Periodic Screening

1. Do a periodic health assessment in a proactive or opportunistic manner (i.e., address health maintenance even when patients present with unrelated concerns).

2. In any given patient, selectively adapt the periodic health examination to that patient’s specific circumstances (i.e., adhere to inclusion and exclusion criteria of each manoeuvre/intervention, such as the criteria for mammography and prostate-specific antigen [PSA] testing).

3. In a patient requesting a test (e.g., PSA testing, mammography) that may or may not be recommended:

   1. Inform the patient about limitations of the screening test (i.e., sensitivity and specificity).

   2. Counsel the patient about the implications of proceeding with the test.

4. Keep up to date with new recommendations for the periodic health examination, and critically evaluate their usefulness and application to your practice.

Screening

• Harms of screening

  • Overdiagnosis

  • False positive, anxiety, quality of life and consequences

  • Follow-up testing (infection, bleeding), medical intervention, hospitalization

• Benefits unclear

  • Cancer screenng does not seem to extend lifetime (except possibly colorectal cancer screening with sigmoidoscopy)

Cervical Cancer (HPV and pap tests)

• Consider Pap screening for anyone with a cervix from 25-69yo  q3y (weak recommendation 25-29yo, strong recommendation 30-69yo)

  • ≥ 70yo, stop if 3 successive negative Pap tests in last 10 years

    • Consider 21-69yo as per SOGC

    • Consider 21-65yo as per INSPQ

  • All-cause mortality NNS and harms unknown due to limited data, although possible benefit seen through epidemiological trends

    • Mortality benefit seems to be based on an RCT in India where a single lifetime HPV (but not cytology screening) test reduced 8-year mortality

  • False-positive rates of 0.7-22%

    • Often leads to LEEP or cold knife conisation which may lead to negative outcomes in future pregnancies

• Primary HPV test screening  for anyone with a cervix from from 25-65yo q5y is preferred over regular pap screening as per INESSS (but will only be implemented by 2025 in Quebec)

  • HPV 16 or 18 positive should be referred to colposcopy

  • Other HPV positive results can be triaged by cytology (pap)

    • If cytology does not warrant colposcopy referal, follow-up one year with HPV testing

      • If HPV positive on repeat, refer to colposcopy

      • If HPV negative, return to regular screening (HPV q5y)

Breast Cancer (Mammogram) 

• Consider in women 50-74yo q2-3y (Conditional recommendation; low-certainty evidence)

  • CTFPHC recommends shared decision-making with women (avoiding harms vs. modest absolute reduction in breast cancer mortality)

  • No significant reduction in all-cause mortality in three trials

    • A 2013 Cochrane review argues minimal benefit of breast cancer screening

  • 50-69yo would benefit from a 0.13%  absolute risk reduction (0.64% to 0.51%)

    • Out of 720 women (see graphic)

      • 204 would experience a false positive mammogram requiring further imaging

      • 26 would undergo biopsy to confirm they do not have cancer

      • 4 would have their breast unnecessary removed

      • 1 would escape a breast cancer death

  • 70-74yo would benefit from a 0.22% absolute risk reduction (0.68% to 0.46%)

    • Out of 450 women (see graphic)

      • 90 would experience a false positive mammogram requiring further imaging

      • 11 would undergo biopsy to confirm they do not have cancer

      • 2 would have their breast unnecessary removed

      • 1 would escape a breast cancer death

Colorectal Cancer

• Consider 50-74yo FOBT (or FIT) q2y or flexible sigmoidoscopy q10y (weak recommendation 50-59yo, strong recommendation 60-74yo)

  • No significant reduction in all-cause mortality

  • gFOBT reduced CRC mortality (ARR 0.27%, NNS 377)

    • Out of 1000 people screened with gFOBT

      • 30 would test positive and require a colonoscopy

      • 3 would escape a colorectal cancer death

  • FIT 19% false negative rate

  • Harms per 100,000 screening colonoscopy

    • 80-240 bleeding complications

    • 30-40 bowel perforations

  • Notes

    • If risk (1st degree relative ≤60yo CRC, high risk adenomas, or 2+ relatives) consider screening colonoscopy at 40yo or 10y prior to index case

    • A retrospective cohort study (n=70124) found that after a positive FIT, risks of colon cancer and advanced stage did not increase until 10 months

Lung Cancer

• Consider 55-74yo with ≥30 py smoking history (current or quit <15y ago) low-dose CT q1y x 3 (weak recommendation; low quality evidence)

  • Benefits (see graphic)

