Screening for cancer: progress, but more can be done.
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Aged↗
Biomedical subjects
P S Frame
Publications and source records attributed to P S Frame.
Screening for skin cancer.
CONTEXT: Malignant melanoma is often lethal, and its incidence in the United States has increased rapidly over the past 2 decades. Nonmelanoma skin cancer is seldom lethal, but, if advanced, can cause severe disfigurement and morbidity. Early detection and treatment of melanoma might reduce mortality, while early detection and treatment of nonmelanoma skin cancer might prevent major disfigurement and to a lesser extent prevent mortality. Current recommendations from professional societies regarding screening for skin cancer vary. OBJECTIVE: To examine published data on the effectiveness of routine screening for skin cancer by a primary care provider, as part of an assessment for the U.S. Preventive Services Task Force. DATA SOURCES: We searched the MEDLINE database for papers published between 1994 and June 1999, using search terms for screening, physical examination, morbidity, and skin neoplasms. For information on accuracy of screening tests, we used the search terms sensitivity and specificity. We identified the most important studies from before 1994 from the Guide to Clinical Preventive Services, second edition, and from high-quality reviews. We used reference lists and expert recommendations to locate additional articles. STUDY SELECTION: Two reviewers independently reviewed a subset of 500 abstracts. Once consistency was established, the remainder were reviewed by one reviewer. We included studies if they contained data on yield of screening, screening tests, risk factors, risk assessment, effectiveness of early detection, or cost effectiveness. DATA EXTRACTION: We abstracted the following descriptive information from full-text published studies of screening and recorded it in an electronic database: type of screening study, study design, setting, population, patient recruitment, screening test description, examiner, advertising targeted at high-risk groups or not targeted, reported risk factors of participants, and procedure for referrals. We also abstracted the yield of screening data including probabilities and numbers of referrals, types of suspected skin cancers, biopsies, confirmed skin cancers, and stages and thickness of skin cancers. For studies that reported test performance, we recorded the definition of a suspicious lesion, the "gold-standard" determination of disease, and the number of true positive, false positive, true negative, and false negative test results. When possible, positive predictive values, likelihood ratios, sensitivity, and specificity were recorded. DATA SYNTHESIS: No randomized or case-control studies have been done that demonstrate that routine screening for melanoma by primary care providers reduces morbidity or mortality. Basal cell carcinoma and squamous cell carcinoma are very common, but detection and treatment in the absence of formal screening are almost always curative. No controlled studies have shown that formal screening programs will improve this already high cure rate. While the efficacy of screening has not been established, the screening procedures themselves are noninvasive, and the follow-up test, skin biopsy, has low morbidity. Five studies from mass screening programs reported the accuracy of skin examination as a screening test. One of these, a prospective study, tracked patients with negative results to determine the number of patients with false-negative results. In this study, the sensitivity of screening for skin cancer was 94% and specificity was 98%. Several recent case-control studies confirm earlier evidence that risk of melanoma rises with the presence of atypical moles and/or many common moles. One well-done prospective study demonstrated that risk assessment by limited physical exam identified a relatively small (<10%) group of primary care patients for more thorough evaluation. CONCLUSIONS: The quality of the evidence addressing the accuracy of routine screening by primary care providers for early detection of melanoma or nonmelanoma skin cancer ranged from poor to fair. We found no studies that assessed the effectiveness of periodic skin examination by a clinician in reducing melanoma mortality. Both self-assessment of risk factors or clinician examination can classify a small proportion of patients as at highest risk for melanoma. Skin cancer screening, perhaps using a risk-assessment technique to identify high-risk patients who are seeing a physician for other reasons, merits additional study as a strategy to address the excess burden of disease in older adults.
Basal Cell Carcinoma↗
Routine screening for lung cancer?: Maybe someday, but not yet.
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Humans↗
Preventive dentistry: practitioners' recommendations for low-risk patients compared with scientific evidence and practice guidelines.
