Lisa Clacka is a past president and a fellow of our college and has a long and distinguished career. She is a former army officer. She's a public health guru and does a lot of lectures for us on vaccines and in the public health recommendations. So Dr. Lisa Clacka. Thank you. Good to be back here speaking to you again. We're going to talk about some I'm going to call pearls in clinical preventive medicine because we are going to talk about U.S. Preventative Services Task Force. And we're really going to kind of hone in on a couple of specific items and changes I wanted to talk about today. And we will just focus a little bit on we'll reference a healthy people 2030 highlights because we're going to be pulling into pulling those into some of our discussion. So what we want to do is briefly I'm going to describe the roles of those to the task force and the healthy people. And we're going to go through some methods on how we access those recommendations. And then we're going to use a case format to go over some examples of those recommendations. So Preventive Services Task Force was created in 1984. What it is it's a all it's a volunteer group 16 individuals that are selected that are under the auspices of Health and Human Services but they are not government employees. It's a task force of generally composed of public health primary care. There's some input from behavioral health and nursing. So very primary care focused evidence based focus. So they make evidence based recommendations for preventive services. And the other function they have a mission is to identify evidence gaps priority areas that are needed for to make for future recommendations. They will assign and they'll assign a letter grade to each recommendation. A and B recommendations probably familiar with but let's review briefly. So A and B grade recommendations are recommended. A grade A means that there's there's good evidence that there's substantial benefit from the service. Grade B moderate evidence that there is some benefit to the service. So those two are recommended that they be provided. A grade in a grade C it's selectively recommended. So those are so that's those are situations where there's moderate certainty of a small benefit or possibly benefit in in selected populations. And then grade D have either evidence that there's harm the harm exceeds the benefit or that there's no benefit from the service. And then an inclusive I recommendation in the case that the evidence just is not felt to be conclusive to make a recommendation for or against. So again A and B are the recommended the ones that are recommended to be provided. There are 359 published recommendations and we're not going to talk about all 359. We again we will hone in on a couple of ones that I wanted to talk about because either they're having recent updates or that they may have some they're just frequently provided services and some where maybe there's some controversy in you know among other groups we'll talk about. Some of them they may be counseling for example dietary counseling. It may be preventive medication like medication to reduce risk of HIV in people and certain people that are at risk or breast cancer in women that are at increased risk or of course many of them are screening recommendations we're going to talk about today or they can be broken down. So basically on their website they can be searched by condition by health condition by age group adolescent older adults etc by sex by pregnancy status and so forth. Then we're going to focus on some of the screening recommendations. Healthy people we've probably all heard of but this is healthy people is a program that is they set goals on measurable specific measurable public health objectives again like screening for particular cancers. Again they're broken down you can search them by different different categories and that's their website. We're not going to go to that right now but that's their website. It was actually started in 1979 so the first healthy people was healthy people in 1990 and then every 10 years they they reset they look at where they are and set new goals they measure compliance with certain with those recommendations and provide guidance as to how how to improve them. So and that's just an example of what you might see from a healthy people in this case increase the proportion. So it's always a goal increase the proportion of adults who get screened for colorectal cancer. They'll look at the most recent data and the target. So it's a good example of that's actually a good example of a smart objective because you would think you know all these targets are different and you think well why isn't it 100% right we'd like it for it to be 100% well has to be obtainable right measurable obtainable. So that's felt to be and that's calculated through their calculations they determine what they feel is is conceivably attainable. So that's where they come up with those target goals. And then jump back to the preventive services task force. We're going to look at the tools or we're just going to navigate real briefly how to how to find those tools. So if you have somebody patients