CANCER SCREENING Objectives Screen patients appropriately for - - PowerPoint PPT Presentation

CANCER SCREENING

Berdi Safford, MD

Objectives

• Screen patients appropriately for prostate,

breast, colon, cervical cancer.

• Be able to discuss with patient the

controversies surrounding screening.

• Understand barriers to screening
• Become familiar with the principles of shared

decision making

Why do we Screen?

Cancer is the 2nd leading cause of death in the United States It is the leading cause of death in people under the age of 85!

SAFFORD

Cancer Screening SAFFORD

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Cancer Screening SAFFORD

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Cancer Screening SAFFORD

Ideal Screening Test

• Prevalence of disease high enough to justify

cost of screening

• Effective acceptable treatment is available
• Asymptomatic period during which detection

and treatment significantly reduces morbidity and mortality.

• Test is sensitive enough to detect disease when

asymptomatic, specific enough to minimize false positives, acceptable to the patient.

Harms of Screening

• False-positives high anxiety, additional tests

with cost and at times potential harm

• Over-diagnosis  harms of treatment that

might not have been needed.

Cervical Cancer Screening

USPSTF/ AAFP ACS NCCN Pap Age 21 – 65* every 3 years

• r

Age 30-65* with neg HPV every 5 years *stop at age 65 if normal screen in previous 10 yrs

Colorectal Cancer Screening

USPSTF* / AAFP ACS / NCCN Adults age 50 – 75 FIT every year Flex sigmoidoscopy every 5 years Colonoscopy every 10 years Age 76-85 – recommend against (unless individual considerations) Do not address upper age limit; also mention Virtual colonoscopy (every 5 years) Stool DNA test (every 3 years) Age 86+ - recommend against * Under review

Colorectal Cancer Screening

• FIT test: screening for cancer, not polyps
• Colonoscopy: evidence suggests it prevents

cancer as well as screens Colonoscopy is the only recommended screening test for high risk adults

High Risk for Colon CA

• Personal hx of adenomatous polyp(s)
• First degree relative with colon cancer
• Personal hx of inflammatory bowel disease
• Certain hereditary syndromes (such as Lynch)
• Some guidelines also mention personal hx of
• vary, endometrium or breast cancer.

Breast Cancer Screening

USPSTF* / AAFP ACS / NCCN Age 40 – 49 – “shared decision making” Age 40+ annual mammogram Age 50 – 75 Mammogram every 2 years * Under review

Breast Cancer Screening (ACS)

• High risk (20-25% lifetime risk) should have

MRI and mammogram annually

• High risk = BRCA 1 or 2 gene mutation, 1st

degree relative with BRCA mutation and not tested herself, radiation therapy to chest between ages 10 – 30 years, or rare syndrome

• Not enough evidence to recommend MRI for

women with personal hx of breast CA

“Dense Breasts”

?US? ?MRI?

ACS: “Not enough evidence to recommend MRI” State law 21/50 states: “Breast US must be offered to women with dense breasts” (some states mandate insurance coverage for this) (Assessment of “dense breasts” is very subjective)

Dense Breasts: Evidence

• Women with “dense breasts” 1.2 to 2.1 times

lifetime risk of breast CA vs average

• “Dense breasts”= normal finding; present in

40-50% of women undergoing mammography

• Sensitivity of mammogram in women with

fatty breasts > 85%, in digital mammogram with dense breasts >82%

• Extremely high false + rate with US (94%)

Prostate Cancer Screening

USPSTF / AAFP ACS NCCN AUA Recommend against PSA screening Age 50+ shared informed decision making Age 50-70 – PSA after thorough discussion of risks/benefits Age 55-69 shared decision making, consider every 2 years

Prostate Cancer – Consensus

• Very important prior to screening to have man

understand the pros/cons of PSA, that elevated PSA may not result in immediate testing for cancer, that some prostate cancers do not require early treatment.

• Not all prostate cancers need treatment
• Men with < 10 year life span at any age

probably should not be screened.

Prostate cancer – Controversies

• Screen at all?
• Digital rectal exam?
• Baseline at age 45?
• Screening interval?
• How to manage PSA 2.5 – 4.0
• How to manage PSA > 3-4 - ?biopsy vs follow

Best references: American Cancer Society and NCCN

How are We Doing?

Commercial Insured

Screening Test WA Average Nat’l Average Nat’l 90%ile Breast CA 67% 68% 77% Cervical CA 73% 75% 80% Colorectal CA 62% 60% 72%

How are We Doing?

Medicaid Insured

Screening Test WA Average Nat’l Average Nat’l 90%ile Breast CA 53% 52% 63% Cervical CA 70% 64% 77% Colorectal CA No measurements available

Barriers to screening

• Financial – improved with ACA, though

many people are not aware of the increased coverage

• Time – lack of availability out of normal work

hours

• Resistance due to history of physical/sexual

abuse

• Cultural

Improving screening rates

2 studies:

• Brief education and reminders + nurse support

increased colorectal CA screening rates (especially FOBT use)

• FCN: track and address at most visits, extend

the role of clinical assistants to address No longer can rely on well adult visits to discuss screening recommendations

New Frontier

“Shared Decision Making”

Shared Decision Making “SDM”

Shared decision making is NOT informed consent, nor is it “ informed medical decision making.” It is a partnership in which both the patient and clinician share information, their reasoning, their values and biases with each other, then reach a course of action.

USPSTF Definition

The patient…

• Understands the risk or seriousness of the disease or

condition to be prevented.

• Understands the preventive service, including the

risks, benefits, alternatives, and uncertainties.

• Has weighed his or her values regarding the potential

benefits and harms associated with the service.

• Has engaged in decision making at a level at which

he or she desires and feels comfortable

Decision Support Tools

• Designed to help patients faced with complex

decisions

• Standards have been developed: International

Patient Decision Aids Standards (IPDAS)

• Not yet widely available

What’s Ahead?

Affordable Care Act

• Establishment of independent standards for

patient decision aids + grants to support implementation

• Development of a quality measure that

includes the use of Shared Decision Making This section of ACA is not yet funded.

Washington State

• 1st state to implement use of certified SDM

aids as evidence of informed consent.

• Initiated in 2007 a demonstration project

within the state (done at Group Health)

• In 12/14 awarded a 4-year, $65 million CMS

Innovation grant for “Healthier Washington” plan, including implementation of SDM starting in pregnant women.

Good Resources

• Shared Decision Making Tools

– www.ghc.org  “Search Health Topics”  “Exams, tests and monitoring” (open to the public)

• Patient information on pros/cons of tests

– Foundation for Informed Decision Making – interactive online information for patient – National Cancer Institute (Prostate Screening PDQ) – written information available.

Our Challenge

• Continue our quest for improved, less invasive

cancer screening tools

• Reach the 25% – 35% of Washington state

residents who have not had recommended cancer screenings performed.

• Continue to remind and encourage those who

have been screened to continue. Remember – cancer is the leading cause of death for those of us under age 85!

Question 1

• Women with personal history of breast CA

should receive an MRI of their breasts

– Yes – No

Question 2

• If financial barriers were completely removed

from cancer screening tests, many people still would not get recommended screening.

– Yes – No

Question 3

• Shared decision-making is another way of

describing informed decision-making.

– Yes – No