June 2020 Dr Cleo Mavriplis MD CCFP FCFP Adjunct professor Department of Family Medicine University of Ottawa I have no pharmaceutical or financial conflict of interest Except I am passionate about prevention ID: 1044349
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1. Prevention and Screening for Canadian adults June 2020Dr Cleo Mavriplis MD, CCFP, FCFPAdjunct professor Department of Family Medicine University of Ottawa
2. I have no pharmaceutical or financial conflict of interestExcept I am passionate about prevention!
3. Why preventive care?Estimated 50-70% of disease could be prevented.Cost savings++
4. ObjectivesGeneral :After this session learners will Promote prevention as an essential part of health careKnow where to find up-to-date information on preventive care in Canada
5. Specific ObjectivesFor a well adult female or male, what does the evidence say about the:-history-physical exam-screening tests-counseling
6. Polling questionIn medical school, I have counselled a patient on preventing disease or taking a screening test:YesNo
7. Type in Chat:Barriers to prevention and screeningencountered or imagined when counseling a patient
8. VideosVideo about screening testshttps://www.youtube.com/watch?v=8c7qTsVVxXwVideo about benefits of exercise for patients by Dr Mikehttps://www.reframehealthlab.com/23-and-12-hours/
9. Review answers to question about barriers
10. New ways to deliver preventive careNew opportunity post COVID-19Technology: (save time for clinicians)Interdisciplinary teams Motivational interviewing, behavioural change
11. Sources of information on Canadian preventive care guidelinesPublished in CMAJ usuallyFor family docs also check Can Fam Physwww.canadiantaskforce.caOther associations (specialty and disease-specific)
12. Conflict of interest in guidelinesResearch shows that many guidelines from disease specific or specialty organizations have conflict of interest less from government bodiesYou may choose to use but be awarehttps://www.cmaj.ca/content/cmaj/192/23/E617.full.pdfhttps://www.cfp.ca/content/66/4/235.1
13. 3 age groupsNot perfect some overlap18-50 yo , Remember at 40 yo to start lipid screening50-64 yo65+
14. Small group work6 groupsCasesName a reporter, to bring back your answers to the large group
15. Group work: healthy patient for preventive visitCaseHistory and PhysicalScreening and Counseling (includes immunizations)Amanda 33 yo femaleGroup 1Group 2Paul 52 yo maleGroup 3Group 4George 72 yo maleGroup 5Group 6
16. Amanda 33 yo femaleGroupe 1 HistoryPhysicalGroup 2Screening testsCounseling
17. History Complaints, risks (family hx, occupation etc.)Lifestyle (50-70% of chronic diseases can be prevented)Physical activity : 150 min of moderate intensity a weekNutrition : <3 min : Canadian food guide picture/website or https://www.dietitians.ca/SmokingETOH, idrugs
18. 33 yo : history cont’dSexual/contraceptive/perinatal historyFamily/relationshipsPoverty
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21. Mike Evans video on healthy eatinghttps://www.youtube.com/watch?v=fqhYBTg73fw
22. Poverty screening “Do you ever have difficulty making ends meet at the end of the month?”https://portal.cfpc.ca/resourcesdocs/uploadedFiles/CPD/Poverty_flow-Tool-Final-2016v4-Ontario.pdf
23. Life cycle:For young women and men specific areas of interview to exploreSexual activity/contraception/family planning: Safe sex, sti counseling, family planning : www.sexandu.caETOH, drugs
24. Women Women: SOGC Guideline: Women aged 20-30 year range should be counseled about age related infertility .They should be aware that natural and artificial reproductive success is significantly lower in their late 30’s and 40’s (with the exception of egg donation).
25. Alcohol: https://www.camh.ca/-/media/files/canadas-low-risk-guidelines-pdf.pdf
26. Immunizations for adultsFor best information download the CanImmunize appThe following schedule assumes the patient has been vaccinated in childhood•Td (Tetanus-diphtheria) every 10 years•Tdap(Tetanus, diphtheria, acellular pertussis or whooping cough) once ever•Measles Mumps Rubella: advised that most adults should have 2 doses • HPV: recommended for all females and males from ages 9 to 26, but safe above 26• Influenza: recommended for all adults. For high risk groups see the CanImmunize app•Pneumococcal, varicella, meningococcal are recommended for some high risk groups see the CANImmunize app
27. Physical Exam for a 33 yo BP, weight, BMI, waist circumferenceDon’t forget : pertinent physical exam relating to any risks, family history, personal history.In women: not necessary to do a bimanual pelvic exam with the pap if all normal
28. CHEP: BP reference valueshttps://guidelines.hypertension.ca/wp-content/uploads/2019/06/Diagnostic_Algorithm_2018-online.jpg
