroid disease
Lipid levels
Tobacco use
Blood Pressure
Depression
AAA
more …
and more …. 
References
– American Cancer Society (ACS)
– United States Preventive Services Task Force (USPSTF)
– American College of Obstetricians and Gynecologists
(ACOG)
– National Comprehensive Cancer Network (NCCN)
– National Cancer Institute (NCI)
– American College of Physicians (ACP)
– United States Advisory Committee on Immunization
Practices (ACIP)
– Center for Disease Control (CDC)