Screening Tests and Treatments for the Prevention of Disease, Cancer, and Infections – Part 2

In Part 1, I discussed preventative screenings and treatments for children, adolescents, and pregnant women. Please take a look at Part 1 if you have not already, or try to read the first section and introduction prior to reading Part 2. In Part 2 we are going to discuss cancer prevention, disease, and infections in adults.

In general, more medical studies related to disease prevention have been performed on adults than on children and pregnant women. The reasons are simple. We care less if we hurt adults and are much easier to enroll in studies. However, more research is needed regarding disease prevention, even in adults. Patients tend to think healthcare providers know a lot about human physiology, health, and disease. As a physician, I feel like we have only scratched the surface regarding knowledge of these topics- do not let this deter you from reading on.

Please note that the preventative screening and treatment recommendations in this article are those performed by healthcare providers on patients. It is also important to understand that there are too many screening tests to discuss in a two part blog series. These posts are meant to highlight some of the most important screening tests. They are also intended to serve as a starting point for further investigation.

Grade A Recommendations

Blood Pressure

• Check blood pressure for the prevention of heart disease in people older than 18 years. Correlate findings with blood pressure checks outside of a medical setting to check for white coat syndrome (increased blood pressure only in clinical settings). Hypertension (high blood pressure) is very common and over many years it can cause irreversible damage to the heart. Blood pressure that is consistently > 140 systolic (top number) or > 90 diastolic (bottom number) should be lowered with lifestyle changes and medication.

Tobacco

• Ask about tobacco smoking and advise people to quit smoking. Additionally, there are several medications available to help people to stop smoking. Healthcare providers should offer anyone serious about quitting tobacco multiple medications to reduce cravings. Tobacco is very chemically addictive and can control the actions of its users. Medication can help break this control.

Colon Cancer

• Check for colon cancer between the ages of 50 and 75. After age 75, the benefit of screening is unclear. Annual stool tests (checks for blood in the stool) and the dreaded (but sometimes lifesaving) colonoscopy every 10 years are among the most common tests used to check for colon cancer. Colon cancer is the 3rd leading cause of cancer-related death and with screening, most often preventable.

Cervical Cancer

• Women aged 21 to 29 years should get a papanicolaou smear (pap smear) every 3 years to check for cervical cancer. Women aged 30 to 65 should get a pap smear every 3 years, or alternatively, a test for high risk HPV (genital warts) every 5 years. Women < 21 years should not be screened for cervical cancer. Women > 65 years should not be screened for cervical cancer, unless they have risk factors for cervical cancer. The HPV vaccine, Gardasil may drastically reduce the amount of cervical cancer in the future. The FDA just recently approved the use of Gardasil 9 for males and females ages 9 to 45.

Human Immunodeficiency Virus

• Check for Human Immunodeficiency Virus (HIV) in people aged 15 to 65. Usually a one-time check is sufficient but if continued risks are present such as high-risk sexual behavior, repeat testing as needed. Test outside of these age groups if risk factors exist.

• Individuals with a high risk for contracting HIV should be given daily medication to prevent HIV infection. Such medication regimens are referred to as pre-exposure prophylaxis, or PEP. With good compliance, PEP is very effective at preventing HIV, but greatly underutilized. Risk factors for contracting HIV include injection drug use and high-risk sexual behavior including having a sexually transmitted infection in the past 6 months, having a sexual partner with HIV, and unprotected anal sex outside of a monogamous relationship. Individuals should be checked for HIV prior to starting PEP.

Syphilis

• Check anyone with risk factors for syphilis. Risk factors include sexual contact outside of a monogamous relationship (both partners known to be negative). Syphilis is a bacterial sexually transmitted infection spread by contact with infected individuals.

Grade B Recommendations

Hepatitis B and C

• Check for Hepatitis B Virus (HBV) in individuals at high risk for infection. Risk factors include spending time in a country with a high prevalence of HBV, HIV infected individuals, injection drug use, high risk sexual behavior such as men who sleep with men, household contacts infected with HBV, un-vaccinated status, hemodialysis, and medications which lower the immune system. Between 700,000 and 2,200,000 people are infected in the United States. HBV can cause liver disease, liver cancer, and liver failure.

• Check for Hepatitis C Virus (HCV) infection in all individuals aged 18 to 79. This is usually a one-time screening but can be performed more if risk factors exist. Unfortunately, primary care providers often miss this screening. Now that we have very effective treatments, testing has a greater potential benefit than ever. HCV is thought to affect 1% of the US population and it kills more people than the top 60 other reportable infectious diseases combined. Risk factors include injection drug use and blood transfusion prior to 1990.