29. BMI: : reference values Reference : http://guidelines.diabetes.ca/cpg/chapter17#sec2
30. Waist circumference: reference values Reference : http://guidelines.diabetes.ca/cpg/chapter17#sec2
31. What screening tests for a 33 yo male or female?
32. Screening tests 18-50 yo STI (PHAC)Offer HIV testing to all adultsChlamydia-GC testing annually under 25 if sexually activeSTI testing if at risk (know risk factors, see app)Women: Pap start at 21yo (some provinces e.g Ontario) or at 25yo (Canadian Task Force) Pre-conception: Rubella , varicella, Hep B serology (think of every young woman as pre-conception)References: https://www.canada.ca/en/public-health/services/hiv-aids/hiv-screening-testing-guide.html
33. With HBA1C or FBSCanadian Task Force (CTF): use tool: FINRISC or CANRISK, best evidenceCanadian Diabetes Assoc (CDA):Screen every 3 years at 40 and aboveScreen earlier if risk factors Screen earlier if high risk on risk calculatorScreening for Diabetes References: https://canadiantaskforce.ca/guidelines/published-guidelines/type-2-diabetes/Online calculator CANRISK: https://canrisk.diabetes.ca/http://guidelines.diabetes.ca/screening
34. Diabetes screening tool
35. Age to start screening :Simplified lipid guidelines:40 yo for men, 50 or menopause for womenCan CVS Soc: 40 yo men, 40 yo womenBoth earlier if hi riskRisks: HTN, DM, fam hx, CKD, etc.. See guidelinesScreening for hyperlipidemia LipidsReferences: https://www.cfp.ca/content/cfp/61/10/857.full.pdfhttps://www.onlinecjc.ca/article/S0828-282X(16)30732-2/pdf
36. Canadian Cardiovascular Society Guideline (2016)
37. Tests not needed in asymptomatic , healthy patientsCBCTSH: CTF don’t screen if asymptomaticCreatinineElectrolytes
38. CounselingLifestyleSun exposureSupplementsCalciumVit DWomen: Folic acid: 0.4 to 1 mg 3mos before and after conception or alwaysReference: https://www.jogc.com/article/S1701-2163(15)30230-9/pdfhttps://www.canada.ca/en/public-health/services/pregnancy/folic-acid.html
39. Calcium and Vit D : source Osteoporosis.caBe aware that there are studies showing cardiovascular risk with increased calcium supplements and questioning their usefulness in preventing osteoporosis. Most calcium should be through food, supplements should not be above 500 mg a day
40. Paul 52 yo maleGroupe 3 HistoryPhysicalGroup 4Screening testsCounseling
41. 52 yoWhat do you add? (50-65 age group)Life cycle : chronic disease more prevalent many screening tests start at 50
42. Excellent video explaining PSA testing benefits and harms (USPSTF)Explains concepts of overdiagnosis, other harmshttps://www.youtube.com/watch?v=tYii98gcejA
43. Prostate cancer screening52 yo man says to his family MD: “My friends say I should get a PSA test and DRE” Canadian task force (2014): Do not screen with PSA.Canadian Urological Association (2017) Offer screening, shared-decision makingUSPSTF (2018) : confirmed Canadian Task Force , shared decision making: leaning towards not screeningReferenceshttps://canadiantaskforce.ca/wp-content/uploads/2016/12/CTFPHC_Prostate-Cancer_HarmsBenefits_FINAL.pdfhttps://www.cua.org/themes/web/assets/files/4888.pdf
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45. Official recommendation of the CTFPHC: Mammography at 50-74 yo q 2-3 yrs“Very low certainty evidence”Self-exam not recommended and clinical exam in asymptomatic pts with no risk but…Shared decision-making very importantSCREENING FOR BREAST CA
46. Polling question
47. 43 yo female comes to your office and says her best friend same age just was diagnosed with breast cancer and she wants a mammogramWhat do you say?. Screening for breast cancer
48. Harms:Many false positives causing worryRemoval of normal breast tissue +Overdiagnosis: labelling someone with dx of cancer when never would have had morbidity or mortality with this.Screening for breast cancer
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50. CTFPHC (2018) Breast caner guideline. Available from: http://www.cmaj.ca/content/190/49/E1441
51. Video re harms of breast ca screeninghttps://www.youtube.com/watch?v=UZlY6Q4m-MM
52. Age 50-75 : FOBT, FIT q 2 yrs, Flexible sigmoidoscopy q 10 yrs (not available everywhere) Is colonoscopy recommended in average risk asymptomatic patients for colon cancer screening? in Canada: No (no RCTs yet, 4 underway finishing in 2020s, not enough resources, more harm 1/2000 perforation risk, often not discussed)For some high risk patients: family history of polyposis, colon ca, IBD etc.Screening for colorectal cancerReference:https://canadiantaskforce.ca/wp-content/uploads/2016/05/ctfphccolorectal-cancerrecommendation-tablefinal160121-1.pdf
53. CTFPHC recommends:Adults aged 55-74 years at least a 30 pack-year smoking historywho currently smoke or quit less than 15 years agorecommend annual screening with LDCT up to three consecutive times Screening should ONLY be carried out in health care settings with expertise in early diagnosis and treatment of lung cancer.Weak recommendation; low quality evidence.Screening for lung cancer
