HEALTHY PEOPLE. Aims Interpret evidence about a screening programme and decide whether it is worthwhile – for individuals or groups Demonstrate an.

HEALTHY PEOPLEHEALTHY PEOPLE

AimsAims

Interpret evidence about a screening Interpret evidence about a screening programme and decide whether it is programme and decide whether it is worthwhile – for individuals or groupsworthwhile – for individuals or groups

Demonstrate an understanding of the Demonstrate an understanding of the concept of risk and be able to concept of risk and be able to communicate risk effectively to the patient communicate risk effectively to the patient and his or her family and his or her family

Assess your own knowledge of Assess your own knowledge of immunisation with a Quiz.immunisation with a Quiz.

criteria for screening criteria for screening

• THE WHO CRITERIA IS AS FOLLOWSTHE WHO CRITERIA IS AS FOLLOWS The condition screened for should be an The condition screened for should be an

important one important one There should be an acceptable treatment There should be an acceptable treatment

for the diseasefor the disease The facilities for diagnosis and treatment The facilities for diagnosis and treatment

should be availableshould be available

SCREENING CRITERIA SCREENING CRITERIA there should be a suitable test or examination there should be a suitable test or examination

which has few false positives - specifity - and which has few false positives - specifity - and few false negatives - sensitivity few false negatives - sensitivity

there should be a recognised latent or early there should be a recognised latent or early symptomatic stage symptomatic stage

the test or examination should be acceptable to the test or examination should be acceptable to the population the population

the cost, including diagnosis and subsequent the cost, including diagnosis and subsequent treatment, should be economically balanced in treatment, should be economically balanced in relation to expenditure on medical care as a relation to expenditure on medical care as a whole whole

Clinical Scenario'sClinical Scenario's A 50 year old female consults A 50 year old female consults

you asking for screening for you asking for screening for ovarian cancer as she had a ovarian cancer as she had a step sister who died of this step sister who died of this disease when she was 45. disease when she was 45. What information would you What information would you want from her and what would want from her and what would you tell her about screening you tell her about screening for ovarian cancer ?for ovarian cancer ?

CLINICAL Scenario'sCLINICAL Scenario's A 60 year old male attends A 60 year old male attends

asking if he can be entered asking if he can be entered into a screening programme into a screening programme for prostate cancer as he for prostate cancer as he has heard that it is common has heard that it is common in men as they grow older. in men as they grow older. What information would you What information would you ask for and what would you ask for and what would you want to communicate to him want to communicate to him about prostate screening ? about prostate screening ?

CLINICAL SENARIOCLINICAL SENARIO

A 50 year old female A 50 year old female with newly diagnosed with newly diagnosed type 2 DM asks you if type 2 DM asks you if she really has to go for she really has to go for diabetic retinal diabetic retinal screening as she has screening as she has not got time. How do not got time. How do you answer this and you answer this and does this screening does this screening programme fulfil the programme fulfil the WHO criteria ? WHO criteria ?

screening (for ovarian cancer)screening (for ovarian cancer)

There is little information concerning the There is little information concerning the nature of the precursor to a malignant nature of the precursor to a malignant ovarian tumour and there is, as yet, no ovarian tumour and there is, as yet, no proven role for screening for ovarian cancer .proven role for screening for ovarian cancer .

The common epithelial cancers may develop The common epithelial cancers may develop from ovarian inclusion cysts. Unfortunately from ovarian inclusion cysts. Unfortunately screening by ultrasonography does not screening by ultrasonography does not reduce mortality from ovarian cancer.reduce mortality from ovarian cancer.

