Published September 2021
Authors: Meara Melton, MD1
Executive Editor: Yilin Zhang, MD2
1 Geriatrics Fellow, Department of Medicine, University of Colorado
2 Assistant Professor, Department of Medicine, University of Washington
- Describe which characteristics of a disease and the available screening tool that create favorable conditions for screening.
- Establish a framework for approaching disease prevention and screening in the primary care setting.
- Identify appropriate cancer screening recommendations using current guidelines and propose recommendations based on unique patient circumstances.
Plan to spend about 60 minutes preparing for this talk. Learners should receive a copy of the Adult Disease Prevention handout to use as a guide for Parts 1 and 2. The second part of this talk is Adult Disease Prevention Part 2: Cardiovascular Disease, Psychosocial, Family/Safety. Please print this prior to the lecture. Use the interactive boards as an outline to present the talk while adding information from the facilitator guide and your own knowledge. This content is important but can be dry. Do your best to prompt the learners to fill in the guidelines prior to clicking to make it more interactive.
Anticipated time to deliver the talk with and without cases or other features: without cases 20-30 minutes. The cases may take an additional 10-15 min.
The talk can be presented in two ways:
1. Project the “Interactive Board” OR
2. Reproduce your own drawing of the presentation on a whiteboard.
Objective 1: Describe which characteristics of a disease and the available screening tool that create favorable conditions for screening.
Prior to delving into a discussion of each of the cancer screening recommendations, take a few minutes to discuss the principles of cancer screening. We consider screening for a disease if it meets the following criteria:
- The disease is common in the general population
- There is a screening test available with acceptable sensitivity and specificity and is low-cost, easy to complete and has minimal patient harm
- There is a time period when the condition is asymptomatic that can be detected
- Early treatment is more effective than treatment later in the disease.
The bottom line is that screening should provide value, and the benefits of screening (preventing death/suffering from cancer) should outweigh potential harms (over-diagnosis/false positives) and cost. The decision to screen should consider comorbidities and life expectancy, as well as if diagnosis and treatment would be pursued if screening is positive.
Objective 2: Establish a framework for approaching disease prevention and screening in the primary care setting.
Briefly introduce the framework that includes 5 key areas for disease prevention and screening we need to consider when seeing patients: Cancer, Infectious Disease, Psychosocial, Cardiovascular and Family/Safety. It might be helpful to add that many organizations have best practice advisories for cancer screening and immunizations, but the clinician should be aware of the guidelines in all five of these areas and address them as indicated. There are situations when patients should not be screened (limited life expectancy, comorbidities), elect not to be screened or would not pursue treatment if a screen was positive.
Emphasize that the handout and this lecture cover the current recommendations for adults at average risk. You can add knowledge about those at higher risk as you see fit and be sure to remind the learners that guidelines are always changing. In general, they can access updated screening guidelines via the USPSTF website (https://www.uspreventiveservicestaskforce.org/uspstf/) with the caveat that there are often discrepancies between the USPSTF guidelines and those of other societies. Updates on changes are typically published in major medical journals or shared by your organization.
Objective 3: Identify appropriate cancer screening recommendations using current guidelines and propose recommendations based on unique patient circumstances.
There are only 5 types of cancer in which screening is indicated, and each has limitations.
Remind the learners that in addition to screening for these 5 cancer types, lifestyle modifications can reduce the risk of additional cancers and should also be addressed with patients. These include:
- avoiding tobacco use and limiting alcohol use
- maintaining a healthy weight and balanced diet
- engaging in physical activity
- avoiding excess sun exposure
- preventing sexually transmitted diseases
Use the interactive board to unveil the population, screening modalities/frequency and discontinuation guidelines for the 5 cancer types. Use this guide to add information about the nuances of each screening type.
Screening mammography is indicated for all females aged 50-74. For females aged 40-49, the recommendation is to engage in shared decision making with the patient to decide if screening will be completed. The absolute benefits for screening are lower for younger patients compared with older patients due to decreased incidence and sensitivity of mammography. All patients should receive counseling on the risk of false-positive results leading to additional testing. The interval for screening differs among societal guidelines but is recommended every 1-2 years and frequency should be determined by shared decision making with the patient. Discontinuation should be a discussion with the patient. The USPSTF does not recommend ongoing screening after age 74, but many clinicians consider a life expectancy less than 10 years to be a helpful guide for discontinuation.
Breast exams by a clinician or self-exams by the patient are no longer routinely performed for screening due to lack of evidence that they detect more cancer and sometimes lead to unnecessary testing.
You can add to this discussion by bringing up factors that make patients high-risk such as personal or family (parent, sibling or child) history of breast, ovarian, tubal or peritoneal cancer; ancestry or known carrier of a genetic mutation; known dense breast tissue. For these patients, a risk prediction model can be used to help determine appropriate testing. High risk patients will often need to undergo breast MRI and mammogram annually.
Colon cancer screening is recommended in average risk adults aged 45-79 with discontinuation recommended after age 85 or earlier depending on patient factors such as comorbidities and life expectancy. There are several appropriate testing modalities with different intervals depending on the test. These are listed on the interactive board and learner handout. The gold standard is still a colonoscopy as all other screening tests would require a colonoscopy for diagnosis if positive. You can ask learners to comment on the pros and cons of the different testing modalities. You can add information specific to your institution about how to talk with patients about their testing (such as colonoscopy prep/scheduling or how to return a FIT card).
