Update in Preventive Care

notation we can stop the questions along the way if it’s a two-part presentation we talk about vaccinations and and cancer prevention that I call this an update and preventive care so what is preventive care mean preventive care is a medical care that focuses on disease prevention and health maintenance this definition I gotten the medical dictionary and screening tests health education we’re right in the heart of our vacation and immunization programs are common to preventive care so I’m talking about some screening tests and some immunizations as part of preventive care let’s start with a patient a point of reference our first patient is a 65 year old male with a history of type 2 diabetes who comes to your office for a routine exam so in terms of a preventive care what kind of vaccines should this patient receive here’s a list of the common adult vaccines that you may be familiar with that I deal with on a daily basis as a general internist there’s the annual influenza or flu shot if you’re aware of this a manufacturing comes out in the fall every year there’s a booster vaccine which contains tetanus and pertussis and it’s a booster vanquish and get your first Texas and pertussis vaccines when you’re a child and as adults we’re not talking about giving a booster what’s called a Tdap or refer to as a Tdap vaccine then this herpes zoster is the shingles vaccine the brand name is Austin backs and then we also have vaccines that prevent disease by the pneumococcal pneumonia bacteria I’m not going to talk about the flu shot today but there’s been some changes and some recommendations of these vaccines but I’ll talk about now let’s stop start with the herpes zoster or shingles vaccine first of all what is it who should receive the vaccine and why should there be seen so varicella-zoster virus is an infection that can lead to two different distinct diseases varicella that are known as chickenpox which is usually a childhood disease and herpes zoster also known as shingles both caused by the same virus after the primary infection or chickenpox the virus lies dormant in a nerve root near the spinal cord by the spinal cord reactivation of this dormant virus can lead to herpes zoster or shingles so the virus is hiding out your body the 30 40 50 60 years and reappears as an adult possibly causing shingles here’s a picture of shingles or herpes zoster this is the classic rash across someone’s mid thoracic or mid-back area it’s a large area of redness covered in small what we call it vesicles which are small little fluid covered lesions and along a particular pattern which is typical zoster which is along the nerve group from which it emerged so here is a thoracic nerve root that is becomes inflamed by reactivation the virus and that nerve root goes along the back along the long side of a rib and wraps around it can occur in any nerve root and be up on the arm and the leg and also on the face so who gets herpes zoster estimated about a million cases in the United States occur every year it’s incident increases with age especially over the age of 70 over the age of 50 but you more about age of 70 age is related to decreased immunity to the virus the immunity which we gain at the primary infection or chickenpox and there are other risk factors associated with developing zoster including having cancer or a compromised immune system frequently medications can compromise

your immune system such as steroids or chemotherapies or other medications that we use to treat rheumatoid arthritis or inflammatory bowel disease patients which chronic lung disease are at higher risk for developing zoster as well as patients with kidney disease also at increased risk so one of the problems that we’re concerned about in terms of preventing exhaust or well zoster journeys acute manifestations can be very painful maybe mild pain or severe pain and typically lasts in the uncomplicated fashion up to four weeks the most concerning complication the dreaded complication of zoster is something called post herpetic neuralgia which is pinging that occurs after the first four weeks of the onset of shingles this pain is often very very severe and thus can significantly affect the quality of life of the patient moreover it’s frequently difficult to treat specific type of pain syndrome called neuropathic pain which is often needs a certain types of medications to treat and can be very difficult to manage and the incidence of neuropathic pain or post-traumatic neuralgia increases with age about one-third of patients who get herpes zoster over the seven over 79 years old will develop postherpetic neuralgia so we have an elderly may be more frail population developing a chronic pain which is obviously a huge problem so the zostavax the herpes zoster vaccine was developed and the current guidelines recommend that vaccinations be given to every adult one time starting at the age of 60 the FDA has approved the vaccine for over 50 but the Advisory Committee on Immunization Practices currently advises getting at age 60 to ensure adequate protection in those later