    • All-cause mortality 6.5 years when compared to screening CXR

      • ARR: 0.46% 

      • NNS: 219 (95% CI 115–5556) 

  • Harms per 1000 screened

    • 351 false positive rate (benign lymph nodes and noncalcified granulomas)

      • 7 diagnosed lung cancers would not have caused illness/death (overdiagnosis)

      • 3 will have major complications from invasive procedure (including pneumothorax, MI, CVA)

      • 1 deaths from follow-up procedures per 1000 screened

    • Radiation dose ~8 mSv over the three years (including both screening and diagnostic examinations)

      • Estimated one radiation-associated cancer death per 2500 people screened with low-dose CT

Note: USPSTF 2021 recommends annual screening with low-dose CT for 50-80yo with 20py smoking history, and to discontinue once a person has not smoked for 15 years or develops a health problem that limits life expency or ability/willingness to have curative lung surgery (B recommendation)

Consider using PLCOm2012 risk calculator (based on age, education, family history, BMI, COPD, smoking duration/intensity/quit time, personal history of cancer, race/ethnicity), and screen those at a risk of 2%+ of lung cancer in 6 years

Prostate Cancer

• CTFPHC recommends against screening with PSA

  • Urological associations suggest discussing risks and benefits of PSA screening with patients >50yo (or >40yo if fam hx or african american) with >15y life expectancy

  • Meta-analysis found no statistically significant differences in prostate cancer-specific mortality or all-cause mortality

    • Only two studies have found a statistically significant decrease in prostate cancer-specific mortality (NNS 791 in ERSPC 2014, and NNS 139 in Goteborg 2014)

    • Overdiagnosis up to 67%  for PSA screening (leads to unnecessary biopsy and treatment of clinically insignificant prostate cancer)

      • Harms of screening include infection, hospitalization, death (0.17% of biopsies following a positive PSA screening test)

Abdominal Aortic Aneurysm

• Consider Men 65-80yo with one-time screening ultrasound for abdominal aortic aneurysm (weak recommendation; moderate quality evidence)

  • Benefits (see graphic)

    • All-cause mortality 13-15 years

      • ARR: 0.67%

      • NNS: 149 (95% CI 77-4505)

  • Harms

    • Elective operations (Note: Reduced emergency operations)

      • NNH 100

Visual Acuity

• CTFPHC recommends against screening for vision impairment in community-dwelling adults aged 65 years and over (weak recommendation; low quality evidence) 

• Consider screen at school age

Hypertension

• >18yo at all visits or earlier if risk

• Consider >3yo

Osteoporosis

• ≥ 65yo BMD or earlier if risk

STI

• Gonorrhea, Chlamydia, Syphilis, HIV if sexually active or risk

  • CTFPHC recommends Gono/Chlam for opportunistic annual screening for (non-high risk) sexually active <30 years old (conditional recommendation; very low evidence)

  • Consider HBV (if not immunized)

• HCV

  • CTFPHC recommends against screening adults who are not at elevated risk

    • This recommendation does not apply to pregnant women, or adults who are at elevated risk - including IVDU, incarcerated, immigrants from Hep C endemic region, recipient of blood products before 1992 in Canada, needle stick injuries, engaged in other risks with HCV exposure

  • USPSTF recommends screening all 18-79 years old based on treatment evidence 

Diabetes

• Diabetes Canada recommends ≥40yo A1C or FPG q3y or earlier if high risk (FINDRISC)

• CTFPHC recommends not screening patients low-moderate risk (using validated calculator such as FINDRISC)

Hyperlipidemia

• ≥40yo non-fasting lipids q5y (annually >20%) or earlier if risk 

Immunization

• See link above

Lifestyle

• Smoking cessation

  • Canadian Taskforce recommends asking all children/youth and parents about tobacco use, and brief intervention (attitudes, beliefs, risks, strategies, printed/electronic material) to prevent smoking

• Alcohol intake ≤10 drinks/w (≤2/d) for women, ≤15 drinks/w (≤3/d) for men 

• 150 min/w of moderate-vigorous intensity exercise

• Balanced diet (vegetables, whole grains, healthy fat)

  • Limit trans and saturated fats

  • <2000mg daily sodium intake (1 tsp of salt)

  • Increase fiber (vegetables)

• Limit sun exposure (eg. sunscreen, protective clothing)

• STI/contraception counselling

• Supplement

  • Vitamin D 400-2000 IU daily, if age>50 years (or risk) 800-2000IU daily

  • Calcium 1200 mg/d from diet (increase to 1500-2000 mg/d if pregnant or lactating)

  • Folic acid 0.4-1mg daily for all women of childbearing age