Transcript

 

Lee Tetreault:

Hello, and welcome to frequently asked questions, from updates on screening from the USPSTF 2019. We are joined today by Dr. M. Susan Burke. Doctor, before we begin, can you provide a few key pointers from our audience from today's session?

Dr. Burke:  

Well, what we did was we reviewed guidelines released by the USPSTF, and also presented guidelines from other groups as well, such as the American Cancer Society. The task force evaluates current evidence to assess benefits and harms of various preventive interventions in asymptomatic people of average risk. This is in contrast to a diagnostic test, which we would order for someone who presents with a specific symptom sign or illness. After reviewing all the guidelines please remember that many factors need to be weighed by the clinician, and the decisions and care applied to a specific patient or situation needs to be individualized. In other words, clinical judgment must prevail.

Lee Tetreault:

Thank you, Doctor. Now, let's get into some of these frequently asked questions. First, do you still recommend breast self-exam and perform clinical breast exam with a Pap?

Dr. Burke:  

The USPSTF does not endorse clinical or self-breast examination. In 2015, the American Cancer Society noted that breast exams are no longer part of the screening recommendations either, because research does not show that they provide any clear benefit. Still they say that all women should be familiar with how their breast normally look and feel, and report any changes to their health care provider right away. ACOG, The American College of Obstetrics and Gynecology, suggests that for women who are at average risk of breast cancer and who do not have symptoms, clinical breast exams can be done every one to three years for women aged 25 to 39, and yearly for those 40 and older. Because breast cancer is usually found by the woman herself. They also endorse that patients have breast self-awareness, so patients can have a sense of what's normal for their breasts and so they can tell if there are any changes, even small changes, and report these to the gynecologist or their healthcare professional.

Lee Tetreault:

Was the screening colonoscopy age dropped to 45 from 50?

Dr. Burke:  

In 2016, the task force re-affirmed its recommendation to perform colorectal cancer screening beginning at age 50, and every 10 years until 75. This was their grade A recommendation, and then for older patients, 76 to 85, it becomes a C recommendation. In other words, it can be offered to select patients depending on individual circumstances. However, a recent guideline from the American Cancer Society in 2018, was revised, and their recommendation is now to offer colorectal cancer screening starting at age 45. Now, it's important to note that this is a qualified recommendation, it's qualified mostly because studies only enrolled people who are 50 and older, but since colon cancer is seen in growing numbers in this age group, they released this new recommendation. The American Gastroenterological Association supports this approach as well, that is supports starting screening at 45. The bottom line is, as with any decisions in medicine, one needs to pick a guideline or path that makes sense to the clinician.

Lee Tetreault:

What is the FRAX score for which treatment is advised?

Dr. Burke:  

So although a BMD at or below minus 2.5 is associated with an increased risk for fracture, the greatest number of fractures in a population is actually seen in those with a decreased BMD, who do not meet the threshold of minus 2.5, they're actually between minus one and minus 2.5. But they may have other risk factors that put them at higher risk for fracture, and that's what the FRAX score calculates. They look at risk like age, family or personal history of fracture, steroid use and so forth. And this helps us in an algorithm, identify those at higher risk. So the threshold score for which treatment is recommended in the US, and this varies by country. In the US, the threshold score is a 10-year hip fracture probability of 3% or greater. Or a 10-year probability of major osteoporotic fracture. That's the composite risk of hip, spine, humerus, et cetera, of 20% or more. So those are our thresholds for which we would then consider treating a patient, even though their BMD is not by definition osteoporosis, it's not below minus 2.5.

Lee Tetreault:

How can we calculate a FRAX score without a BMD?

Dr. Burke:  

Well, interestingly the FRAX calculator was set up to be able to determine one's risk without doing a BMD or without doing any labs, you could actually calculate a FRAX score in the office with the patient right there, and check their age, weight and height, previous personal history of fracture, family history of hip fracture, current smoking status, steroid use. A secondary osteoporosis diagnosis like rheumatoid arthritis, or other inflammatory disorder, which incidentally increases your fracture risk even without steroid use. And then the other risk that they look at is alcohol intake of three drinks or more per day. Although a BMD is part of the tool, the FRAX calculation can actually be done without this number, so you can be doing this right in the office, right with that patient in front of you.

Lee Tetreault:

Should men on long-term steroid therapy have a DEXA?

Dr. Burke:  

I really think this is an important question because there is now ample evidence that shows that if acute pain is not adequately treated it can go on to actually become chronic pain. So let's take chronic post-surgical pain. This would be an ideal model for us to talk about how we might impact the development of pain in a person who's having surgery because... Especially if it's an elective surgery we can plan for it. So one of the big things that's being done now in surgical centers is what we call pre-emptive analgesia, patients actually get medications prior to the surgery, during the surgery, and then targeted therapy after the surgery to try to blunt the pain response, cut down the pain, what a reflex arc if you will, and down-regulate the pain. And I think that treating acute pain is very important. Is there a role for opioids in treatment of acute pain? Yes, there is, but that role for opioid should be, again, in the acute phase at the lowest dose possible and maybe with other medications at the same time, so that it's easier to wean the patient off of the opioid quickly.

Lee Tetreault:

And lastly, Dr. Please give us a quick summary of the available medications for pain.

Dr. Burke:  

Yes, absolutely. Although the task force has released an I-statement regarding screening for osteoporosis, these same risk factors for fracture that we consider in women also apply to men, including things like steroid use, or use of other meds that can raise their risk, like GNRH agonist for prostate cancer, chemo drugs and so forth. Other things like hypogonadism, or hyperparathyroidism, they can have Celiac disease which can be associated with a low vitamin D and impaired calcium absorption, or long-standing alcohol use. So all of these risks should prompt BMD testing. So that now leaves the screening arena and goes into more of a diagnostic arena. You're worried about these patients' risks, and you should do a BMD. If a low bone mass is even seen on an x-ray, like sometimes you get a lateral film of a chest x-ray, and you see that their bones aren't as dense as you'd like them to be.

That could be a reason to do a bone mineral density test as well. In fact, that correlates with the T-score of about minus 3, if you can actually see osteopenia on x-ray. So again, in these cases, a BMD is no longer a screening tool, but a diagnostic tool. There are screening guidelines and recommendations other than the task force, which address men. For example, the National Osteoporosis Foundation recommends that BMD testing be done in all men, 70 and older. And the Endocrine Society recommends screening men 70 and older, and actually even adults 50 to 69 with significant risk factor, or with a fracture after age 50. And the International Society for Clinical Densitometry official position also recommends bone density testing in men 70 and older. Because hip fractures are associated with even greater mortality in men than in women, we should have a low threshold to obtain BMD testing in men with risk factors.

Lee Tetreault:

And last question, Doctor, are digital rectal exams or DREs ever recommended for prostate cancer screening?

Dr. Burke:  

Actually DREs are not recommended. Many of us have been taught to do a Digital Rectal Exam as part of prostate cancer screening. However, it's not recommended for screening either alone or in combination with PSA screening. The reason is that there are no controlled studies that show any reduction in prostate cancer morbidity or mortality when detected by DRE at any age performed. Any cancers palpated during a rectal exam are usually so pathologically advanced at diagnosis their detection would not change the outcome. And by definition, a stage T1 prostate cancer is actually not even palpable. Incidentally, DRE is also not recommended for colorectal cancer screening.

Lee Tetreault:

This is great information, Doctor, thank you so much for your time today.