that you are looking at what are the recommendations for that particular patient those can be found through their website and we'll actually jump through how to do that. But on the website I see all products and then there is a there are a couple options. There is the web I just like using the web. I don't use a lot of apps myself but there is an app apps there's widgets. So I'm just going to jump through I'll jump through how to how to access that on the web. So again that's what that looks like and it'll bring up a page that looks like this and you can enter in you'll enter in the key a keyword if you want to look for keyword or if you just want to enter age height sex pregnancy status tobacco tobacco status. So so let's run through we're going to run through a couple of different cases. So let's and we'll start with a female 41 year old female. We've asked her these some of these questions she's married she's sexually active monogamous she's not pregnant never tobacco user no particular past medical history family history. Maybe she has a say she has breast cancer and a first degree relative height and we have our height and weight and then let me go back. Sorry back one. So I'm going to navigate here hopefully we're going to navigate to the web. So so we're going to go if we go on our PC or on our on our app if you said we use shorty one we'll add it we can enter this. Yeah yeah I'm not pregnant. If you don't know the answers to some of these you can leave them blank but then you get a whole bunch of recommendations because it doesn't it doesn't hone it down as much. So the more information you have to enter that was a no yes and then I think you will actually don't have to update. So then it'll pull up and these are in your screenshots that are in the slide packet. I just put them in there if you want to look at them later. But this is what it'll it'll pull up. So what's recommended. You'll see it's listed as a recommendations B recommendations 20 of them. So you get a lot of recommendations. It'll actually list all of them the C selectively recommended not recommended and inconclusive. So it's going to list a lot of recommendations real briefly. I'm going to go through what some of these are cervical cancer. Yes B questions what is B like B Bravo. So B is recommend A and B are recommended. B just means there's a moderate evidence that there's a benefit. A is it's more strongly recommended. There is substantial evidence that there is at least moderate benefit. But for our purposes you're going to recommend these. Now notice some of these aren't recommended in everybody. Some it'll say at increased risk for example increased risk of HIV. She's probably not at increased risk of HIV syphilis tobacco. She doesn't use tobacco. So anyway that's so that's what these are going to look like. And you can actually click on any of these. So I say I wanted to see cervical cancer. I go then open the recommendation and so you can navigate through there. And again I'm not going to do all that here today but that's kind of how to access those. And I'm just going to scroll through these because we just looked at these on the Web site. So so I'm but I'm going to what I'm going to do is I'm just going to hone in on a couple for each for each case and one of them that was recommended for her. I think it was an a recommendation was cervical cancer. So go through that epidemiology. It's we of course still see cervical cancer incidents about 13 14000 new cases. This is in the U.S. per year. Incidents of cervical cancer has declined markedly. And I believe on our slide we just have are showing from 1975 down. If you go back even farther since cervical cytology was developed and then became really developed starting in the 20s became more commonplace decades later throughout the following decades. But if you look at the 50s onward incidents of cervical cancer in the U.S. has gone down about 85 percent not so much in the rest of the world. It's still a big cause of mortality in other less developed countries and screening methods. When we talk about screening we're talking about cytology cervical cytology either through conventional means or liquid based cytology which is really pretty much taken over. Interestingly they don't they don't specify a preference for conventional or liquid based cytology in their review did not feel that one was preferable to the other. Some specialists in OBGYN may may disagree. In any case liquid cytology has pretty much taken over as most commonplace type of screening because a couple big advantages that is because we can test for HIV human papillomavirus and cervical cancer screening since recommendations have been made has really been turned on its head because of our understanding of HP HPV the role of HPV in the development in the pathogenesis of cervical cancer and in the natural history of HPV infection and of cervical cancer. So briefly this is as I think we is common knowledge now that HPV is the cause of cervical cancer high risk HPV probably 99 plus percent of cases there are other rare cervical cancers but almost all cases of cervical cancer are attributable to high risk HPV