Cervical cancer screening guidelines differ the most among different societies due to recent updates. The age to initiate screening is 21 (USPSTF) or 25 (ACS). The recent ACS guidelines propose a higher age for initiation due to increasing rates of HPV vaccination and decreased incidence of cervical cancer. However, ACOG, ASCCP and SGO continue to endorse the USPSTF recommendation to initiate at 21 at this time due to concerns about racial, ethnic, socioeconomic, and geographic disparities in HPV vaccination rates. Please comment on your institution’s current practice.
Types of screening tests are consistent among the guidelines and consist of primary high-risk HPV testing, cytology alone or hrHPV + cytology co-testing. The uptake of primary high-risk HPV testing has been slow due to limited availability of tests and the laboratory infrastructure changes required to switch to primary hrHPV testing. It is likely that over the next several years this will become the preferred method. One of the cases will ask the learners to determine what next steps should be taken for a patient with abnormal cytology and introduces the ASCCP tool.
Lung cancer screening is indicated in all adults ages 50-80 with at least a 20 pack-year history of smoking and is not indicated if they have quit for >15 years. Remind learners how to calculate the pack-years (number of packs of cigarettes multiplied by the number of years the patient has been smoking). This can be challenging if a patient’s smoking habits have changed over time so encourage them to be as accurate as possible and document it.
An annual low-dose CT scan is indicated for lung cancer screening. More importantly, if the patient still smokes, tobacco cessation should be addressed. For Medicare to cover lung cancer screening, a shared decision-making conversation must be documented in the patient’s chart prior to the first screening. This is the only cancer screening that requires this type of visit. The mandate was a result of a lot of direct-to-consumer advertising for CT scans and concern that patients were not notified of the potential risks (radiation exposure, overdiagnosis, additional testing). Learners should get comfortable having this discussion with patients whether they have Medicare or another payor source. We will revisit this in one of our cases.
Screening for prostate cancer in men using a prostate specific antigen (PSA) level is controversial. It was recommended until the 2012 USPSTF statement that recommended against screening. At that time, it was thought that the benefits did not outweigh the expected harms enough to recommend routine screening due to significant overdiagnosis and modest mortality benefits. In 2018, the recommendation was updated to individualize screening in males aged 55-69 (Grade C). Long-term data from the European Randomized Study of Screening for Prostate Cancer (ERSPC) showed a decline in late-stage disease with an absolute risk reduction of metastatic disease of 3.1 per 1000 men. We know that PSA testing increases detection, but mortality benefit has not been shown. In addition, there are ongoing concerns about risks of screening. These include false-positive results, complications from biopsies, overdiagnosis, and harms of treatment.
It is important to share with the learners that the message is not that we “don’t check the PSA anymore” and to emphasize that we consider the patient’s risks and have a discussion with the patient prior to proceeding. If the decision is made to screen, an appropriate interval to retest is every 1-2 years and should be discontinued after age 70. Use of the digital rectal exam is not recommended for prostate cancer screening due to low sensitivity and specificity.
Objective 4: Identify appropriate infectious disease screening and immunizations using current guidelines.
This section should be covered quickly as a refresher and should be self-explanatory. To make this section interactive, ask your learners “which immunizations should all patients receive?”, “which immunizations should you consider in younger patients?” and “which immunizations should you consider in older patients?” Using the interactive board, click each demographic to reveal which screenings are recommended for those patients. Click on each immunization to reveal more specific information.
You can expand on this discussion by reminding learners that PCV13 (Prevnar) is no longer indicated in average-risk adults. You might also add pearls on communication tools you use for discussing vaccinations with patients.
Screening for certain infections is recommended in all patients and others only for patients with risk factors. Ask your learners to identify which infections are recommended in all patients and click to reveal these infections. Click on each infection to reveal more specific information.
Take Home Points
- Cancer screening is designed to detect cancers that are common in an asymptomatic phase to allow for early treatment
- Consider unique patient characteristics that may impact the decision to pursue screening and which testing is ordered
- Be aware of the guidelines and resources for where to find updates and how to address positive screening
- American College of Obstetricians and Gynecologists. (2021, April). Updated Cervical Cancer Screening Guidelines. ACOG Practice Advisory. https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2021/04/updated-cervical-cancer-screening-guidelines
- Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes—2021. (2021, January). American Diabetes Association Diabetes Care. 44 (Supplement 1) S15-S33
- ASCCP Management Guidelines Web Application. Accessed June 28, 2021. https://app.asccp.org/
- Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Stopping Elderly Accidents, Deaths and Injuries (STEADI). Centers for Disease Control and Prevention. Accessed June 28, 2021. https://www.cdc.gov/steadi/index.html
- Jensen, T. et al. (2015, February). Decision Memo for Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439N). Centers for Medicare & Medicaid Services Center for Clinical Standards and Quality. https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=274
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- U.S. Preventive Services Task Force., & United States. In U.S. Preventive Services Task Force (USPSTF), U.S. Dept. of Health & Human Services, Agency for Healthcare Research and Quality, Rockville, MD. (Accessed June 28, 2021)
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