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 lbdeppe@gmail.com Riverside San Bernardino County Indian Health, Inc.