INTRODUCTION: The purpose of this article is to compare published evidence supporting procedures to prevent dental caries and periodontal disease, in low-risk patients, with the actual preventive recommendations of practicing dentists. METHODS: Methods included (1) a survey questionnaire of general dentists practicing in western New York State concerning the preventive procedures they would recommend and at what intervals for low-risk children, young adults, and older adults; and (2) review of the published, English-language literature for evidence supporting preventive dental interventions. RESULTS: The majority of dentists surveyed recommended semiannual visits for visual examination and probing to detect caries (73% to 79%), and scaling and polishing to prevent periodontal disease (83% to 86%) for low-risk patients of all ages. Bite-wing radiographs were recommended for all age groups at annual or semiannual intervals. In-office fluoride applications were recommended for low-risk children at intervals of 6 to 12 months by 73% of dentists but were recommended for low-risk older persons by only 22% of dentists. Application of sealants to prevent pit and fissure caries was recommended for low-risk children by 22% of dentists. Literature review found no studies comparing different frequencies of dental examinations and bite-wing radiographs to determine the optimal screening interval in low-risk patients. Two studies of the effect of scaling and polishing on the prevention of periodontal disease found no benefit from more frequent than annual treatments. Although fluoride is clearly a major reason for the decline in the prevalence of dental caries, there are no studies of the incremental benefit of in-office fluoride treatments for low-risk patients exposed to fluoridated water and using fluoridated toothpaste. CONCLUSIONS: Comparative studies using outcome end points are needed to determine the optimal frequency of dental examinations and bite-wing radiographs for the early detection of caries, and of scaling and polishing to prevent periodontal disease in low-risk persons. There is no scientific evidence that dental examinations, including scaling and polishing, at 6 month intervals, as recommended by the dentists surveyed in this study, is superior to annual or less frequent examinations for low-risk populations. There is also no evidence that in-office fluoride applications offer incremental benefit over less costly methods of delivering fluoride for low-risk populations.
Adult↗
Preventive care for the elderly: getting by in the absence of evidence.
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Aged↗
U.S. Preventive Services Task Force: highlights of the 1996 report.
The recent report of the U.S. Preventive Services Task Force is a compendium of the scientific evidence supporting clinical preventive services that might be offered by primary care physicians. Pediatric recommendations include height, weight and blood pressure measurements, neonatal screening for hemoglobinopathies and counseling about injury prevention, diet and exercise, sexual behavior, substance abuse and dental health. Lead screening is recommended in communities with a high prevalence of elevated lead levels. Adult recommendations include measurement of blood pressure and weight, selective screening for elevated total cholesterol level, screening persons over age 50 for colorectal cancer, screening women for cervical cancer at least every three years, and screening women 50 to 69 years of age for breast cancer with mammography every one to two years. Counseling patients about substance abuse, diet and exercise, injury prevention, sexual behavior and dental health is recommended. Women of childbearing age should receive folic acid supplementation to prevent neural tube defects if they should become pregnant. Multiple marker testing is recommended for women over age 35 to screen for Down syndrome. Immunization recommendations are similar to those of other national groups.
Adolescent↗
Cancer occurrence and screening in family practice. A 20-year experience.
BACKGROUND: This article is a sequel to a previously published article describing the occurrence of cancer in a rural family practice and the contribution of screening to the diagnosis of breast, colorectal, and cervical cancer. Together, the two articles describe a 20-year family practice experience in diagnosing and screening for cancer. METHODS: The study is a retrospective chart review of all cancers diagnosed in a family practice from January 1985 through December 1994. Records of a regional tumor registry were reviewed to validate and ensure completeness of the cancer diagnoses. RESULTS: One hundred twenty-one cancers were identified during the 10-year study period in a population of approximately 4000 patients. Screening by fecal occult blood testing identified 11 of 20 colorectal cancers, mammography and physician examination identified 9 of 12 breast cancers, and a program of biannual Papanicolaou smears resulted in the diagnosis of 3 of 3 cervical cancers. Only 3 melanomas, 3 ovarian cancers, and 1 testicular cancer were diagnosed in this practice during the entire 20 years of the combined studies. CONCLUSIONS: The five most common cancers--skin, colorectal, lung, breast, and prostate--accounted for 71% of the cancers diagnosed. A high rate of provider and patient compliance with screening was achieved. Screening detected a majority of breast and colorectal cancers. Annual Papanicolaou smear screening would have provided no incremental benefit over the biannual screening used in this practice.