Carcino-embryonic antigen is insufficiciently Carcino-embryonic antigen is insufficiciently sensitive or specific to be used as a sensitive or specific to be used as a screening test screening test

prostate cancer screeningprostate cancer screening

interim results from a large European interim results from a large European random controlled trial (1) and a large US random controlled trial (1) and a large US study show that screening with prostate-study show that screening with prostate-specific antigen (PSA) testing (combined specific antigen (PSA) testing (combined with digital rectal examination [DRE] in the with digital rectal examination [DRE] in the US study) (2) detects many more cancers US study) (2) detects many more cancers than usual care than usual care

PROSTATE CA SCREENINGPROSTATE CA SCREENING however a review notes caution and stateshowever a review notes caution and states "..the value of prostate cancer screening is still "..the value of prostate cancer screening is still

unclear.... whether or not this (results of the unclear.... whether or not this (results of the studies mentioned) translates into a survival studies mentioned) translates into a survival benefit from prostate cancer remains benefit from prostate cancer remains uncertain.."(3) uncertain.."(3)

interim results from the European study interim results from the European study (n=162,243) suggest that, over nine years, 1,410 (n=162,243) suggest that, over nine years, 1,410 men would need to be screened with PSA men would need to be screened with PSA testing (and 48 additional men with cancer would testing (and 48 additional men with cancer would need to be treated) to prevent one death from need to be treated) to prevent one death from prostate cancer prostate cancer

ReferencesReferences

1. MeReC Extra No 40 July 2009 1. MeReC Extra No 40 July 2009 2. 2.

Schröder FH, Hugosson J, Roobol MJ, et al, for tSchröder FH, Hugosson J, Roobol MJ, et al, for the ERSPC investigators. Screening and prostatehe ERSPC investigators. Screening and prostate-cancer mortality in a randomized European stud-cancer mortality in a randomized European study. N Engl J Med 2009;360:132-8 y. N Engl J Med 2009;360:132-8

3. 3. Andriole GL, Crawford ED, Grubb RL, et al, for tAndriole GL, Crawford ED, Grubb RL, et al, for the PLCO Project Team. Mortality results from a rhe PLCO Project Team. Mortality results from a randomized prostate-cancer screening trial. N Enandomized prostate-cancer screening trial. N Engl J Med 2009;360:1310-9gl J Med 2009;360:1310-9

screening for diabetic screening for diabetic retinopathyretinopathy

Screening guidance for diabetic retinopathy has been Screening guidance for diabetic retinopathy has been outlined by NICE (1):outlined by NICE (1):

examine the eyes of people with type 2 diabetes at the examine the eyes of people with type 2 diabetes at the time of diagnosis and at least annually thereafter time of diagnosis and at least annually thereafter (including those registered blind and partially sighted). (including those registered blind and partially sighted).

use tests that have been demonstrated to achieve: use tests that have been demonstrated to achieve: sensitivity of 80% or higher; specificity of 95% or higher; sensitivity of 80% or higher; specificity of 95% or higher; and technical failure rate of 5% or lower and technical failure rate of 5% or lower

Retinal photography, which is currently the most Retinal photography, which is currently the most practical method, when conducted and evaluated by practical method, when conducted and evaluated by trained personnel, or slit-lamp indirect ophthalmoscopy, trained personnel, or slit-lamp indirect ophthalmoscopy, which is effective in trained hands. which is effective in trained hands.

COMMUNICATING RISK TO COMMUNICATING RISK TO HEALTHY PATIENTSHEALTHY PATIENTS

A 50 year old man A 50 year old man comes to see you and comes to see you and as a final passing as a final passing comment he asks comment he asks should he get his should he get his cholesterol checked ? cholesterol checked ?

What do you need to What do you need to know to answer this know to answer this and how do you and how do you communicate his risk ? communicate his risk ?

primary prevention - high primary prevention - high cholesterolcholesterol

with respect to primary prevention of CVD in with respect to primary prevention of CVD in primary care: primary care:

a systematic strategy should be used to identify a systematic strategy should be used to identify people aged 40-74 who are likely to be at high people aged 40-74 who are likely to be at high risk risk

people should be prioritised on the basis of an people should be prioritised on the basis of an estimate of their CVD risk before a full formal estimate of their CVD risk before a full formal risk assessment. Their CVD risk should be risk assessment. Their CVD risk should be estimated using CVD risk factors already estimated using CVD risk factors already recorded in primary care electronic medical recorded in primary care electronic medical records records