infection. Most of those due to type 16 or 18 there are other high risk HPV types. So and what we know now is a couple of things one it takes many years to develop from 5 to 20 years to develop. We also we know that HPV infection is very common. Eighty percent or more women will be exposed sometime at some point in their lifetime. Most of the time those infections clear over 90 percent of the time. However in some cases it will lead to persistent infection. Some of those can still clear you see the arrows going back and forth. They can clear it can progress to a low grade LSIL low grade squamous intrapithelial lesion which is roughly equivalent to the histological change CIN1 cervical intrapithelial neoplasia. Those are roughly those are terminology terms that are cytologic versus histologic. What's important is they're roughly equivalent. They roughly correlate with each other. So when you see LSIL usually that correlates with CIN1. Again that will regress in many of the cases will regress. It however may go on to a higher grade high grade HSIL or CIN2 or CIN3. At that point the risk of development of it going on to develop cervical cancer is much higher. So go forward one is just my little picture kind of what it looks like. Normal cells CIN1 some atypical cells two and then three going through the entire layer and then going on to develop cervical cancer. So the goal of screening now is change. It's not so much diagnosis based or lab result based it's risk based. So and there's an organization I think we all hopefully know ASCCP American Society for cervical colposcopy and cervical pathology which is kind of the goal really the gold standard for diagnosis and management of cervical changes. And they are risk based. In other words looking at the cytological changes, age of the patient, duration of the changes. They will do they have algorithms. You look at the risk of a lesion a CIN3 or greater lesion being present at that point. Then they go on to more invasive procedures. So why the concern? You know why not just test treat everybody? Well over diagnosis, over treatment and when you see some of the types of procedures removing part of the cervix. So over treatment can lead to a series of obstetric complications. So there's much more understanding of all that now and which has led to a lot of changes many changes in the recommendations. So how many of us probably still the old recommendations are they don't want to go away. So how many have women say I need my annual pap and I think they need an annual pap or they think a younger relative must have a pap before they get on before they'll get on birth control. Those are not we understand now that is not necessary. So the older look how different the recommendations are from old recommendations. Regular pap test which they didn't really define at least every three years for all women who have been sexually active. Again, that is out of the recommendation now, regardless of sexual activity. And now, then they gradually went on. Three years after, that was in place for a long time when I was younger and practicing. Three years after onset of sexual activity. Again, that's out. No relation to onset of sexual activity in the recommendations now. And there's an update in progress, so it'll be interesting to see where they go with that. Now, age 21 to 29, type of screening depends on, we won't go into that, but 21 to 29, there's more chance of HPV clearing, so they're a little less aggressive. 30 to 65, you can do co-testing, pap and HPV. So, the algorithms will direct as to, according to the age of the patient, what type of testing we're going to do. But just keep in mind, the big changes is older age at initiation, no correlation with sexual activity as far as the recommendations for pap testing. And the ethical populations doesn't apply to people that are at increased risk from DES exposure. There are still potentially women exposed to DES in utero. Of course, it's an immune system. HIV-infected women, their screening recommendations will be different. So, again, guidelines also apply regardless of HPV vaccine status. And it's not indicated in women that have had removal of the cervix. So, yes. The question is, so why is it not recommended in women over 65? Well, one of the caveats is in women over 65, that's probably a couple slides ago, who have had adequate screening. So, most cases, most cases of cervical cancer are going to be in women who were never screened or inadequately screened. So, if your 65-year-old has never been screened or is not up to date with screening or has had abnormal screening in the past, then, you know, they would probably continue to be screened. But in women who, most women at that age have already been exposed to HPV, cleared HPV. So, it's, in women, older women that have, are diagnosed are generally people that have never been screened before at all. So, it's, the biggest bang for the buck seems to be in that younger age group, but not under 21. So, the other quick comment is, you know, when HPV vaccine became available in 2006, it was known then that it would be many years or decades before we saw an impact on cervical