Adult↗
The complete annual physical examination refuses to die.
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Family Practice↗
Computer-based vs manual health maintenance tracking. A controlled trial.
OBJECTIVE: To compare computer-based with manual health maintenance tracking systems to determine whether (1) a computer-based system will result in better provider compliance with the practice health maintenance protocol, (2) the incremental cost of operating a computer-based vs a manual health maintenance tracking system differs, and (3) inactive patients will respond to health maintenance reminders. DESIGN: Two-year prospective, randomized, controlled trial. SETTING: Rural, multiple-office, nonprofit, fee-for-service family practice. PATIENTS: Adult members of families in which at least one member had been seen by the practice within the past 2 years. INTERVENTION: A computer-based health maintenance tracking system that generated annual provider and patient reminders for all patients regardless of appointment status compared with a manual flowchart-based tracking system in which patient reminders were triggered by provider request. OUTCOME MEASURES: Provider compliance with the health maintenance protocol determined by preintervention and postintervention chart audits, costs of computer-based tracking, and response of inactive patients to health maintenance reminders. RESULTS: Overall provider compliance with the health maintenance protocol increased 15 percentage points in the computer-based tracking group and four percentage points in the manual group. The computer-based tracking group had significantly higher provider compliance than the manual group for eight of 11 procedures. The computer-based tracking system cost 78 cents per patient per year to operate. It was not associated with increased office visits or patient billings. CONCLUSIONS: Computer-based health maintenance tracking improved provider health maintenance compliance compared with a manual system. The finding that health maintenance compliance improved without a significant increase in patient visits or billings requires confirmation in other settings but suggests that considerable health maintenance can be incorporated into ongoing patient care.
Adult↗
U.S. Preventive Services Task Force is back.
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Cost-Benefit Analysis↗
Screening for abdominal aortic aneurysm in men ages 60 to 80 years. A cost-effectiveness analysis.
PURPOSE: To evaluate the cost-effectiveness of screening by physical examination or abdominal ultrasonography for abdominal aortic aneurysm (AAA) in men aged 60 to 80 years. DATA SOURCES: A systematic review of the pertinent literature by the Canadian Task Force on the Periodic Health Examination, augmented by an additional computerized search (MEDLINE) and references identified from bibliographies of pertinent articles. Several experts reviewed the data for completeness. STUDY SELECTION: Published English-language studies that present data relevant to screening for abdominal aortic aneurysm. DATA EXTRACTION: Several reviewers determined a range of data and the most probable value for each parameter. DATA SYNTHESIS: A computer spreadsheet model was constructed to simulate the costs and effectiveness of various screening protocols in a cohort of 10,000 men during a period of 20 years. The primary cost-effectiveness measure computed was incremental present-value dollar expenditures for screening and treatment per incremental present-value life-year saved by the screening program. Using the "most probable" values for the simulation parameters, a single screening procedure of abdominal palpation followed by abdominal ultrasound scan for patients with positive screening results is estimated to gain 20 life-years at a cost of $28,741 per life-year. A single ultrasound screen gains 57 life-years at a cost of $41,550 per life-year. A repeated ultrasound screen after 5 years gains 1 additional life-year at a cost of $906,769. CONCLUSIONS: A single screen for AAA by abdominal palpation in men from age 60 to 80 years might be considered cost-effective but of small benefit. A single screen with ultrasonography is at the high end of the cost-per-life-year range that might be considered cost-effective and also is of modest benefit. Repeated screening is not cost-effective.
Aged↗
How primary health care providers can integrate cancer prevention into practice.
