UBC Objectives: Women's Health, UBC Objectives: Care of Men, Priority Topic: Cancer, Priority Topic: Periodic Health Assessment/Screening, & Priority Topic: Prostate
By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Key Feature 2: In all patients, provide the indicated evidence-based screening (according to age group, risk factors, etc.) to detect cancer at an early stage (ex: with Pap tests, mammography, colonoscopy, digital rectal examinations, prostate-specific antigen testing).
Skill: Clinical Reasoning, Selectivity
Periodic Health Assessment/Screening
Key Feature 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).
Skill: Selectivity, Patient Centered
Phase: Investigation, Hypothesis generation
Key Feature 3a: In a patient requesting a test (ex: PSA testing, mammography) that may or may not be recommended: Inform the patient about limitations of the screening test (i.e., sensitivity and specificity).
Skill: Clinical Reasoning
Phase: Treatment, Investigation
Key Feature 3b: In a patient requesting a test (ex: PSA testing, mammography) that may or may not be recommended: Counsel the patient about the implications of proceeding with the test.
Skill: Clinical Reasoning, Patient Centered
Phase: Treatment, Investigation
Key Feature 4: Keep up to date with new recommendations for the periodic health examination, and critically evaluate their usefulness and application to your practice.
Phase: Treatment, Diagnosis
Key Feature 1: Appropriately identify patients requiring prostate cancer screening.
Phase: Diagnosis, History
Key Feature 6: Given a suspicion of benign prostatic hypertrophy, diagnose it using appropriate history, physical examination, and investigations.
Skill: Clinical Reasoning
Today I will be doing a Pap clinic with the Portland Hotel Society. Although I've done many Pap smears during my training, this afternoon will be great to refine my skill at performing this procedure. The population I will be screening will be women from the Downtown East Side (DTES) of Vancouver, often with significant histories of trauma, higher rates of infection include sexually transmitted ones, and who may present infrequently for care. I am not exactly sure what to expect, but I am looking forward to learning from these women.
The Pap test is a screening test to look for evidence of cervical cancer. It is not a test for sexually transmitted infections (STIs), although many people think it is (and I know that's what I used to think before entering Medicine). So it is important to consider that women who present for Pap tests may really be more concerned about a possible STI. I expect this may be the case with the sample of patients I screen today, given their risk factors. Nevertheless, this provides an opportunity to perform both cervical cancer screening and STI testing (or screening), if indicated. STI screening or testing can also be done without collecting a Pap smear, and indeed it is a waste of resources if Pap tests or any other forms of cancer screening tests are overdone. If women are concerned about STIs, it's also an opportunity to ask about immunization against HPV. Nowadays Canadian students are offered this vaccination during the middle school years, but it is a relatively new initiative and so many people are not covered. When STI screening comes up, or when patients present for a Pap, I use this as an opportunity to discuss HPV vaccination for those who may not be covered and who are at increased risk (the HPV vaccine is recommended in all women up until the age of 45, in all males age 9-26, and in men who have sex with men [MSM]). This vaccine helps to prevent transmission of strains of HPV that can precipitate cellular transformations that can then lead to cervical, oral, anal, and penile cancer.
The recommendations by the Canadian Task Force on Preventive Health Care give the following recommendations for cancer screening, given the sensitivity and specificity of available screening tests within a landscape influenced by logistics, economics, and politics. Note that for those patients who meet exclusion criteria for recommendations, consider referring to local (provincial) screening guideline for guidance. Some patients may present inquiring about or actually requesting screening investigations when it is not recommended according to guidelines. It is important to remember that guidelines are not the law of how to practice medicine, but rather offer guidance in a context of having to make so many medical decisions in a day, which is also in the language of the guideline "recommendations" themselves. For any patients for which screening investigations are recommended according to guidelines, it is always important to remember to obtain informed consent, which includes patient understanding as to why a test is being done and what the likely outcomes are. Just because a screening intervention may be recommended for a given population by guideline authorities, it does not mean that every individual within that population will want and choose to do the test. #patientcenteredcare
Cervical Cancer Screening Recommendations
Recommendations are presented for screening asymptomatic women who are or have been sexually active. They do not apply to women with symptoms of cervical cancer, previous abnormal screening results (until they have been cleared to resume normal screening), those who do not have a cervix (due to hysterectomy), or who are immunosuppressed.
Breast Cancer Screening Recommendations
Recommendations are presented for the use of mammography, magnetic resonance imaging, breast self exam and clinical breast exam to screen for breast cancer. These recommendations apply only to women at average risk of breast cancer aged 40 to 74 years. They do not apply to women at higher risk due to personal history of breast cancer, history of breast cancer in first degree relative, known BRCA1/BRCA2 mutation, or prior chest wall radiation. No recommendations are made for women aged 75 and older, given the lack of data.
Colorectal Cancer Screening Recommendations
These recommendations apply to adults aged ≥50 years who are not at high risk for colorectal cancer (CRC). They do not apply to those with previous CRC or polyps, inflammatory bowel disease, signs or symptoms of CRC, history of CRC in one or more first degree relatives, or adults with hereditary syndromes predisposing to CRC (ex: familial adenomatous polyposis, Lynch Syndrome).
Lung Cancer Screening Recommendations
These recommendations apply to adults aged 18 years and older who are not suspected of having lung cancer. These recommendations do not apply to individuals who have a history of lung cancer, or suspected lung cancer.
Prostate Cancer Screening Recommendations
This clinical practice guideline applies to all men not previously diagnosed with prostate cancer. This includes men with lower urinary tract symptoms (nocturia, urgency, frequency and poor stream) or with benign prostatic hyperplasia (BPH).*
*Note that BPH and prostate cancer may present with the same lower urinary tract symptoms, so when making a diagnosis of BPH it's important to ensure there are no symptoms or signs suggestive of malignancy (or other diagnoses such as prostatitis), and that the PSA is not abnormally elevated. In this setting, the measurement of a normal PSA is done to assist in the diagnostic workup of BPH rather than as a screening test for prostate cancer, which would be done only if a male did not have any symptoms suggesting a current diagnosis of prostate cancer. If a man is diagnosed with BPH that responds well to treatment, recurrent testing of PSA in the interest of screening for prostate cancer is not indicated.