Berdi Safford, MD CANCER SCREENING

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 2 nd 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

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 Pap USPSTF/ AAFP ACS NCCN Age 21 65* every 3 years or 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 ovary, endometrium or breast cancer.

Breast Cancer Screening USPSTF* / AAFP Age 40 49 shared decision making Age 50 75 Mammogram every 2 years ACS / NCCN Age 40+ annual mammogram * 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, 1 st 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.

The patient USPSTF Definition 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 1 st 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