Pre test Question 2. Emily D. Babcock, DHSc, PA C, DFAAPA CAPA Annual Conference Palm Springs, California October 4, 2013

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1 Emily D. Babcock, DHSc, PA C, DFAAPA CAPA Annual Conference Palm Springs, California October 4, 2013 Objectives After completion of this presentation, the participant will be able to: Explain the current recommendations for breast cancer screening for women. Explain the rationale for the recommendation to begin screening mammography at age 50. Describe the most recent changes in cervical cancer screening recommendations. Assess various case scenarios to make preventive medicine recommendations regarding breast cancer and cervical cancer screening. Pre test Question 1 The most current USPSTF guidelines state that a woman s initial screening mammogram should be performed at what age? A. 35 years B. 40 years C. 45 years D. 50 years Pre test Question 2 The most current USPSTF guidelines state that the recommended interval for repeat screening mammograms for women aged is: A. Every 6 months B. Every year C. Every 2 years D. Every 5 years 1

2 Pre test Question 3 The groups involved in the most current cervical cancer guideline update agree that a woman s first pap smear should be done at what age? A. 19 years B. 20 years C. 21 years D. 25 years Varying recommendations exist regarding Types of breast cancer screening Timing of breast cancer screening Utility of breast cancer screening Most guidelines don t take into consideration cost, insurance coverage and patient desires Creates a challenge for clinicians USPSTF (U.S. Preventative Services Task Force) made substantial changes to their recommendations in 2009 Other groups don t agree with all of their most current recommendations Varying opinions exist about the different methods of breast cancer screening as well as the timing Mammography Ultrasound MRI BSE (breast self examination) Clinical breast exam 2

3 Various groups have weighed in on the USPSTF changes ACS (American Cancer Society) ACR (American College of Radiology) ACS (American College of Surgeons) ASCO (American Society of Clinical Oncology) ACOG (American Congress of Obstetricians and Gynecologists) USPSTF Makes recommendations about the effectiveness of aclinical preventive service for patients without signs or symptoms Bases its recommendations on the evidence of both the benefits and harms of the service and assesses the balance Does not consider the cost of providing a service Recognizes that clinical decisions involve more than evidence alone Wants clinicians to understand the evidence, and then make individualized decisions for specific patients and situations USPSTF rating system Recommendations are ranked according to strength of data analyzed A recommendation for the service with expectation of high benefit B recommendation for the service with expectation that benefit is moderate C recommendation against routinely providing the service D recommendation against the service I insufficient evidence to recommend for or against the service USPSTF Updates in 2009: Time to begin screening Mammogram starting at age 50 (change from 40) Evidence to support not screening women aged with mammography: Looked at reduction in 10 year mortality due to providing mammograms in the 40 s 1 death due to breast cancer could be prevented by screening 1904 women aged with mammography 1 death due to breast cancer could be prevented by screening 1339 women aged with mammography 3

4 USPSTF Updates in 2009 Interval for repeat screening Every 2 years for women aged B rating This was a change from every 1 2 years Endpoint for screening Age 75 Screening women older than 75 received an I rating USPSTF Updates in 2009 Clinical Breast Exam Received an I rating Neutral in regards to the value of clinical breast exam by a health care provider Breast Self Exam Advised that health care providers discontinue teaching breast self exam to women Received a D rating Mammography initial Mammography repeat Mammography endpoint USPSTF American Cancer Society (2010, 2012) American College of Surgeons ASCO ACOG ACR Every 2 years Every year 1 2 years 75 No recommendation CBE neutral About every 3 years age 20 39; yearlyage 40+ BSE against optional Much Clearer Now The panel concluded that we had overestimated the value of mammography: that mammography is good, but not that good; that it is necessary for many women, but not all; and that it should be performed at some frequency, but perhaps not every year, for every woman. Published in the New England Journal of Medicine, September

5 Case 1 A 44 year old woman presents for her yearly wellwoman exam. She has no family history of breast cancer, and no complaints or concerns. She has a normal breast exam and has never had a mammogram. What is your recommendation for this woman in regards to having a mammogram? A. Have one now as a baseline B. Have one at age 45 C. Have one at age 50 D. She should have an ultrasound instead Case 2 A 58 year old woman had her last mammogram 1 year ago. At that time, the mammogram results were normal, she had no complaints, and a negative clinical breast exam. She is back now for her check up and wants to know when she needs to get her next mammogram. She d prefer to wait if she can. What do you recommend? A. She needs to have one now B. She can wait until next year C. She can wait until she is 60 D. She can stop all together Case 3 A 22 year old female presents for her yearly wellwoman exam. She had a clinical breast exam last year, and is wondering if she needs another this year. She has no family history of breast cancer and had a normal clinical breast exam last year. What do you recommend? A. She needs another CBE this year B. As long as she s doing BSE, she doesn t need a CBE this year C. She can wait until she is 24 for another CBE D. She doesn t need a CBE until she is 40 5