years so how effective is the shingles vaccine well we have data from some studies and sympathy i’m going to talk about the shingles prevention study which involved 30,000 adults were over the age of 60 and they were followed for three years it was a placebo controlled trial which means half of the 38,000 adults received the shingles vaccine and half do not receive the vaccine and what they found that the following these patients was that the incidence of zoster was reduced by fifty fifty one percent compared with the patients who did not scene and the patients develop doster the instance of postherpetic neuralgia was reduced two-thirds the greatest benefit of the vaccine was seen in patients were over 70 years old I do want to point out that even if you get the vaccine doesn’t mean you’re guaranteed to be protected from zoster it reduced the incident like fifty percent but the other fifty percent still could get it softer similarly just because you get the vaccine against Oscar doesn’t mean you’re not going to develop post affect morale Joe with your chances of developing that complication are decreased so it’s a vaccine that’s effective but no guarantee some precautions about the vaccine but it is a live attenuated virus so can cause a good reaction in the injection site is also at some pain usually manageable with some ice and tylenol as a live virus you should never give it to a pregnant women or any women of childbearing age you shouldn’t give it to people who are immune suppressed we’re giving getting chemotherapy or high-dose steroids and other immune suppressed patients who are transplants or HIV if you’re allergic to neomycin or gelatin or other constituents of the vaccine you cannot get it it’s paid for by medicare d unlike the flu shot which is part of europe your visit medicare d is your prescription plan and therefore often you have to pay out of pocket get reimbursed sometimes your doctor will give you a prescription and you can take it to a pharmacy and look give the injection there so you have to know that the payment mechanism for Medicare patients is often a little different than other routine vaccines next I like to talk about pneumococcal disease and Prevention with the Pneumovax pneumococcal is caused by pneumococcal disease is caused by the bacteria streptococcus pneumoniae a and it’s the leading cause of what we call community-acquired pneumonia that’s what I’m you pneumonia that you get when you live at home and the normal life as opposed to normal as opposed to them pneumonias you get if you’re in the hospital or pneumonia that you may

acquire your nursing home in addition to pneumonia pneumococcal disease can give you sinusitis otitis media which is near infections meningitis serious infection of the surrounding of the brain endocarditis a serious infection of the valves of the heart osteomyelitis infection of bones and sepsis which is a syndrome with bacteria enters your blood and causes decreases in blood pressure and other complications so pneumococcal disease is not just about pneumonia but other serious disease here’s a photograph of an x-ray showing classic pneumococcal pneumonia so here are the lungs this black area is nice aerated lung where you have the healthy lung being aerated and this is your spine here your heart and this area here this white wedge is where air is being obscure because it’s filled with fluid or infection in this pizza shape consolidation we call this is your classic pneumococcal pneumonia or lobar pneumonia so what vaccines are available to prevent pneumococcal related disease well we have a vaccine that many you might be familiar with called the Pneumovax or the fancy name is the PPS v23 or pneumococcal polysaccharide vaccine which immunize against 20 30 types or different species of pneumococcus it is recommended for all adults 65 years or older and we also give it at a younger age to patients have some chronic medical conditions that might predispose them to pneumococcal infection including patients with diabetes chronic lung disease such as emphysema bronchitis asthma or patients with congestive heart failure just to name a few knitted you mail or we receive new mex however there’s a second pneumococcal vaccine which is important to know about because of recent recommendations this is called the brand name is called prevnar or the PCV 13 it’s a pneumococcal conjugate vaccine which protects against 13-0 times it’s related to vaccines have been used in infants and children since the year 2000 but as of the fall 2014 the CDC has recommended that all adults 65 or older you see this second pneumococcal vaccine we also give this prevnar or PCV 13 in certain subpopulation of adults who have serious diseases that we dispose them to pneumococcal infections including the leg See’s patients of kidney failure or on dialysis or patients with HIV so now we have to pneumococcal vaccines which what are we do we give it to him does it matter we give them both at once who should get them for a typical patient that’s a otherwise healthy 65 year old we start with the PCV 13 or prevnar the second