HIGH RISK PATIENTSHIGH RISK PATIENTS

The following patients have higher risks: The following patients have higher risks: Significant family history (Men <55 and women Significant family history (Men <55 and women

<65 years) increases risk by a factor of 1.5; as <65 years) increases risk by a factor of 1.5; as does impaired fasting glucose and South Asian does impaired fasting glucose and South Asian origin.origin.66

Obesity (BMI ≥30 kg/m2 (especially central Obesity (BMI ≥30 kg/m2 (especially central obesity men with waists ≥102 in white obesity men with waists ≥102 in white caucasians (≥90 cm in asians). Corresponding caucasians (≥90 cm in asians). Corresponding waist values for women are ≥88cm and ≥80 cm). waist values for women are ≥88cm and ≥80 cm). Obesity increases risk by a factor of 1.3. Obesity increases risk by a factor of 1.3.

HH

HIGH RISK PATIENTSHIGH RISK PATIENTS Serum triglyceride of 1.7mmol/l or more increases CVD Serum triglyceride of 1.7mmol/l or more increases CVD

risk by 1.3 times risk by 1.3 times A low HDL cholesterol (< 1.0 mmol/l in men and <1.2 A low HDL cholesterol (< 1.0 mmol/l in men and <1.2

mmol/l in women) also increases risk. mmol/l in women) also increases risk.


people older than 40 should have their people older than 40 should have their estimate of CVD risk reviewed on an estimate of CVD risk reviewed on an ongoing basis ongoing basis

people should be prioritised for a full people should be prioritised for a full formal risk assessment if their estimated formal risk assessment if their estimated 10-year risk of CVD is 20% or more 10-year risk of CVD is 20% or more

the Framingham 1991 10-year risk the Framingham 1991 10-year risk equations should be used to assess CVD equations should be used to assess CVD risk risk


statin therapy is recommended as part of the statin therapy is recommended as part of the management strategy for the primary management strategy for the primary prevention of CVD for adults who have a 20% prevention of CVD for adults who have a 20% or greater 10-year risk of developing CVDor greater 10-year risk of developing CVD

the suggestion is that treatment is initiated the suggestion is that treatment is initiated with simvastatin 40mg per day and then with simvastatin 40mg per day and then there is no indication to check lipid levels there is no indication to check lipid levels again. This seems to be based on the again. This seems to be based on the findings of the Heart Protection studyfindings of the Heart Protection study


A 41 year comes to see you A 41 year comes to see you about another problem but you about another problem but you notice she has had a BMI notice she has had a BMI recorded recently of 44. In recorded recently of 44. In addition she has had an addition she has had an admission to AGH for chest pain admission to AGH for chest pain where a cardiac cause was where a cardiac cause was excluded but the discharge excluded but the discharge summery has requested the GP summery has requested the GP discuss her BMI. discuss her BMI.

How do you proceed to How do you proceed to communicate her risks ? communicate her risks ?

obesity and cardiovascular obesity and cardiovascular disease (CVD) riskdisease (CVD) risk

waist circumference is the most practical marker waist circumference is the most practical marker for abdominal obesity for abdominal obesity

overweight and abdominal obesity are overweight and abdominal obesity are associated with other cardiovascular risk factors associated with other cardiovascular risk factors including small and dense atherogenic LDL including small and dense atherogenic LDL cholesterol, low HDL cholesterol, raised cholesterol, low HDL cholesterol, raised triglycerides, elevated blood pressure, insulin triglycerides, elevated blood pressure, insulin resistance, and impaired glucose regulation resistance, and impaired glucose regulation including diabetes including diabetes

obesity and cardiovascular obesity and cardiovascular disease (CVD) riskdisease (CVD) risk

obese women have four times the risk of CHD than non-obese women have four times the risk of CHD than non-obese women. obese women.

in men being obese (BMI >30) or overweight is strongly in men being obese (BMI >30) or overweight is strongly associated with an increase in the risk of atherosclerotic associated with an increase in the risk of atherosclerotic disease.disease.

a cohort study revealed that the adverse effects of a cohort study revealed that the adverse effects of overweight on blood pressure and cholesterol levels overweight on blood pressure and cholesterol levels could account for about 45% of the increased risk of could account for about 45% of the increased risk of CHD.CHD.