Tuberculosis

• Screen for tuberculosis, a bacteria that causes infections of the lung and body, in people who have risk factors. Being from a country with a high rate of tuberculosis, homelessness, incarceration, or those with concerning symptoms or lung findings are all risk factors for tuberculosis. If you are starting a medication that lowers the immune system, you should also be checked for tuberculosis.

Chlamydia, Gonorrhea, and Sexually Transmitted Infections (STI)

• Screen asymptomatic women < 24 years of age who are sexually active for the sexually transmitted infections (STI) chlamydia and gonorrhea annually. Screen men and women with risk factors or symptoms at any age, as frequently as indicated. Chlamydia is the most common STI in the United States. These infections can cause permanent damage and reproductive problems if not treated.

• Provide counseling for all adults and adolescents at risk for STIs. Any sexual contact outside of a monogamous relationship, in which both partners have been screened for STIs, is considered a risk. Counseling should include the prevention of unwanted pregnancy, barrier protection like condoms, recommendations for STI screening, consideration of PEP for HIV prevention, screening for abuse, as well as other pertinent information.

Abdominal Aortic Aneurysm

• Abdominal Aortic Aneurysm (AAA) is an enlarged area in the lower part of the aorta that supplies blood to the body. Screening is recommended in men aged 65 to 75 years who have a history of smoking. An AAA can burst, often leading to sudden death.

Breast Cancer and Women's Health

• Get a mammogram to check for breast cancer every other year between the age of 50 and 74 years. It is not clear that the benefits of starting mammograms at age 40 outweigh the risks. Risks of mammography include exposure to radiation and positive tests in individuals that do not have cancer. Most benefits from mammography occur between the ages of 60 to 69.

• Treat women at risk of breast cancer with medications that lowers the risk of breast cancer. 1 in 8 women will develop breast cancer. Risk factors include increasing age, family members with breast cancer, genetic mutations that increase the risk of breast cancer, and a history of radiation to the chest.

• Check women at high risk for breast cancer for genetic mutations, such as the BRCA gene mutation, that can increase the risk of breast cancer.

• Screen women of reproductive age for violence from their partner.

Obesity, Cholesterol, Heart Disease, and Colon Cancer

• Anyone with a Body Mass Index (BMI) > 30 (obese) should be referred to programs which can provide aggressive behavioral interventions. These interventions include things like dietary counseling, exercise programs, and other healthy lifestyle interventions.

• Start a cholesterol medication to prevent heart disease and strokes in adults between 40 and 75 years old, with cardiovascular risk factors, who have at least a 10% chance of having a heart attack or stroke in the next ten years. Risk factors include high cholesterol, diabetes, smoking tobacco, and high blood pressure. Risk of heart attack and stroke is calculated using scoring systems like the ASCVD (atherosclerotic cardiovascular disease) risk calculator.

• Adults age 50 to 59 with a > 10% ASCVD risk score should consider taking a baby aspirin (81 mg) daily to prevent heart disease and colon cancer. Grade C recommendation for adults age 60-69. Insufficient evidence exists for adults < 50 or > 70 years old.

Diabetes

• Check for abnormal glucose in adults age 40 to 70 who are overweight or obese. A blood glucose less than 140 mg/dL is considered normal. A reading between 140 and 199 mg/dL is indicative of prediabetes.

Osteoporosis (weak bones)

• All women older than 65 years should have their bone density checked. Osteoporosis, or weak bones, is very common in older women.

• Measure bone density in men and women < 65 years old who are at increased risk for fractures. Risk factors include alcohol and tobacco use, history of bone fractures, age, having a family member who broke a hip, taking certain medications such as steroids, and having rheumatoid arthritis.

Skin Cancer

• Talk with individuals (or their parents) aged 6 months to 24 years with fair skin about how to avoid ultraviolet light exposure from the sun. This includes wearing sunscreen and protective clothing.

Lung Cancer

• People aged 55 to 80 years old who have smoked more than 30 pack years and have been smoking in the last 15 years should be checked for lung cancer annually using a low dose computed tomography, or CT scan. Stop screening if the individual has quit smoking more than 15 years ago or has a limited life expectancy. A pack year is measured by the number of packs smoked a day everyday, for an entire year.

Alcohol Use

• Screen all adults for unhealthy alcohol use. Consuming 7 or more drinks a week is considered excessive or heavy drinking for women, and 15 drinks or more a week for men.

Depression

• Screen adults that have lost interest in things that would normally bring them joy for depression. A common screening is the PHQ-9 Questionnaire.