cancer. Why? Because it takes so long to develop. Now, fairly early on, we did see changes in these, a reduction in some of these cervical changes. And now, we are, in fact, seeing. This is kind of exciting. This is a study in Scotland, not really a study, but a review of, because through their national health system, have access to every woman who was, was vaccinated at or before age, before age 14, there were zero cases of cervical cancer in those women. So, it's very, that's very exciting. It's kind of what we expected, but it's, it is, it's certainly very exciting. Now, currently, we do not have any, there's no change in recommendation in women based on vaccination status. Will we see that change in the future? Possibly. So, there's an update underway. We'll see what that shows when it, when it comes out. Other, interesting though, American Cancer Society and some other countries actually start screening at age 25. So, and quick knowledge check. So, 22-year-old asymptomatic woman asked about cervical cancer testing, and recommendation is what? So, and it is B. So, answer is B. So, remember A, no screening if she's never had sexual intercourse. That's not, now, is she probably at less risk? Possibly, you know, minimal risk, probably, but according to task force recommendations, that does not play a part. Initiation of sexual activity doesn't play a part, and again, HPV vaccine does not play a part yet, possibly will. Okay, then breast cancer. I'm going to focus real quick on breast cancer. Again, most frequently not diagnosed non-skin cancer in the U.S., just some pictures of incidence of different types of cancers among men and women, and in about 7.1% of all cancer deaths in women. So, mammography, when we talk about breast cancer screening, we're talking about mammography. Again, benefit, goals of screening is to detect early stage breast cancer. Now, keep in mind, and one of the things that a draft publication came out, right now, the USPSDF has recommended screening mammography starting at age 50, and that's been not consistent with some other groups' recommendations. They actually did use, many years ago, it was at 40, because they felt that the evidence, again, they're very evidence based, in women from 40 to 50, the number of deaths averted, breast cancer deaths averted, was fairly small, and actually in confidence intervals, was not significant. However, that data is about 30 years old, that's been revisited, and also there's more attention now, first of all, to breast cancer incidence in women between 40 and 50 is going up. Now, there's a lot of concern for some racial disparities in breast cancer, so in white women, a little bit overall, higher incidence, black women, higher incidence in young women, higher mortality, and potentially a lot of reasons why, because there are a lot of factors that influence risk of breast cancer, so pregnancy status, breastfeeding status, access to care, access to insurance, type of cancer, so black women, the incidence of hormone negative types of breast cancers is higher, and those are more difficult to treat and have higher mortality, so there's a lot of concern, so there's focus on that, but in any case, it did lead to a recommendation to bring this onset of breast cancer screening in women to age 40, so we're going to see that. That is a draft recommendation. It was, I think, published about, the draft was published, I think, about a year ago, so probably any day, I've been checking it, it's not out yet, but probably will be formally published any time now, so it actually will be age 40, so potential harms, again, we always look at risk versus benefit, correct, so potential harms, false positives, additional, you know, imaging, surgery procedures that aren't necessary, and particularly because dense breast tissue is more common in younger women, and there are more false positives, so the task force does not really get into different types of screening or different types of testing that may be more applicable to women, either women at higher risk of overdiagnosis because of dense breast tissue, but there are other procedures like ultrasounds and MRIs that some clinicians may use, but they don't really get into that with their current recommendations, so again, current recommendation is age 50, but with the draft recommendation, it's going to go down to 40, and that is, yeah, somewhere in the old draft procedure, but probably will be published fairly soon, so applicable populations, asymptomatic, I know that's redundant, they always say asymptomatic, and that's what screening means, it's in asymptomatic people, 40 or over who do not have pre-existing breast cancer or high-risk lesion, not at high risk, now remember I mentioned she had a family history of breast cancer, so she might be one, and we're not really going to get into these recommendations, but the task force does have specific recommendations for women that are at, that are BRCA positive, one or two carrier gene mutation, and there are two recommendations specific to that, one is for evaluation, and then one is for medications to reduce risk, but that's going to be a little beyond the scope