54. In Ottawa: there is a pilot project ongoing, slightly different criteria Fear of overwhelming resources for CTSmoking cessation should be linked to thisReference: https://canadiantaskforce.ca/guidelines/published-guidelines/lung-cancer/Screening for lung cancer
55. George 72 yo maleGroupe 3 HistoryPhysicalGroup 4Screening testsCounseling
56. 72 yoHistory Same as younger: lifestyle, substances, smoking etc.Advance care planning: Falls : ask every year (patients don’t mention)Driving Immunization Referenceshttps://www.advancecareplanning.ca/https://www.cfp.ca/content/cfp/62/9/717.full.pdf
57. Immunization as adults age Td : every 10 years, Tdap once in life or if cocooning for new grandchild for instance Zoster vaccine AGE 50+ Shingrix, not covered in most provincesAGE 60+ Zostavax Covered in some provinces, Ontario 65-70 yoAGE 65+PneumococcalPNEU-P-23 advised for all immunocompetent,epeat once in 5 years only if low immunity.PNEU-C-13 advised for immunocompetent but not covered in most provinces.BE AWARE OF SCHEDULING correct time between these 2 vaccines• Pneu-C-13 vaccine should be provided first followed by Pneu-P-23 vaccine at least 8 weeks later.• If previously received Pneu-P-23 can receive Pneu-C-13 vaccine if at least one year has passed since immunization with Pneu-P-23 vaccine.Influenza yearly
58. Physical examinationDepends on their risks, co-morbidities, medications etc.Watch how they walk, sit Frailty
59. What investigations would you order ?for male only : abdo U/S for AAA (screen men 65-80 with abdo U/S x1) (CTF)PSA : discuss, not recommended for female only: mammogram (50-74), pap (25-69), stop at 69 yo if 3x normal in last 10 yrs, if not do pap until 3 normal in last 10 yrs), George 72 yo (and his wife )
60. Do they need cognitive screening? Any other screening? NO to cognitive screening – if specific concerns about memory, and if family concerned, may be appropriate to do formal cognitive testing, however this is case finding not screeningFALLSBP, height, weight, BMICouple in their 70s
61. Screening testsLipids: if healthy , no pertinent medicationsno evidence on testing after 75yo Bone density measurement: 65+ everyone, younger if risksNote 2010 Osteoporosis Canada recommendation old, may be changinghttps://osteoporosis.ca/wp-content/uploads/Quick_Reference_Guide_October_2010.pdf
62. Key messagesLifestyle counseling makes a difference, learn how to do it effectively <5minWhere to get your info for guidelines: CMAJ , and CFP for fam docsFor asymptomatic patient, no risks:18-49 yo: safe sex, sti, fam planning, etoh, smoking, drugs, bp, wt, waist, pap, dm, lipids at 4050-64 yo: same+ colorectal , lung ca?, women: breast, men: AAA ,no PSA (know the ages for the different screening tests, see slides)65+: continue above screening tests until ages to stop andFalls, advance care planning, BMD Immunizations: Td q 10yrs, Tdap once, MMRx2, HPV; Influenza all ages or >=65; 50 yo: offer Shingrix; Zostavax at 60 or age covered; Pneu23 at 65 , Pneu13 if can afford or risks( schedule)
63. Ages for screening tests if no risks/symptomsTestAge rangeCommentsPap21 or 25 to 69Stop at 69 if 3 normal last 10 yrsColorectal ca50-74Breast ca50-74Lipids40 (?50 ♀︎)-75DiabetesStart at 18 or 4018 :with calculator40 :HBA1C or FBSAAA65-80Men onlyOsteoporosis-BDM65+Lung cancer ca55-74If qualify
64. Resources-BibliographyPractitioner’s role in implementing varying guidelineshttps://www.cfp.ca/content/66/4/235.1Conflict of interest in guidelines https://www.cmaj.ca/content/cmaj/192/23/E617.full.pdfApproach to preventive care in the elderly: https://www.cfp.ca/content/cfp/62/9/717.full.pdfCollege of Family Physicians of Canada checklisthttps://www.cfp.ca/content/66/4/270/tab-cfplusMotivational interviewing: google videos on line to learn , e.g.https://www.youtube.com/watch?v=URiKA7CKtfcSmall book: Motivational Interviewing in Health Care: Helping Patients Change Behavior –by Rollnick and Miller, excellent, I read it and still needed to watch videos to know how to put into practice
65. Extra slides
66. Specific objectives Conduct a patient interview in a well adult female or male so as to identify anysignificant age-, sex-, context-specific risk factors for health conditions including exercise, diet, substance use, immunizations, and falls.
67. Specific objectivesConduct an age-, sex-, and context-specific evidence-informed physical exam in a well adult female or male including blood pressure, weight, and waist circumference.
68. Specific objectivesDiscuss pertinent screening tests for well adult females and males and explain their purposes & limitations including For women: Pap testing, mammography, colorectal cancer screening, bone mineral density, diabetes mellitus type 2 and hyperlidipemia screening.For men: colorectal cancer screening, bone mineral density, PSA testing, diabetes mellitus type 2 and hyperlidipemia screening.
69. Specific objectivesCounsel well adult females or males on relevant health promotion/ disease prevention strategies including immunizations, exercise, diet, calcium/Vitamin D, and smoking cessation.Describe the cycle of change involved in changing health behaviours in a well adult female or male