6 New recommendations in 2012 Later initiation of pap testing Longer inter test intervals (time between pap tests) for women with negative pap histories American Congress of Obstetricians and Gynecologists (ACOG) comment: The annual visit is much more than just a pap smear, and decreased cervical cancer screening frees up time to handle other issues 2012 guidelines were released by two separate groups at the same time USPSTF Multidisciplinary partnership group (ACS/ASCCP/ASCP) American Cancer Society, American Society for Colposcopy and Cervical Pathology, American Society for Clinical Pathology ACOG had participants in both groups when guidelines were developed USPSTF conducted systematic evidence review Key focus areas Liquid cytology alone HPV testing alone Liquid cytology plus HPV testing ( co testing ) Goals Clarify the age at which to begin screening Determine when screening can be discontinued Identify the optimal interval for screening Clarify which methods of screening were most appropriate USPSTF Recommendations No screening for women younger than age 21 No screening for women aged with HPV testing alone or co testing with cytology Women aged cytology (Pap) every 3 years Women aged who want to lengthen their screening interval: cytology plus HPV testing every 5 years 6

7 Screening for cervical cancer. Clinical summary of U.S. Preventive Services Task Force recommendation. USPSTF Recommendations, cont d No screening for women older than 65 who have had adequate prior screening and are not at otherwise high risk for cervical cancer No screening for women who have had a hysterectomy with removal of the cervix and who do not have a history of high grade precancerous lesion Moyer V A Ann Intern Med doi: / by American College of Physicians ACS/ASCCP/ASCP Recommendations Begin screening at age 21 Age Pap every 3 years No use of HPV testing unless needed after an abnormal Pap test Age Pap test plus HPV co testing every 5 years preferred approach Pap test alone every 3 years acceptable approach ACS/ASCCP/ASCP Recommendations, cont d Age >65 No further screening if had regular testing with adequate negative prior screening Women with history of cervical pre cancer Continue screening until 20 years post diagnosis Women who have had a hysterectomy for benign reason Discontinue testing Women who have received the HPV vaccine Screen according to their age group 7

8 Summary The only difference between the USPSTF and the ACS/ASCCP/ASCP recommendations: Age years USPSTF Pap every 3 years OR co testing every 5 years ACS/ASCCP/ASCP Pap test every 3 years is acceptable Co testing every 5 years is preferred Case 4 An 18 year old female presents for a physical exam. She became sexually active at age 16 and asks you when she needs to have her first pap smear. What is your recommendation? A. She needs both a pap and an HPV test now B. She needs only a pap now C. She can wait until she is 19 for her first pap D. She can wait until she is 21 for her first pap Case 5 A 25 year old female presents for a well woman exam. She had her first pap at age 18, and had a pap again last year (at age 24). Both of her paps have been normal. She received the HPV vaccine when she was 20. Which is the most appropriate recommendation? A. She needs a pap and an HPV test now B. She needs only a pap now (no HPV test) C. She needs a pap and HPV test at age 27 D. She needs a pap only at age 27 (no HPV test) E. She needs her next pap at age 30, and can opt out of HPV testing because she has had the HPV vaccine Case 6 A 57 year old female with a history of normal pap smears presents for her well woman exam. She has a normal physical exam and you perform a pap as well as an HPV test. Both results are negative. Which of the following is the most appropriate recommendation as to when she needs repeat screening? A. Pap only 3 years from B. Pap and HPV test 3 years from now C. Pap and HPV test 5 years from now D. HPV test only 5 years from now 8

9 Post test Question 1 The most current USPSTF guidelines state that a woman s initial screening mammogram should be performed at what age? A. 35 years B. 40 years C. 45 years D. 50 years Post test Question 2 The most current USPSTF guidelines state that the recommended interval for repeat screening mammograms for women aged is: A. Every 6 months B. Every year C. Every 2 years D. Every 5 years Post test Question 3 The groups involved in the most current cervical cancer guideline update agree that a woman s first pap smear should be done at what age? A. 19 years B. 20 years C. 21 years D. 25 years Take Home Pearls The USPSTF has recommended that screening mammography begin at age 50 since 2009; however, many expert groups disagree with this recommendation and still recommend that screening mammography begin at age 40 The USPSTF and many expert groups recommend that cervical cancer screening should be done with co testing (pap + HPV test) every 5 years for women ages

10 References American College of Obstetricians & Gynecologists. (2012). New cervical cancer screening recommendations from the U.S. Preventative Services Task Force and the American Cancer Society/American Society for Colposcopy and Cervical Pathology/American Society for Clinical Pathology. Retrieved from Annals of Internal Medicine. (2011). The benefits and harms of more and less frequent screening mammography. Retrieved from American Cancer Society. (2012). American cancer society guidelines for the early detection of cancer. Retrieved from Bope, ET, & Kellerman, RD. Conn s Current Therapy Elsevier Saunders. Gluz, O. & Liedtke, C. (2010). Screening of breast cancer an eternal discussion revisited? Breast Care. DOI: / References Kizer, N., & Peipert, J. (2012). Cervical cancer screening: Primum non nocere. Retrieved from Moyer, V.A. (2012). Screening for cervical cancer: U.S. Preventative Services Task Force recommendation statement. Retrieved from Quanstrum, K.H., & Hayward, R.A. (2010). Lessons from the mammography wars. New England Journal of Medicine, (363)11, Smith, R.A., Cokkinides, V., Brooks, D., Saslow, D., & Brawley, O.W. (2010). Cancer screening in the United States, 2010: A review of current American Cancer Society guidelines and issues in cancer screening. CA: A Cancer Journal for Clinicians. DOI: /caac Stern, L. (2010). Navigating the evidence about cancer screening. Clinical Advisor, (13)5, Thank You! Questions or Comments? Emily.babcock@nau.edu 10

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