Week 1 - Screening Flashcards
1
Q
define “screening”
A
examination of a group of usually asymptomatic individuals to detect those with a high probability of having or developing a given disease
2
Q
8 elements of a good screening test
A
- should be seeking important health problem
- effective/acceptable treatment exists
- suitable test exists
- accurate
- acceptable to patients
- natural hx of the condition should be well understood
- overall benefits of screening should outweigh harm
- should ensure informed choice, confidentiality, and respect for autonomy
3
Q
3 advantages of screening
A
- early detection
- improve outcomes
- reassurance
4
Q
4 disadvantages of screening
A
- false positives
- uses resources
- over-treatment
- harm of test procedure itself
5
Q
sensitivity
A
ability to detect disease (proportion of actual positives identified as positives)
6
Q
specificity
A
ability to detect health (proportion of people without disease detected as such)
7
Q
PPV (positive predictive value)
A
PPV = TP / TP+FP
8
Q
NPV (negative predictive value)
A
NPV = TN / TN+FN
9
Q
sensitivity equation
A
TP / TP+FN
10
Q
specificity equation
A
TN / TN + FP
11
Q
AUDIT questionnaire
0-7
A
Zone I
alcohol education
12
Q
AUDIT questionnaire
8-15
A
Zone II
simple advice
13
Q
AUDIT questionnaire
16-19
A
Zone III
simple advice + brief counselling & continued monitoring
14
Q
AUDIT questionnaire
20-40
A
Zone IV
Referral to specialist for diagnostic
15
Q
What is the Alcoholism single question test
A
“On any single occasion during the past 3 months have you had more than 5 drinks containing alcohol?”
Positive answer accurately identifies patients who meet either NIAAA’s criteria for at-risk drinking or the criteria for alcohol abuse or dependence specified in DSM–IV
16
Q
what fraction of Canadian women is expected to develop breast cancer during her lifetime (by age 90)
A
1/9
17
Q
what fraction of Canadian women will die of breast cancer?
A
1/29
18
Q
if 2000 women screened regularly for 10 years, how many healthy women will be turned into cancer patients & treated unnecessarily?
A
10
19
Q
if 2000 women screened regularly for 10 years, how many will benefit from screening, as they will avoid dying from breast cancer because the screening detected the cancer earlier
A
1
20
Q
if 2000 women screened regularly for 10 years, how many healthy women will experience a false alarm
A
200
21
Q
mammography screening recommendation for women 50-74
A
USPSTF recommends biennial screening
CTFPHC:
For women aged 50–69 years we recommend routinely screening with mammography every 2 to 3 years.
For women aged 70–74 we recommend routinely screening with mammography every 2 to 3 years.
22
Q
mammography screening recommendation for women <50 yoa
A
USPSTF: The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms.
CTFPHC: for women aged 40–49 we recommend not routinely screening with mammography.
23
Q
recommendation for breast self-examination
A
The USPSTF recommends against teaching breast self-examination (BSE).
CTFPHC: Women younger than 40 years: There is little evidence for effectiveness specific to this group. Because the incidence of breast cancer is low in this age group, the risk of net harm from BSE and BSE instruction is even more likely.
Women aged 40–69 years: Because there is fair evidence of no benefit, and good evidence of harm, there is fair evidence to recommend that routine teaching of BSE be excluded from the periodic health examination of women in this age group.
24
Q
USPSTF cervical cancer screening [pap + HPV] recommendation women 21-65
A
The USPSTF recommends screening for cervical cancer in women age 21 to 65 years with cytology (Pap smear) every 3 years or, for women age 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years.
25
USPSTF recommendation - cervical cancer w/HPV testing women younger than 30 yrs
The USPSTF recommends against screening for cervical cancer with HPV testing, alone or in combination with cytology, in women younger than age 30 years.
26
USPSTF cervical cancer screening recommendations women younger than 21
The USPSTF recommends against screening for cervical cancer in women younger than age 21 years.
27
CTFPHC cervical cancer screening recommendation women aged 25-69
For women aged 30 to 69 we recommend routine screening for cervical cancer every 3 years
28
CTFPHC cervical cancer screening recommendation women aged
For women aged 0 to 24 we recommend not routinely screening for cervical cancer.
29
HPV DNA test
- In April FDA approved HPV DNA test as primary screening for cervical cancer (alone without cytology) for women ages 25 and older
- Tests for strains 16 and 18 and 12 other strains (31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68).
