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Linda B. Deppe, DO
Woman Specific Health Screening: Changing Recommenda7ons
No disclosures to report
Woman Specific Health Screening: Changing Recommendations
Cervical Cancer Screening Breast Cancer Screening Sexually Transmitted Infection screening Guidelines and Recommendations Shared decision making with patients Resources and References
Objec7ves
Participants will understand the importance and benefits of screening women for cervical cancer,
breast cancer and STI's
Participants will understand the use of guidelines and protocols for screening women in the clinical setting , and be comfortable discussing the source of these
recommendations to patients.
Participants will understand how frequently guidelines have changed and take home resources for
remaining up to date on current and future practice changes.
Cervical Cancer Screening
Cervical Cancer Screening
From: “Pap early, do annually, never stop” To : “Once every three years and do not pap women under the age of 21”
Cervical Cancer Screening Objec7ves
Prevent morbidity and mortality from cervical cancer Prevent overzealous management of precursor lesions that will most likely regress or disappear and for which the risks of management outweigh the benefits.
Cervical Cancer Screening
Why not just look for lesions?
Don’t know which lesions will progress Need to find: Persistent HPV
CIN3 (no margin for error) CIN2 in older women, no risk to
pregnancies Persistent CIN2, CIN2/3 in non adolescent
women
Cervical Cancer Screening
Possible harms from screening: Scary words: “abnormal pap smear”
Pain/bleeding SOgma of STI
Treatment-‐related complicaOons: largely prenatal
The more colposcopies we do, the more risk we impart.
Cervical Cancer Screening
Pap starOng age 21 21 -‐29 years: q three years, cytology alone
30-‐65 years: q 3 years cytology alone
or Every 5 years if combined with HPV tesOng If pap and HPV test results are negaOve,
wait at least 5 years to rescreen
AAFP, ACOG, ACS/ASCCP/ASCP and USPSTF
Cervical Cancer Screening
HPV comes and HPV goes! IniOal tesOng: yes/no high risk Human Papilloma Virus HPV (hr HPV) No one should be tesOng for low risk HPV: if you see warts, treat them… Remember, having the oncogenic HPV isn’t the problem, it is persistence of the virus that increases risk
Cervical Cancer Screening
We must now begin teaching paOents that a well-‐woman exam or pelvic exam is not synonymous with “a pap smear”. We have spent decades calling it that, even if a paOent does not need a pap smear.
No wonder they are confused. Educate about other screenings, and care
for symptoms.
Cervical Cancer Screening
DisconOnue a^er total hysterectomy for benign reasons and no history of CIN2 or 3
or cervical cancer A^er 65 years of age with adequate prior
screening
Cervical Cancer Screening
“Adequate prior screening”: 3 consecuOve negaOve cytology OR 2 neg hrHPV within 10 years
RouOne screening should conOnue 20 years a^er regression or management of high grade lesion, even if past age 65 years
Cervical Cancer Screening
Being rarely or never screened is the major contribuOng factor to cervical cancer death
today in US. At risk are the poor, the uninsured, and
immigrant populaOons
We need more women to be tested! Be “opportunisOc” about screening.
Ovarian Cancer: No Screening
Bimanual exams, transvaginal ultrasonography and CA 125 are NOT recommended. It does not reduce ovarian cancer mortality, and leads to complications from diagnostic evaluation of false-positive results.
Ovarian Cancer Screening
Bimanual pelvic exams as a screening tool: No evidence to support efficacy, and mixed
recommendaOons. Suggest taking the 10 minutes of clinician and nurse Ome instead to address the myriad of other prevenOve issues we should with our paOents. AAFP
Sexually Transmitted Infection Screening
STI Screening
High risk sexually acOve adults: MulOple partners
STI currently or within the past year, Non-‐monogamous relaOonship,
living in an area with high rate of STIs
Screen annually for chlamydia, gonorrhea and syphilis USPSTF
STI Screening
In California, screening for chlamydia is done annually unOl age 25. NaOonally,
recommendaOon is unOl age 24.
STI Screening: HIV
HIV screening is recommended for high risk patients in all health-care settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening). Persons at high risk for HIV infection should be screened for HIV at least annually.