vaccine the new maps of the PPS b23 should be given that must be given at least six to 12 months later that’s the weight ask me a time interval to give the second I’ve seen many patients in the community especially over 65 have already received the new of X so what do we do with them if you’ve only you’ve seen the new of X you should receive the Prevnar vaccine at least one year since you received that knew about adverse reactions generally a very well tolerated a vaccine some pain and tenderness just like with any other vaccine by sixty percent will experience a minor pain at the injection site swelling less common redness even less common third vaccine I want to talk about the Tdap vaccine Tdap is a combination vaccine which protects against tetanus diphtheria and pertussis yeah stands for a cellular pertussis intellij the vaccine was produced so tetanus you may know is also called lockjaw it’s a severe muscle tightening and stiffness it’s very lethal caused by a bacteria and we found in contaminated or soiled metal and you can enter the skin through cuts and bruises to Theory up frequently a childhood disease is responsible for a

lot of childhood death 60 70 80 years ago it’s a thick coating the back of the throat that can lead to respiratory failure we don’t see much of it now because of vaccines that we give in childhood and pertussis known as the whooping cough is a severe coughing spells which too often used to frequent hospitalizations the diagnosis is often often this and we’re missing more because of recent outbreaks that we not used to seeing tour 10 10 years ago there was very little pertussis nuvo population and now we’re seeing more frequently with epidemics reported in different cities one of the reasons why we are now boosting the Tdap is not just for the tetanus foot for the pertussis so here’s a picture of a patient with pertussis and you see a young person can be some pertussis affects people of all ages with severe cough grabbing his chest because the chest the cost can come into companies violent violent paroxysms that’s the hallmark of what we call you not coffee at all and then you had these violent violent spells like me so forceful that patients can actually break ribs and these grabbed his chest because he feels like he’s going to break his rib these violent violent coughing spells so a little bit about the Tdap vaccine there’s a version of it very similar which is a routine childhood vaccine however there is waning immunity we know I test the adults that about half of the adults over age 20 will have only half will have protective antibodies against these diseases the tetanus diphtheria booster should be given every 10 years that’s the recommendation of familiar with we now recommending in the last five years or so that the Tdap the combination of the pertussis should be one of these boosters so you get a TD booster every 10 years you replace one of them with the Tdap booster and these guidelines since 2010 also include adults over the age of 65 side effects again usually mild pain or tenderness of the injection site mild fever headache / fatigue I haven’t seen this patient get any serious side effects that they reported to me so back to our original patient there’s a 65 year old male the history of type 2 diabetes who came into your office for a routine exam he should be see the zoster vaccine and he has not already been given it you should receive the TD Tdap not he has received in the last 10 years and you should receive either the PCV 13 or prevnar if you never received the new viveks or the PCV 13 if you receive the move acts or this year ago caution you do not give disaster or numa backs in the same visit they have to be spread apart in order for them to be effective so those are three vaccines that want to talk about the second part of my talk I want to briefly talk about some concepts involving screening for cancer especially to creating the cancer in the elderly so patient number two is an eighteen-year-old winning the history of congestive heart failure and moderate and two zima she’s not had a mammogram in five years or a colonoscopy in 10 years what should you divisor in terms of cancer prevention eight year old woman is a mild significant medical problems which we advise regarding wants to be and mammograms so here is a list of some common cancer screening test screening for colon cancer is done with colonoscopy ideally breast cancer screening as you know is done with mammograms we screened for cervical cancer and women with a pap smear prostate cancer highly controversial screening the only real test that’s be employed widely as the PSA or with the blood test and lung cancer again up for debate we are often screening people with history significance to your smoking with cats games to look for early stages of lung cancer just make sure we’re on the same page what do we mean by screening or screening is during a test to find the disease in a patient who has no symptoms of the disease the patient has a symptom you’re not screening you are diagnosing if we detect the disease then we must be able to save lives if we detect a