- If positive for 16 or 18 follow up with colposcopy
- If Positive for other strains follow up with cytology
30
American College of Physicians recent recommendation for pelvic exams
- Routine pelvic exams should not be performed on non-pregnant adult women (except for cervical cancer screening)
- Bimanual exams should not be used for screening purposes
- Screening for chlamydia and gonorrhea can be accomplished with nucleic acid amplification testing of urine specimen
31
USPSTF chlamydia screening recommendation women
The USPSTF recommends screening for chlamydia in sexually active women age 24 years and younger and in older women who are at increased risk for infection.
32
USPSTF chlamydia screening recommendation men
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men.
33
USPSTF chlamydia screening recommendation pregnant women
The USPSTF recommends screening for chlamydia in sexually active women age 24 years and younger and in older women who are at increased risk for infection. INCLUDING PREGNANT WOMEN
34
what fraction of men dx w/colorectal cancer
1/13
35
what fraction of women will be dx w/colorectal cancer
1/16
36
90% colorectal cancer detected after what age?
50 yrs old
37
screening for colorectal cancer for average risk individuals begins at what age
50-75 yoa
38
USPSTF colorectal cancer screening recommendation
The USPSTF recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary.
The USPSTF recommends against routine screening for colorectal cancer in adults 76 to 85 years of age. There may be considerations that support colorectal cancer screening in an individual patient.
39
3 methods of colorectal cancer screening
colonoscopy
sigmoidoscopy
FOBT
40
frequency of sigmoidoscopy?
q 5 yrs w/ FOBT q3yrs
41
frequency of colonoscopy?
q 10 yrs
42
frequency of FOBT?
q 1 yr
43
USPSTF depression screening recommendation, adults
Adults age 18 and over -- When staff-assisted depression care supports are in place: The USPSTF recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up.
Adults age 18 and over -- When staff-assisted depression care supports are not in place: The USPTF recommends against routinely screening adults for depression when staff-assisted depression care supports are not in place. There may be considerations that support screening for depression in an individual patient.
44
CTFPHC depression screening recommendation
For adults at average risk of depression, we recommend not routinely screening for depression.
For adults in subgroups of the population who may be at increased risk of depression, we recommend not routinely screening for depression.
These recommendations do not apply to people with known depression, with a history of depression or who are receiving treatment for depression.
45
describe the 2-item screening tool for depression
```
Over the past 2 weeks, how often have you been bothered by any of the following problems?
- Little interest or pleasure in doing things
- Feeling down, depressed or hopeless
Scale of 0-3
0=not at all
1=several days
2=more than half the days
3=nearly every day
```
Cutoff score of 3.
46
What do you do if depression screening is positive?
Proceed to full interview based on DSM-IV criteria for extent of depression and type of depression
47
What are the DSM-IV criteria for a major depressive episode?
At least five of the following symptoms have been present during the same 2-week period and represent a change from previous functioning: at least one of the symptoms is either 1) depressed mood or 2) loss of interest or pleasure.
1. Depressed mood most of the day, nearly every day, as indicated either by subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated either by subjective account or observation made by others) 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide
48
CTFPHC screening recommendation DMII
For adults at low to moderate risk of diabetes (determined with a validated risk calculator), we recommend not routinely screening for type 2 diabetes.
For adults at high risk of diabetes (determined with a validated risk calculator), we recommend routinely screening every 3–5 years with A1C.
For adults at very high risk of diabetes (determined with a validated risk calculator), we recommend routine screening annually with A1C.
49
USPSTF screening recommendation DMII adults w elevated BP
The USPSTF recommends screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg.
50
describe A1C test
The A1C test is a common blood test used to diagnose type 1 and type 2 diabetes and then to gauge how well you're managing your diabetes. The A1C test goes by many other names, including glycated hemoglobin, glycosylated hemoglobin, hemoglobin A1C and HbA1c.
The A1C test result reflects your average blood sugar level for the past two to three months. Specifically, the A1C test measures what percentage of your hemoglobin — a protein in red blood cells that carries oxygen — is coated with sugar (glycated). The higher your A1C level, the poorer your blood sugar control and the higher your risk of diabetes complications.