STI Screening: HIV
Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing. Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings. (Efficacy not strong) CDC
STI Screening: HIV
USPTF dra^ released: RouOne screening for all adults, consistent with CDC
recommendaOons of 2006. If adopted, it affects who pays: no copay for
a grade A recommendaOon under the Affordable Health Care Act
RaOonale: 20-‐25% of 1.1 million do not
know they have HIV, missing the chance to start early retroviral therapy
NEJM Feb 2013
Breast Cancer Screening
Breast Cancer Screening
Confusing and conflicOng recommendaOons from different organizaOons
ACOG/ACS: annual mammogram: begin age
40 with no defined ending age Clinical breast exam every 1-‐3 years unOl 50
years, then annually
Breast Cancer Screening
USPSTF/AAFP: biennial screening mammogram from 50 to 75 years of age. Consider at 40 to 49 years of age based on “discussion of values, benefits, and harms” Insufficient evidence to recommend clinical breast exam
Shared Decision Making
Shared Decision Making
“…………based on discussion of values, benefits, and harms………………….” How do you do this in pracOce? What tools can help?
Shared Decision Making
• An incredible 30% of healthcare spending : $700 billion per year: is spent on services that may not improve people’s health and may actually harm.
Shared Decision Making
Our culture values paOent autonomy and free choice. Physician opinion-‐driven decision making leads to a striking geographic variaOons in preference and supply sensiOve-‐care not explained by illness, medical evidence, or paOent preferences.
Shared Decision Making
PaOents want to be listened to and involved in decisions. Physicians have an ethical obligaOon to consider paOents concerns and values over their own interests.
Shared Decision Making
Many clinical decisions involve value judgments. IntervenOons have different benefits/risks that paOents value differently. There is no single right answer for everyone. Ethical, legal and cultural principles of paOent autonomy and informed consent.
Shared Decision Making
Shared decision making is reflected in 4 of the 10 “simple rules” for redesign of Healthcare:
PaOent-‐Centered Care CustomizaOon based on paOents needs and values
Shared knowledge and free flow of informaOon
Evidence based decision making Institute of Medicine 2001 “Crossing the Quality Chasm”
Shared Decision Making
Ask paOents about values…. Explain risks in a way that paOents
understand……
Sounds like informed consent on steroids.
Shared Decision Making
Sounds great. How do I do that?
Technical is easier “What patients want is not rocket science, which is really unfortunate because if it were rocket science, we would be doing it. We are great at rocket science. We love rocket science. What we’re not good at are the things that are so simple and basic that we overlook them.” • Laura Gilpin, Griffin Hospital
Shared Decision Making
Improve paOent knowledge Reduced decisional conflict about being uninformed and being unclear of values. Reduced porOon who are undecided. Reduced porOon who were passive. Simpler aids (compared to more detailed) lead to improved knowledge and greater agreement between values and choice. Decision Making Aids: Cochrane review of 55 RCT’s O’Connor, Cochrane Collaboration, 2009
Shared Decision Making
Examples
Resources/Tools
http://www.asccp.org American Society for Colposcopy and Cervical Pathology : good source for all the data, recommendations, and patient handouts “Pap guide” is an I-phone app for screening recommendations, info at the point of care
Decision Aids Resources
InternaOonal PaOent Decision Aids CollaboraOon: hop://ipdas.ohri.ca/ Ooawa PaOent Decision Aids: hop://decisionaid.ohri.ca/ Dartmouth Center for Decision Making: hop://www.dhmc.org/shared_decision_making.cfm Mayo Clinic Wiser Choice Program: hop://mayoresearch.mayo.edu/mayo/research/ker_unit/decision-‐aids.cfm
References
M. Riley, M. Dobson, E. Jones, N. Kirst: Health Maintenance in Women, American Family Physician, Vol. 87, No 1, january 1,
2013, p.29. All ACOG, USPSTF, ACS, AAFP guidelines
referenced here, tables for each http://www.aafp.org/afp/2013/0101/p30.html
References
Article summarizing the data from the colposcopic and pathology organizations http://journals.lww.com/jlgtd/PublishingImages/ASCCP%20Guidelines.pdf#zoom=80 Powerpoint version of the above article http://www.asccp.org/Portals/9/docs/pdfs/Practice%20Management/ASCCP_Cervical_Cancer_Screening_Recommendations.pdf#zoom=80
References
• http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings
References
UpdaOng the HIV-‐TesOng Guidelines -‐ A Modest Change with Major Consequences PerspecOve: MarOn, Schackman, Feb 21, 2013, DOI: 10.1056/NEJMp1214630
RouOne HIV TesOng, Public health, and the
USPSTF-‐An End to the Debate: Bayer, Oppenheimer, Feb 20, 2013: DOI: 10.1056/
NEJMp1214535
References
California guidelines chlamydia, 2011 http://www.cdph.ca.gov/pubsforms/
Guidelines/Documents/CT-Screening-Guidelines-Women-FP-PrimaryCare.pdf
Woman Specific Health Screening: Changing Recommenda7ons
Linda B. Deppe, DO [email protected] Riverside San Bernardino County Indian Health, Inc.