disease through a screen test you have to know that cure is possible we have to also know if we detected a disease in a person has no symptoms that we can reduce suffering that treatment is acceptable to look the patient and the family there’s a lot of discussion in the medical community about cancer screening not necessarily what test to do but also when do we start doing tests how frequently do we repeat the test frequency do mammograms how frequently to do colonoscopies but I want to call your attention to one other very important controversial area an area which is going to be very very important to our society as our society ages and our healthcare dollars become more precious is when do we stop screening for cancer when do we stop doing tests to find disease patients who have no symptoms and another way of looking or reframing this question is when do the harms of screening outweigh the benefits the benefits theoretically are to save lives extend life and prevent separate screening can detect both cancers that shorten a patient’s life and cancers that will not affect a patient’s like detecting cancers that will never impact the patient’s life you need to overdiagnosis and unnecessary treatment thus screening may produce potential harms to the patient an extreme example would be a 19 year old woman who has mild dementia and severe arthritis who is bed bound in a nursing home are you going to do mammograms on that women to find the cancer that you would have to treat or would that be subjecting the patient to unnecessary testing treatment suffering arms will that cancer they detect extend their life if we treat it that’s an extreme example looking back up say the patient is only 80 a severe lung disease not demented start figuring out when do we think we’re going to help the patient so cancer screening elderly what benefits could it have finding a curable cancer at an early stage prevent death and reduce suffering all desirable outcomes but what are the harms the risk of the test itself so colonoscopy usually a very safe test unless there’s a calculated risk to it patient has to take a prep might be a biopsy the biopsy as associated risks say you find that cancer in the colon now we have to treat it subject the elderly person to surgery costly chemotherapy and even if we cure the person the person they have to have prolonged hospitalization hospice a shin the elderly very dangerous acquiring infections blood clots balls other complications hospitals a shin the elderly is a very serious thing and more to the point it would be fine to cancer and cure the cancer with that patient died of something else before that cancer affected definitely how long without cancer tape to affect their life relative when they would have died of more natural causes or other diseases that they have so when to stop screening what are some of the considerations so clearly the age of the patient and based on the age we can calculate the average life expectancy however the average life expectancy is going to be affected by the patient’s comorbidities or other illnesses that the patient has significant disease cancer severe heart disease poorly controlled diabetes that is obviously going to affect their life expectancy regardless of their age and of course never forget what the patient’s preferences and values are the patient doesn’t want to be tested because they would never have treatment and you don’t do the test the patient knows they will never be treated because they don’t want any treatment there’s no point in testing so we have official recommendations about when to stop cancer screening for breast cancers most experts recommend stopping mammograms when an individual is life expectancy

less than 10 years sounds like a soft calculation but you can make a pretty reasonable ested in terms of colon cancer screening with colonoscopies similarly the American College of Physicians recommends stopping colonoscopies at age 75 or when the patient’s life expectancy is less than 10 years those are just I’m not talking about the other cancer screenings and just going to focus on mammograms and colonoscopies because that to our patient remember she was an 80 year old woman with a history of congestive heart failure and moderate emphysema was not had a mammogram in five years or colonoscopy ten years what she did advise her given her congestive heart failure and modern emphysema I say she has significant comorbidities significant underlying diseases which will affect her life expectancy i would estimate an eight year old one this his life expectancy has far less than 10 years thus she is unlikely to benefit from the detection of cancer and screening with us introduced harms likely no extension of life however these are just guidelines and there are exceptions and I like this pictures of these guys probably all over 80 running down the beach these guys look that they’re in pretty good shape and i think we would consider them to be good candidates possibly if they wanted for some screening tests so we always individualize thank you very much