Book Preface

Learning Objectives

• Describe appropriate screening methods as they apply to neoplasms of the colon, breast, cervix, and lung
• Describe epidemiological data related to incidence and prevention of common infectious disease, chronic illness, trauma, smoking, and travel risks

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ScreeningS

Cancer Screening

A 39-year-old woman comes to the clinic very concerned about her risk of developing cancer. Her father was diagnosed with colon cancer at age 43, and her mother was diagnosed with breast cancer at age 52. She is sexually active with multiple partners and has not seen a physician since a car accident 15 years ago. She denies any symptoms at this time, and her physical examination is normal. She asks what is recommended for a woman her age.

Screening tests are done on seemingly healthy people to identify those at increased risk of disease.

However, even if a diagnostic test is available, that does not always mean it should be used to screen for a particular disease. That is because diagnostic tests may:

• Have adverse (and possibly iatrogenic) effects (e.g., large bowel perforation secondary to a colonoscopy)
• Be expensive, unpleasant, and/or inconvenient
• Lead to ineffective or even harmful treatment

The 4 malignancies for which regular screening is recommended are cancers of the colon, breast, cervix, and lung.

Colon Cancer

If there is no significant family history of colon cancer, screen everyone starting age 50.

• Colonoscopy every 10 years (preferred)
• Annual fecal occult blood test and sigmoidoscopy with barium enema every 5 years

If there is a single first-degree relative diagnosed with colorectal cancer age <60 or multiple first-degree relatives with colon cancer at any age, screen with colonoscopy starting age 40 or 10 years before the age at which the youngest affected relative was diagnosed, whichever age occurs earlier. 

• Repeat colonoscopy every 5 years
• Routine screening can stop age >75, as per the U.S. Preventive Services Task Force (USPSTF)

Breast Cancer

Mammography plus manual breast exam are used to screen for breast cancer. (Self-breast exam by itself is not recommended as a screening tool.)

• Mammography with or without clinical breast exam every 1–2 years from age 50–74
• If there is a very strong family history of breast cancer (i.e., multiple first-degree relatives), consider prophylactic tamoxifen, which prevents breast cancer in high-risk individuals

Cervical Cancer

The screening test of choice for the early detection of cervical cancer is the Papanicolaou smear (the “Pap” test). In average risk women, screen as follows:

• Starting age 21, screen with Pap (regardless of onset of sexual activity) every 3 years until age 65
• Alternatively, screen with Pap + HPV testing every 5 years, age 30–65
• Higher risk women, e.g., HIV, may require more frequent screening or screening age >65

Lung Cancer

Current recommendations for lung cancer screening are as follows:

• For adults age 55–80 with a 30-pack-year smoking history and currently smoke or have quit within 15 years, screen annually with low-dose CT.
• For those who have not smoked for 15 years; age >80; or who have another medical problem which significantly limits life expectancy or the ability to undergo surgery, screening is not necessary.

Clinical Recall

1. Which of the following patients is undergoing an inappropriate method of screening as recommended by the USPSTF?

   1. A 50-year-old man gets his first screening for colon cancer via colonoscopy
   2. A 50-year-old woman gets her first screening for breast cancer via mammography
   3. A 17-year-old woman is screened for HPV via a Pap smear after her first sexual encounter
   4. A 65-year-old man with a 30-pack-year smoking history gets a low-dose CT
   5. A 21-year-old woman with a high risk of developing breast cancer is given tamoxifen

Answer: C

Osteoporosis Screening

A bone density test uses x-rays to measure how many grams of calcium and other bone minerals are packed into a segment of bone. The bones typically tested are the spine, hip, and forearm.

• Screening with a DEXA bone density scan should be given to all women age >65.
• Screening should begin at age 60 if there is low body weight or increased risk of fractures.

Bone density test results are reported in  2 numbers.

• The T-score compares the patient’s bone density with what is normally expected in a healthy young adult of the same sex. This score is the number of units—standard deviations—that bone density is above or below the average.
  • T-score >2.5 SD indicates the likelihood of osteoporosis and increased risk of fracture.
  • A diagnosis of osteoporosis by DEXA scan also means that treatment should be initiated with bisphosphonates, oral daily calcium supplementation, and vitamin D.

• The Z-score compares the condition of the patient’s bones with those of an average person the same age and body size. It is the number of standard deviations above or below what is normally expected for someone of the same age, sex, weight, and ethnic or racial origin.
  • Z-score ≤-2 may suggest that something other than aging is causing abnormal bone loss (consider drugs causing osteoporosis such as corticosteroids).
  • The goal in this case is to identify the underlying problem.

Hypertension, Diabetes Mellitus, and Hypercholesterolemia

A 45-year-old man comes to the physician anxious about his health. Five years ago his mother was diagnosed with diabetes and high cholesterol. He is worried about his health and risk for heart disease. Physical examination is within normal limits.

Cholesterol screening should commence at age 35 in men who have no risk factors for coronary artery disease. In both men and women with risk factors, screening should be done routinely after age 20. Management should not be determined by an isolated reading because cholesterol levels may fluctuate between measurements. Repeat in 5 years in low-risk individuals.

Screening for diabetes mellitus should be considered only for patients with hypertension (>135/80 mm Hg). Diabetes mellitus is diagnosed in either of these situations:

• Two fasting glucose measurements are >125 mg/dL, HbA1c >6.5%
• Random glucose >200 mg/dL accompanied by symptoms

There is insufficient evidence for or against routine screening. The strongest indication is for those with hypertension and hyperlipidemia.

Screening is recommended for elevated blood pressure in those age >18, at every visit. Screening is not recommended for carotid artery stenosis with duplex.

Abdominal Aortic Aneurysm

U/S should be done once in men age >65 who have ever smoked. There are no screening recommendations for male nonsmokers and women, regardless of smoking history.

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