A1C has been selected as the preferred blood test, but fasting glucose measurement and the oral glucose tolerance test are acceptable alternatives. An A1C level of 6.5% or greater is recommended as the threshold for diagnosing diabetes, but values less than 6.5% do not exclude diabetes diagnosed using glucose tests
e.g. 5% = 97 mg/dL (5.4 mmol/L)
10% = 240 mg/dL (13.3 mmol/L)
51
CANRISK Type 2 diabetes risk questionnaire
- age group
- sex
- BMI
- waist size
- exercise 30 mins a day? e.g. brisk walking
- freq. fruit & vegetable intake
- HTN
- elevated BP
- given birth to large baby 9lbs+
- parent dx with diabetes
- sibling dx with diabetes
- children dx with diabetes
- ethnic group
- education
52
USPSTF screening recommendation hepatitis B
The USPSTF recommends screening for hepatitis B virus (HBV) infection in persons at high risk for infection.
The USPSTF recommends screening for hepatitis B virus (HBV) infection in pregnant women at their first prenatal visit.
53
What are the hep C high risk categories?
- past/present injection drug use
- sex with injected drug user
- blood transfusion before 1992
54
Why screen people born between 1945-1965 for hep C?
People born during 1945 through 1965 are 5 times more likely than other adults to be infected. In fact, 75% of adults with Hepatitis C were born in these years. The reasons why baby boomers have the highest rates of Hepatitis C are not completely understood.
Many of them were inadvertently exposed to HCV-infected blood before the discovery of HCV in 1989 and the development of a screening test in 1992. HCV incidence was highest during the 1980s. Given the slow progression from chronic HCV infection to cirrhosis and hepatocellular carcinoma over decades, now is the time to screen this birth cohort before complications start to appear.
55
USPSTF screening recommendation hepatitis C
Adults at high risk
The USPSTF recommends screening for hepatitis C virus (HCV) infection in persons at high risk for infection. The USPSTF also recommends offering 1-time screening for HCV infection to adults born between 1945 and 1965.
56
USPSTF screening recommendation HIV pregnant women
The USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown.
57
USPSTF screening recommendation HTN
The U.S. Preventive Services Task Force (USPSTF) recommends screening for high blood pressure in adults 18 and over.
58
CTFPHC screening recommendation HTN
We recommend blood pressure measurement at all appropriate primary care visits.
‘Appropriate’ visits may include new patient visits, periodic health exams; urgent office visits for neurological or cardiovascular related issues, medication renewal visits, and other visits where the Primary Care Practitioner deems it an appropriate opportunity to monitor blood pressure. It is not necessary to measure blood pressure on every patient at every office visit if not clinically indicated.
59
CTFPHC diagnosis recommendation systolic >140 or diastolic >90
If systolic BP (SBP) is ≥140 mmHg and/or diastolic BP (DBP) is ≥90 mmHg, a specific visit should be scheduled for the assessment of hypertension (Grade D). If BP is high-normal (SBP 130 – 139 mmHg and/or DBP 85 – 89 mmHg), annual follow-up is recommended (Grade C).
At the initial visit for the assessment of hypertension, if SBP is >140 mmHg and/or DBP is >90 mmHg, at least two more readings should be taken during the same visit.
At visit 2 for the assessment of hypertension, patients with macrovascular target organ damage, diabetes mellitus, or chronic kidney disease (CKD; GFR < 60 ml/min/1.73m² ) can be diagnosed as hypertensive if SBP is ≥140 mmHg and/or DBP is ≥90 mmHg (Grade D).
60
USPSTF lipid disorders screening recommendation Men 35 yrs+
Cholesterol, dyslipidemia
The USPSTF strongly recommends screening men aged 35 and older for lipid disorders.
61
How to determine risk for lipid disorders?
USPSTF (any 1 risk factor will qualify)
Increased risk, for the purposes of this recommendation, is defined by the presence of any one of the risk factors listed below. The greatest risk for Coronary Heart Disease is conferred by a combination of multiple listed factors. While the USPSTF did not use a specific numerical risk to bound this recommendation, the framework used by the USPSTF in making these recommendations relies on a 10-year risk of cardiovascular events:
Diabetes.
Previous personal history of CHD or non-coronary atherosclerosis (e.g., abdominal aortic aneurysm, peripheral artery disease, carotid artery stenosis).
A family history of cardiovascular disease before age 50 in male relatives or age 60 in female relatives.
Tobacco use.
Hypertension.
Obesity (BMI ≥30).
62
USPSTF screening recommendation iron def. anemia in children
The U.S. Preventive Services Task Force (USPSTF) concludes that evidence is insufficient to recommend for or against routine screening for iron deficiency anemia in asymptomatic children aged 6 to 12 months.