of what we're doing today, but if that applies to your patient, then you can navigate to those recommendations, so let's see, and again, healthy people, current target is about 80.3 percent, most recent figures are about 75.6 percent of women that are up to date, now as we go to 40 and up, that number is probably going to be, it may drop because you've increased the pool of women that now are recommended to be screened, so that's pretty typical for some of the common recommendations, that it's about 75, 75 percent, 60, 70, 80 percent, so again, big focus is to reach some of those people that we know are recommended that are not, are not complying with those recommendations, and trying to figure out why, and then again, other, most other, many other organizations have onset dates of screening that are, that are lower, so I'm going to move on, if there's no questions about those, I do want to move on to the second case, yeah, question? What about self-breast examinations? That, yeah, that's good question, so self-breast exam and provider breast exams are, by the task force, they, evidence is not, really is not shown that they reduce mortality, so now is it, they kind of go back and forth, you know, it's good to be, like especially for women, be familiar with their breasts, and but they have, it actually hasn't been found, they, it's not something that's recommended, it might be in that CDE list there, yes, my understanding is the argument against self-breast exams is the number of false positives, that's a good, and as a result, there was a tremendous increase in costs in mammography, whereas a clinical breast exam was able to discern those who are, should be, versus those who might not be, yeah, that's, that's very likely, that's something, that's something I looked into recently, but it's, it's very possible that, so self-breast exam, more, more concern, more false positives, leading to other, leading to overtreatment, so that's, so I'll go on to the next one, I'm not, I'm not going to navigate through like I did before, but I'll just show you the screenshots, just to save time, so now we have a male, he's 46, not married, sexually active, multiple partners, smokes, or smoking history, no, no other history, so what we, what we brought up in him when we, when we looked was, so we have some suggestions for HIV screening, that's actually in everybody, hypertension, prevention of acquisition of HIV, HIV prophylaxis, pre-exposure prophylaxis, he might be a candidate, maybe a candidate for that, maybe a, at increased risk of syphilis infection, so we may need to screen him for that, and then we're, the one we're going to focus on here today, though, is colorectal cancer, we'll talk about that, and again, the rest of these, some of them are, for example, TB, at increased risk of TB, well, maybe from his line of work, so, and we, we won't go, again, in the interest of time, we won't go through them one by one, but we'll just pick out a couple to talk about, so colorectal cancer, yes, so we will, yeah, well, I'll get to that, question was, what is, is it a moderate recommendation of colorectal cancer, we're actually going to get into that, there are two recommendations, one's an A and one's a B, so, yeah, so, second leading cause of cancer deaths in, in the U.S., and as with most, most other cancers, we want to catch them early, because chance of five-year survival is, of course, much greater if that's localized than if it is metastasized, so, so, recommendation, there are two recommendations, 50 to 75, that's been a recommendation for a long time, screening starting at age 50, but in 2021, they added a B recommendation, meaning, so, remember the, in the A recommendation, there's substantial evidence that screening at, from age 50 to 75 provides benefit, but they also found that there is moderate evidence that actually starting screening at age 45 provided benefit, so that was added on in 2021 as, as a recommendation, and with a recommendation, there are six types of tests, the task force is not, does not specify one test is better than the other, either of these tests at the indicated intervals are acceptable, so, we have some that are fecal tests called blood, fecal immunohistochemistry, FIT plus DNA, and then there are direct, direct tests, so, just throw it out there, what are, so, some advantages of some of the stool-based tests might be, what are some advantages of some of these, occult blood, more people will do it, so, yeah, so, more, greater acceptance, maybe, although, on the other hand, some people, they get sicky, and they, you know, they don't want to do, then, where they have to do a stool-based test themselves, but, yeah, probably better compliance for, for, because cost, you know, kind of parallels, more, more available, yeah, convenient, more convenient, how about no, you know, a colonoscopy needs anesthesia, it's expensive, it's a procedure, how about that famous, the famous PrEP, yes, no, so, PrEP, let's see, PrEP, no PrEP, so, that kind of can push people, yes, yeah, well, it doesn't matter, this is a, Dr. Berko says, the PrEP isn't all that bad, so, some of you might not, some of us