NICE state that severe obesity (body mass index greater NICE state that severe obesity (body mass index greater than 40 kg/m2) affects CVD risk and should be than 40 kg/m2) affects CVD risk and should be considered when using risk scores to inform treatment considered when using risk scores to inform treatment decisions.decisions.


A 36 year old consults you with another A 36 year old consults you with another problem but mentions that he recognises problem but mentions that he recognises he is slightly overweight and really should he is slightly overweight and really should exercise more. He is concerned he will exercise more. He is concerned he will end up with hypertension and worse as his end up with hypertension and worse as his father was the same build and inactive and father was the same build and inactive and developed hypertension in his early 40,s. developed hypertension in his early 40,s. How do you communicate the health How do you communicate the health benefits of exercise ? benefits of exercise ?

exercise and cardiovascular (CV) exercise and cardiovascular (CV) riskrisk

people who are physically active reduce their people who are physically active reduce their risk of developing coronary heart disease, stroke risk of developing coronary heart disease, stroke and type II diabetes by up to 50% and type II diabetes by up to 50%

more than two-thirds of the UK population is not more than two-thirds of the UK population is not sufficiently active to accrue cardiovascular sufficiently active to accrue cardiovascular benefits benefits

primary care practitioners should identify and primary care practitioners should identify and advise inactive adults to aim for 30 minutes of advise inactive adults to aim for 30 minutes of moderate intensity physical activity on 5 or more moderate intensity physical activity on 5 or more days of the week days of the week


healthy adults aged 18 - 65 years are healthy adults aged 18 - 65 years are recommended to participate in moderate-recommended to participate in moderate-intensity aerobic physical activity for a intensity aerobic physical activity for a minimum of 30 minutes on five days each minimum of 30 minutes on five days each week or vigorous intensity aerobic activity week or vigorous intensity aerobic activity for a minimum of 20 minutes on three days for a minimum of 20 minutes on three days each weekeach week

Although regular vigorous physical activity Although regular vigorous physical activity confers maximum cardiovascular benefit, it is confers maximum cardiovascular benefit, it is apparent that this level of activity is unattainable apparent that this level of activity is unattainable and unlikely to be sustainable for the majority of and unlikely to be sustainable for the majority of the population.the population.


Regular moderate intensity physical activity:Regular moderate intensity physical activity: reduces adiposity, particularly in those with excess upper reduces adiposity, particularly in those with excess upper

body and abdominal fat body and abdominal fat reduces both systolic and diastolic blood pressure in reduces both systolic and diastolic blood pressure in

individuals with elevated blood pressure by individuals with elevated blood pressure by approximately 3.8mmHg and 2.6mmHg respectively approximately 3.8mmHg and 2.6mmHg respectively

reduces elevated plasma triglyceridesreduces elevated plasma triglycerides increases high density lipoprotein cholesterol level increases high density lipoprotein cholesterol level improves insulin sensitivity and glucose use and reduces improves insulin sensitivity and glucose use and reduces

the risk of type II diabetes the risk of type II diabetes

COMMUNICATING RISKS COMMUNICATING RISKS A 50 year old lady comes to see A 50 year old lady comes to see

you concerned that she should you concerned that she should not be on HRT anymore not be on HRT anymore because of the risks of HRT and because of the risks of HRT and breast cancer. breast cancer.

She has no personal of FH of She has no personal of FH of breast cancer and has been breast cancer and has been taking HRT for 6 months to taking HRT for 6 months to alleviate severe menopausal alleviate severe menopausal symptoms.symptoms.

How do you communicate the How do you communicate the risks to her ? What else do you risks to her ? What else do you need to know about her ?need to know about her ?

