THIQAR COLLEGE OF MEDICINE FAMILY COMMUNITY MEDICINE DEPT

THIQAR COLLEGE OF MEDICINE FAMILY & COMMUNITY MEDICINE DEPT. FAMILY MEDICINE LEC 4 POST GRADUATE-FAMCO DR. MUSLIM N. SAEED TUESDAY, NOVEMBER 25 TH , 2014

PREVENTIVE SERVICES BY DISEASE CATEGORY Cancer: Almost one in every four deaths in the United States is caused by cancer, making it the second leading cause of death. In the United States the lifetime risk of a cancer diagnosis is one in two for men and one in three for women (ACS, 2009). #Potential harms arise when false-positive screens lead to unnecessary invasive testing or false-negative results lead to false reassurance.

PRIMARY PREVENTION OF CANCER EVIDENCE SUMMARY CA breast Minimize Risk Factor Exposure: 1. a. Hormo ne replace me nt the rapy —About 26% increased incidence of invasive breast CA with com bination hormone replac em ent therapy (HRT ) ( estr ogen and progesterone) —Est rog en alo ne with mixe d evidence—unlikely to increase risk b. Sign ificantly Ionizing radiat ion —Inc re ase d risk occurs abou t 10 years after exposure. Risk depends on dose and age at exposure c. O besi ty —RR = 2. 85 fo r breast CA for women > 82. 2 kg compared with wome n < 58. 7 kg d. Alc oh ol —RR f or int ak e of four alcoh olic drinks/day is 1. 32 —RR in cre ase s about 7% for each drink per d ay.

2. THERAPEUTIC INTERVENTION A…Tamoxifen (postmenopausal and high-risk premenopausal women) —Treatment with tamoxifen for 5 years reduced breast CA risk by 40%– 50%. Raloxifene (postmenopausal women) —Similar effect as tamoxifen in reduction of invasive breast CA. —Anastrozole reduces the incidence of new primary breast CAs by 50% compared with tamoxifen. —There is a 65% reduction in the risk of breast CA occurrence in postmenopausal women treated with exemestane for 5 years. B…. Prophylactic bilateral mastectomy (high-risk women ): —Reduces risk as much as 90% —About 6% of women were dissatisfied with their decision.

C…Prophylactic salpingo-oophorectomy among BRCA-positive women. —Breast CA incidence decreased as much as 50% —Nearly all women experience some sleep disturbances, mood changes, hot flashes, and bone demineralization. D…. Exercise —Exercising > 4 hours/week results in average risk reduction of 30%– 40% the effect may be greatest for premenopausal women of normal or low body weight. E…Breast-feeding —The RR of breast CA is decreased 4. 3% for every 12 months of breast-feeding, in addition to 7% for each birth. F…. Pregnancy before age 20 years: —About 50% decrease in breast CA compared with nulliparous women or those who give birth after age 35 years.

Cervical CA 1. Minimize Risk Factor Exposure: a……Abstinence of sexual activity; condom and/or spermicide use b……Cigarette smoke (active or passive) C……Human papillomavirus (HPV) infection: —Increases risk of high-grade cervical intraepithelial neoplasia (CIN) or invasive CA 2 -3 fold among HPV-infected women d……High parity —HPV-infected women with seven or more full-term pregnancies have a 4 -fold increased risk of squamous cell CA of the cervix compared with nulliparous women e……Long-term use of oral contraceptives —Increases risk by 3 -4 folds. —Longer use related to higher risk.

THERAPEUTIC 2. Therapeutic: a…. . HPV vaccination —Reduces incident and persistent infections, impact on longterm cervical CA rates also unknown but likely to be significant. b…. . Screening with Pap smears —Estimates from population studies suggest that screening may decrease CA incidence and mortality by more than 80%. Adding screening for HPV after age 30 years increases sensitivity

Colorectal CA: 1. Minimize Risk Factor Exposure: a…Excessive alcohol use, RR is 1. 41 for > 4. 5 drinks/day. b…Cigarette smoking—RR for current smokers versus never smokers 1. 18 c…Obesity—RR for woman with a (BMI) > 29 is 1. 45. Similar increase seen in colorectal CA (CRC) mortality. d…Regular physical activity—a meta-analysis of 52 studies showed a 24% reduction in incidence of CRC.

2. Therapeutic a…. . Based on solid evidence , (NSAIDs) reduce the risk of adenomas , but how much this reduces the risk of CRC is uncertain. —Based on solid evidence, daily aspirin use for at least 5 years reduces CRC incidence and mortality. b…. Postmenopausal combination hormone replacement (not estrogen alone). —Based on solid evidence, 44% reduction seen in CRC incidence among HRT users —Based on solid evidence, combination HRT users have a 26% increased invasive breast CA risk, a 29% increase in coronary heart disease (CHD) events, and a 41% increase in stroke rates. These risks obviate use of HRT for CRC prevention. c……Polyp removal —Based on fair evidence, removal of adenomatous polyps reduces the risk of CRC.

# Low-fat, high-fiber diet does not reduce the risk of CRC to a significant degree. # Statins do not reduce the incidence or mortality of CRC # Data are inadequate to show a reduction in the risk of CRC from calcium or vitamin D supplementation.

ENDOMETRIAL CA 1. Minimize Risk Factor Exposure: a…. Unopposed estrogen —Use in postmenopausal women (≥ 5 years of use = 10 -fold higher risk) b…. Obesity —risk increases 1. 59 -2 folds for each 5 kg/m change in body mass c…. Lack of exercise—regular exercise (2 hrs/week) with 38%– 48% decrease in risk. d…. Tamoxifen—used for > 2 years has a 2. 3– 7. 5 -fold increased risk of endometrial CA. e…. Nulliparous women have a 35% increased risk of endometrial CA.

2. Therapeutic interventions: a…. Oral contraception (estrogen and progesterone containing) —Use of oral contraceptions for 4 years reduces the risk of endometrial CA by 56%; 8 years, by 67%; and 12 years, by 72% b…. . Increasing parity and lactation — 35% reduction vs. nulliparous women.

Prostate CA 1. Minimize Risk Factor Exposure a……Family history of prostate CA in men aged < 60 years defines risk. One first-degree relative with prostate CA increases the risk 3 -fold, two first-degree relatives increase the risk 5 -fold. b……Incidence of prostate CA in African Americans increased, occurs at a younger age. # High dietary fat intake does not increase risk for prostate CA but is associated with aggressive cancers and shorter survivals

2. Therapeutic a…. . Finasteride Decreased 7 -year prostate CA incidence. Dutasteride associated with absolute risk reduction of 22. 8%. # Vitamin E/alpha-tocopherol—inadequate data—one study showed a 17% increase in prostate CA with vit. E alone. Skin CA : Sunburns (melanoma) Therapeutic: Sunscreen, protective clothing, limited time in the sun, avoid blistering sunburn in adolescence and young adults.

Thank you