Rating: I Recommendation
63
USPSTF screening recommendation iron def. anemia in pregnant women
The USPSTF recommends routine screening for iron deficiency anemia in asymptomatic pregnant women.
Rating: B Recommendation
64
USPSTF screening recommendation iron def. anemia in non-pregnant adults
no recommendation.
65
USPSTF screening recommendation obesity for adults
The USPSTF recommends screening all adults for obesity. Clinicians should offer or refer patients with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions.
66
USPSTF screening recommendation obesity for children
The USPSTF recommends that clinicians screen children aged 6 years and older for obesity and offer them or refer them to comprehensive, intensive behavioral intervention to promote improvement in weight status.
67
Demographic risk factors for osteoporosis
- sex - female
- age - older
- race - you're at greatest risk of osteoporosis if you're white or of Asian descent.
- family hx - Having a parent or sibling with osteoporosis puts you at greater risk, especially if your mother or father experienced a hip fracture.
- body frame size - Men and women who have small body frames tend to have a higher risk because they may have less bone mass to draw from as they age.
68
USPSTF screening recommendation osteoporosis, men
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men.
69
A 65-year old female with no other risk factors has a ___% 10-year risk for any osteoporotic fracture.
9.3%
70
USPSTF screening recommendation prostate cancer w PSA
The U.S. Preventive Services Task Force (USPSTF) recommends against prostate-specific antigen (PSA)-based screening for prostate cancer.
71
benefits of PSA screening?
The Task Force found that the reduction in prostate cancer deaths from PSA screening is at most very small. A large U.S. study showed no benefit from screening. A large European study that found the highest reported benefit suggests that no more than 1 man in 1,000 avoids death from prostate cancer because of screening. Other studies found no benefit at all.
The benefits of screening also decline with age due to competing causes of death, the long natural history of PCa and the lead time bias of PSA screening.
72
USPSTF screening recommendation HIV 15-65 years old
The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened.
According to estimates from the Centers for Disease Control and Prevention (CDC), men who have sex with men account for about 60% of HIV-positive persons in the United States1. Among men living with HIV infection who were diagnosed at age 13 years or older, 68% of infections are attributed to male-to-male sexual contact, 8% are attributed to male-to-male sexual contact and injection drug use, and 11% are attributed to heterosexual contact. Among women living with HIV infection, 74% of infections are attributed to heterosexual contact and the remainder to injection drug use1, 2. According to the CDC, heterosexual contact accounted for an estimated 25% of new HIV infections in 2010 and 27% of existing infections in 2009.
73
USPSTF screening recommendation DMII asymptomatic adults, no elevated BP
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for type 2 diabetes in asymptomatic adults with blood pressure of 135/80 mm Hg or lower.
74
USPSTF screening recommendation HTN children & adolescents
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for primary hypertension in asymptomatic children and adolescents to prevent subsequent cardiovascular disease in childhood or adulthood.
75
USPSTF lipid disorders screening recommendation Men 20-35 at Increased Risk for CHD
The USPSTF recommends screening men aged 20-35 for lipid disorders if they are at increased risk for coronary heart disease.
76
USPSTF lipid disorders screening recommendation Women 45 and Older at Increased Risk for CHD
The USPSTF strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease.
77
USPSTF lipid disorders screening recommendation Women 20-45 at Increased Risk for CHD
The USPSTF recommends screening women aged 20-45 for lipid disorders if they are at increased risk for coronary heart disease.
78
USPSTF lipid disorders screening recommendation Men 20-35, Women Not at Increased Risk
The USPSTF makes no recommendation for or against routine screening for lipid disorders in men aged 20 to 35, or in women aged 20 and older who are not at increased risk for coronary heart disease.
79
Harms of PSA screening?
False positives.
Biopsies can cause harms such as fever, infection, bleeding, urinary problems, and pain. A small number of men will be hospitalized because of these complications.
Because there is so much uncertainty about which cancers need to be treated, almost all men with prostate cancer found by the PSA test now get treatment with surgery, radiation, or hormone therapy. Many of these men do not need treatment because their cancer would not have grown or caused health problems even without treatment. This is called “overtreatment.”
The Task Force found that the treatment of cancers found by the PSA test has important, often lasting harms:
Erectile dysfunction (impotence) from surgery, radiation therapy, or hormone therapy;
Urinary incontinence (leakage of urine) from radiation therapy or surgery;
Problems with bowel control from radiation therapy; and
Death and serious complications from surgery.