Integrating prevention into practice is an important primary care challenge. Cancer prevention is a major part of this effort. In the past decade, concepts of selective longitudinal health maintenance have replaced the previous teaching that all adults should have a "complete annual physical." Physician barriers to implementing prevention include: uncertainty about conflicting recommendations; uncertainty about the value of screening tests; disorganized medical records; delayed or indirect gratification from screening; and lack of time. The following practice strategies can help overcome these barriers: adopting a scientifically based minimum core of preventive procedures; clearly identifying responsibility for prevention; engaging the patient in the responsibility for prevention; and committing resources to institutionalize prevention in the practice. The manual health maintenance flow chart is the most common tool for facilitating health maintenance tracking; however, computerized systems are being developed. The advantages and disadvantages of both types of system are addressed. A model computerized health maintenance tracking system is presented.
Health Promotion↗
An international perspective on the cholesterol debate.
For the past 5 years there has been an intensive debate and a number of conflicting guidelines suggesting what general practitioners (GPs) should do to screen and manage hyperlipidaemia. At a WONCA seminar in Vancouver in 1992, policies and guidelines from Canada, the UK, The Netherlands, New Zealand, Hong Kong and the USA were reviewed. It was concluded that cholesterol policy and guidelines tend to be influenced more by political and economic factors than by evidence of health benefit. International guidelines for cholesterol screening and management would be of minimal value, as GPs would have to interpret the epidemiological evidence of benefit from lipid screening and lipid lowering strategy in the context of each patient to arrive at optimum management.
Adult↗
Breast cancer screening in older women: the family practice perspective.
This article reviews screening for breast cancer in older women from the perspective of the primary care physician. Although breast cancer is a leading cause of cancer in women, the diagnosis of breast cancer in an asymptomatic woman is an uncommon occurrence for the individual physician. Physician compliance with breast cancer screening recommendations is less than optimum: physicians report higher compliance in survey studies than is demonstrated by performance audits. The low yield of screening, cost concerns, concerns about the reliability of radiology reports, concerns about patient compliance, lack of time, and forgetfulness are reasons cited for poor provider compliance with screening recommendations. In general there is no reason not to recommend mammography for older women unless individual factors including biologic age, life expectancy, comorbidities, or patient preference appear to make screening not worthwhile. The decision to stop recommending mammography for an older woman should be made in conjunction with the patient.
Aged↗
Supporting statements and rationale.
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Aged↗
HTRAK, a computerized health maintenance tracking system for primary care.
This presentation describes a computerized health maintenance tracking system for primary care designed to be linked to the practice billing system. Providers enter health maintenance data along with billing data on an encounter form. Physician and patient reminders are generated once a year for all patients regardless of appointment status. Multiple entry options are available and the frequency of procedures can be varied for individual patients. Summary reports are generated to assist compliance and quality assurance.
Information Systems↗
Health maintenance in clinical practice: strategies and barriers.
Obstacles to the implementation of preventive services in clinical practice include barriers raised by patients, physicians and the health care delivery system itself. Physicians may overcome these barriers to a great extent by improving their time management skills, practice organization system and reinforcement mechanisms. For clinical prevention to be successfully initiated and maintained in practice: (1) the program must be simple and include only procedures the providers believe are worthwhile; (2) an organized record system should be used; (3) a system of checks and reinforcements for prevention must be instituted in the practice routine, and (4) adequate time for preventive services must be allocated, either by using paramedical personnel or by restricting the practice size.
Health Behavior↗
Sacroiliac subluxation: a common, treatable cause of low-back pain in pregnancy.
A retrospective review of 100 consecutive pregnancies, involving 94 women receiving prenatal care at a rural western New York family practice, was conducted. Back pain was spontaneously reported to the physician by 23 women in 23 pregnancies. Eleven of the 23 women met diagnostic criteria for sacroiliac subluxation. These criteria include absence of lumbar spine and hip pathology, pain in the sacral region, a positive Piedallu's sign (asymmetrical movement of the posterior superior iliac spines upon forward flexion), a positive pelvic compression test, and asymmetry of the anterior superior iliac spines. A cohort of 11 women meeting criteria for sacroilia subluxation was treated with rotational manipulation of the sacroiliac joints. After manipulative therapy, 10 of the 11 women (91%) had relief of pain and no longer exhibited signs of sacroiliac subluxation.
Adolescent↗