BREAST CANCER RISK WITH BREAST CANCER RISK WITH HRT HRT

HRT used for several years increases the risk of breast HRT used for several years increases the risk of breast cancer but the additional breast cancer risk due to HRT cancer but the additional breast cancer risk due to HRT for an individual is relatively small and multiple other risk for an individual is relatively small and multiple other risk factors also contribute, e.g. alcohol intake, obesity and factors also contribute, e.g. alcohol intake, obesity and lack of exerciselack of exercise

Combined HRT is associated with a higher risk than Combined HRT is associated with a higher risk than oestrogen-alone. The MWS suggested a small increase oestrogen-alone. The MWS suggested a small increase in risk of breast cancer with oestrogen-only HRT in risk of breast cancer with oestrogen-only HRT compared with combined HRT.compared with combined HRT.33 This increase in breast This increase in breast cancer with unopposed oestrogen was not found in the cancer with unopposed oestrogen was not found in the WHI study when oestrogen-only HRT was used for up to WHI study when oestrogen-only HRT was used for up to seven years.seven years.1616

BREAST CANCER RISK WITH BREAST CANCER RISK WITH HRTHRT

The increased breast cancer risk is proportional The increased breast cancer risk is proportional to the duration of HRT but not the age at which to the duration of HRT but not the age at which treatment is started (but the baseline risk of treatment is started (but the baseline risk of breast cancer also increases with age): breast cancer also increases with age):

Using combined HRT for five years, in women Using combined HRT for five years, in women aged 50-59, there are 6 additional cases of aged 50-59, there are 6 additional cases of breast cancer per 1,000 women on a baseline breast cancer per 1,000 women on a baseline incidence of about 10 per 1,000 women. For incidence of about 10 per 1,000 women. For oestrogen-only HRT, there are about 2 extra oestrogen-only HRT, there are about 2 extra cases per 1,000 women cases per 1,000 women


Using combined HRT for five years in women Using combined HRT for five years in women aged 60-69, there are 9 extra cases per 1,000 aged 60-69, there are 9 extra cases per 1,000 women on a baseline incidence of 15 per 1,000 women on a baseline incidence of 15 per 1,000 women. For oestrogen-only HRT, there are 3 women. For oestrogen-only HRT, there are 3 extra cases. extra cases.

If duration of use increases to 10 years, in If duration of use increases to 10 years, in women aged 50-59 taking combined HRT, there women aged 50-59 taking combined HRT, there are 24 additional cases of breast cancer per are 24 additional cases of breast cancer per 1,000 women on a baseline incidence of 20 per 1,000 women on a baseline incidence of 20 per 1,000 women. For oestrogen-only HRT, there 1,000 women. For oestrogen-only HRT, there are 6 extra cases are 6 extra cases


For women aged 60-69 with 10 years' use, For women aged 60-69 with 10 years' use, combined HRT increases cases of breast cancer combined HRT increases cases of breast cancer by 36 per 1,000 on a baseline of 30 per 1,000 by 36 per 1,000 on a baseline of 30 per 1,000 women and oestrogen-only by 9 cases. women and oestrogen-only by 9 cases.

The excess breast cancer risk subsides within The excess breast cancer risk subsides within five years of stopping. five years of stopping.

The invasive breast cancers diagnosed in the The invasive breast cancers diagnosed in the combined HRT group of WHI were larger and combined HRT group of WHI were larger and more advanced than the placebo group.more advanced than the placebo group.22 Previously it had been thought that breast Previously it had been thought that breast tumours found in HRT users had a better tumours found in HRT users had a better prognosis. prognosis.


HRT, especially certain regimes (e.g. HRT, especially certain regimes (e.g. conjugated equine oestrogens +/- conjugated equine oestrogens +/- medroxyprogesterone), can increase medroxyprogesterone), can increase mammographic density and may increase mammographic density and may increase the likelihood of having an abnormal the likelihood of having an abnormal mammogram that needs further mammogram that needs further investigation. investigation.

HEALTHY PEOPLE. Aims Interpret evidence about a screening programme and decide whether it is worthwhile – for individuals or groups Demonstrate an.

Documents

prostate screening

screening criteria

screening test slide

screening programme

prostate cancer slide

prostate ca screening

ovarian cancer

diabetic retinal screening