80
USPSTF screening recommendation osteoporosis, women
65yrs+
The USPSTF recommends screening for osteoporosis in women aged 65 years and older and in younger women whose fracture risk is equal to or greater than that of a 65-year old white women who has no additional risk factors.
81
Hormonal risk factors for osteoporosis
- Sex hormones. Lowered sex hormone levels tend to weaken bone. The reduction of estrogen levels at menopause is one of the strongest risk factors for developing osteoporosis. Women may also experience a drop in estrogen during certain cancer treatments. Men experience a gradual reduction in testosterone levels as they age. And some treatments for prostate cancer reduce testosterone levels in men.
- Thyroid problems. Too much thyroid hormone can cause bone loss. This can occur if your thyroid is overactive or if you take too much thyroid hormone medication to treat an underactive thyroid.
- Other glands. Osteoporosis has also been associated with overactive parathyroid and adrenal glands.
82
Dietary risk factors for osteoporosis
- Low calcium intake. A lifelong lack of calcium plays a major role in the development of osteoporosis. Low calcium intake contributes to diminished bone density, early bone loss and an increased risk of fractures.
- Eating disorders. People who have anorexia are at higher risk of osteoporosis. Low food intake can reduce the number of calories and amount of protein and calcium ingested. In women, anorexia can stop menstruation, leading to weaker bones. In men, anorexia lowers the amount of sex hormones in the body and can weaken bone.
- Gastrointestinal surgery. A reduction in the size of your stomach or a bypass or removal of part of the intestine limits the amount of surface area available to absorb nutrients, including calcium.
83
Medications increasing risk of osteoporosis
Steroids and other medications
Long-term use of oral or injected corticosteroid medications, such as prednisone and cortisone, interferes with the bone-rebuilding process. Osteoporosis has also been associated with medications used to combat or prevent:
Seizures
Gastric reflux
Cancer
Transplant rejection
84
Lifestyle risk factors for osteoporosis
- Sedentary lifestyle. People who spend a lot of time sitting have a higher risk of osteoporosis than do those who are more active. Any weight-bearing exercise and activities that promote balance and good posture are beneficial for your bones, but walking, running, jumping, dancing and weightlifting seem particularly helpful.
- Excessive alcohol consumption. Regular consumption of more than two alcoholic drinks a day increases your risk of osteoporosis.
- Tobacco use. The exact role tobacco plays in osteoporosis isn't clearly understood, but it has been shown that tobacco use contributes to weak bones.
85
USPSTF depression screening recommendation, adolescents
The USPSTF recommends screening of adolescents (12-18 years of age) for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up.
86
USPSTF depression screening recommendation, children
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening of children (7-11 years of age).
87
CMA recommendation prostate cancer screening
Contemporary PCa screening for men with at least a 10-year life expectancy now involves more than just a DRE and PSA. No single PSA value should be the only determinant of whether or not to biopsy a patient. The PSAV, PSAD and PSA free to total ratio may improve PSA sensitivity and specificity.
88
USPSTF skin cancer screening recommendation
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of using a whole-body skin examination by a primary care clinician or patient skin self-examination for the early detection of cutaneous melanoma, basal cell cancer, or squamous cell skin cancer in the adult general population.
89
USPSTF skin cancer counselling recommendation
The U.S. Preventive Services Task Force (USPSTF) recommends counseling children, adolescents, and young adults aged 10 to 24 years who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer.
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of counseling adults older than age 24 years about minimizing risks to prevent skin cancer.
90
USPSTF screening recommendation congenital hypothyroidism
The United States Preventive Services Task Force (USPSTF) recommends screening for congenital hypothyroidism (CH) in newborns - grade A!
91
USPSTF screening recommendation thyroid disease
The USPSTF concludes the evidence is insufficient to recommend for or against routine screening for thyroid disease in adults.
92
USPSTF screening recommendation tobacco use
The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products.
The USPSTF recommends that clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke.
93
5 A strategy for counselling tobacco use
```
“5 A”
Ask about tobacco use;
Advise to quit through clear personalized messages;
Assess willingness to quit;
Assist to quit;
Arrange follow-up and support.
```
94
USPSTF screening recommendation testicular cancer
The USPSTF recommends against screening for testicular cancer in adolescent or adult men.
95
What % of A1C is recommended as the threshold for diagnosing diabetes?
An A1C level of 6.5% or greater is recommended as the threshold for diagnosing diabetes, but values less than 6.5% do not exclude diabetes diagnosed using glucose tests