Grade C Recommendations

Prostate Cancer

• Men 55 to 69 years old should be considered for prostate cancer screening with PSA lab tests. Prostate cancer is the most common, non-skin, cancer in men. However, most men with prostate cancer die of something besides their prostate cancer. Treatment of prostate cancer can often have devastating side effects including erectile dysfunction and urinary incontinence. Prostate cancer screening is a great example of a test that improves cancer detection, but can have serious risks that many believe outweigh the benefits. Having a conversation about the risks and benefits of screening with your doctor and coming to a shared decision about pursuing testing is the current recommendation.

Grade D Recommendations (screening not recommended)

• Do not screen for pancreatic cancer in adults without symptoms.

• Do not screen for prostate cancer with a PSA in men older than age 70.

• Do not screen for ovarian cancer in asymptomatic women.

• Do not screen for thyroid cancer in asymptomatic adults.

• Do not screen for testicular cancer in adolescent and adult men.

• Do not screen asymptomatic adults for heart disease using an electrocardiogram (EKG).

• Do not prescribe vitamin D < 400 IU and Calcium < 1000 mg for community dwelling, post-menopausal women for the primary prevention of fractures. It is unclear if using higher doses may be helpful (again more studies please!). Taking calcium can cause side effects like kidney stones. Fractures, especially of large bones like hips, remains a serious health problem for older adults. It is believed that 20-30% of elderly patients will die following a hip fracture. It is a serious problem but vitamin D and calcium at the above doses do not seem to prevent such fractures.

• Vitamin D supplements do not prevent falls.

• Do not use estrogen or combined hormone therapy to prevent chronic medical problems like osteoporosis in postmenopausal women. However these medications can certainly help with menopausal symptoms.

• Do not screen for the sexually transmitted infection herpes in asymptomatic individuals.

• Do not screen for COPD in asymptomatic adults.

• Do not screen for carotid artery stenosis in asymptomatic adults.

• Do not use vitamin A or beta carotene supplements to prevent cardiovascular disease and cancer.

Remember that as screening tests improve and the rates of disease, cancer, and infections change, recommendations will also change. However, with the current technology available in 2020, all of the Grade D screening tests are not recommended. Hopefully this will change in the future.

Insufficient Evidence (more research needed to assess the benefits and risks)

• Cognitive (mental) impairment screening in older adults.

• Elder abuse screening in the absence of suspicion.

• Illicit drug use screening in adults.

• Atrial fibrillation screening using an EKG.

• Vascular disease screening using an ankle brachial blood pressure reading.

• Cardiovascular disease screening using a lab test for high sensitivity CRP and imaging for heart vessel calcification in asymptomatic adults.

• Osteoporosis testing in asymptomatic men.

• Celiac Disease (gluten allergy) in asymptomatic adults.

• Pelvic exams periodically in asymptomatic women.

• Sleep apnea screening in asymptomatic adults.

• Open angle glaucoma screening in asymptomatic adults.

• Hearing loss screening in asymptomatic adults.

• Skin examinations for cancer screening in individuals who do not have concerning lesions.

• Oral cancer screening in asymptomatic adults.

• Bladder cancer screening in asymptomatic adults.

• Thyroid function tests in asymptomatic adults.

• Checking vitamin D levels in asymptomatic adults.

• Suicide risk screening in asymptomatic individuals.

• Taking a daily multivitamin to prevent cardiovascular disease and cancer.

Conclusion

In medicine we make life-altering decisions based on incomplete information and insufficient research. Providers often say that this is the “art” of medicine. However, every time healthcare providers do anything, the potential to hurt people exists. Always remember this: learn as much as you can about your own health. Read about the screenings recommended for you and speak about them with your healthcare provider. Be an active driver of your health, not a silent passenger. To do this you will need the right information and a lot of self-discipline. You are in the right place! Thank you so much for reading and I hope this two-part blog has improved your health literacy regarding preventative screenings and treatments.

Author

William Brandenburg, MD, owner of Wonder Medicine clinic and full time rural hospitalist.

Editor

Karlee Brandenburg, RN-BSN, owner of Wonder Medicine.

Conflict of Interest

This article promotes Wonder Medicine clinic, which the author and editor own.

Disclaimer

This article was written for educational purposes only. It is not intended to serve as formal medical advice. Please talk with your healthcare provider about the tests and treatments you should consider to prevent cancer, disease, and infection.

References

• United States Preventative Service Task Force. (https://www.uspreventiveservicestaskforce.org/uspstf/).

• United States Preventative Service Task Force. Wikipedia. (https://en.wikipedia.org/wiki/United_States_Preventive_Services_Task_Force)