might not quite agree, well, okay, well, I'm not, well, it used to be 48 hours, so, yeah, they've gone from two days to one day to possibly a little shorter, shorter PrEP, so, the, the GI people and the surgeons, really, they like the direct test, direct vigilation test, better than the indirect test, one of the big reasons is, of course, with the colonoscopy, what happens if they see polyps, they can remove them, if they're precancerous, so, it's actually preventing, so, that's the thought on there, but, of course, it's expensive and requires a procedure and anesthesia and so forth, so, but the task force does not give a preference, one over the other, again, asymptomatic adults, 45 and older, does not apply to people with prior diagnosis, inflammatory bowel disease or Lynch syndrome, other, some of these other genetic conditions, so, and, again, screening rate's not so good, 69.7%, and then, of course, when you, when you add that 45, expand that to 45 to 70, 75 years, compliance goes down even a little bit further. And the recommendations, American Cancer Society also starts at age 45. And then the big industry-wide group that weighs in on this are a conglomeration called the Multi-Society Task Force of Colorectal Cancer. So, the GI, in other words, GI and surgical people do prefer a tiered approach. So, again, giving preference to the direct visualization test. So, another knowledge check. So, which is true? So, a 35-year-old, asymptomatic, recently diagnosed with Crohn's disease should initiate colorectal cancer in? And the answer is, who says D? So, yes, yes, atypical inflammatory bowel disease. In fact, recommendations are to initiate screening within so many years of diagnosis, and it generally is every one to two years. So, yeah, those guidelines are not going to apply, screening guidelines are not going to apply to that patient. So, and then we still actually have plenty of time. So, I'm going to add a couple of monkey wrenches here. We're going to make them 56, same thing, and I don't have the screenshots here, but we'll pick up two other things. I want to talk to you about prostate cancer. So, probably the most controversial, hotly debated topic as far as cancer screening. On one hand, it's, well, do we have the microphone? We can get the microphone. This might be fun to just maybe one to two minutes, get some thoughts, opinions. Who's got the microphone? Okay, all right, then make answers really short and I'll repeat them. So, why is it debatable? Why is there so much debate on prostate cancer, PSA, prostate cancer screening? Two words or less. Anybody, yeah, prostate cancer takes a long time to develop, meaning it's common, right? It's common, but a lot of them have it and it won't affect their lifespan. Okay, any other thoughts? Dr. Clark is going to get the microphone. Treatment's worse than the disease. Treatment is worse than the disease. Yes, so high incidence of, I mean, even if it is diagnosed as prostate cancer, treatment meaning causes what? Yeah, treatment, surgery. So, what kind of side effects? The erectile dysfunction, urinary dysfunction. Yeah, urinary dysfunction for a disease that grows really, really slow. For a disease that grows very slowly and is really low risk in many, many men. Now, on the other hand, have any other comments? What's for prostate, for screening? Microphone's coming. So, since I've been in medicine, we've had at least three systems that have been implemented to try and identify the less than 1% of people where it's going to metastasize, because that's important. Metastatic prostate cancer sucks. Not metastatic prostate cancer is not a big deal. And the trick is, how do we tell them apart? Exactly. And we're on at least our third system since I've been in medicine. We might be on our seventh system by now, because none of them work right. That identify what was aggressive and what was not. They would say, this is aggressive, that's not, and then the non ones metastasize and the aggressive ones didn't do anything. So I'm just, that to me, that's a key thing driving prostate cancer screening. And PSA is probably not super helpful, unless it's really high. But again, this is always one of those preventive medicine things like, we need more science. Exactly. We need it, yes. Good comment, we need. So good comments there. It is a big deal for men who develop it. 11% of men will be diagnosed with. Of course, many more men, if you do autopsies on 80-year-old men, a lot of them will have preclinical prostate cancer. But 35,000 deaths a year, that's the second leading cancer death in men. So it is, it's not a small thing. And in those men, so it's an excellent point. The science has been slow to develop as to who's gonna benefit from screening, who's gonna benefit from treatment. And any other comments, or I'll move on. So, and how about the, and again, so, well, here again, this metastatic disease, five-year survival rate is poor. But localized and regional disease probably doesn't affect their lifespan. So that's why the issue is controversial. And the PSA test, what's a normal PSA? We don't really know. Is it four nanograms per milliliter? Yes, Dr. Schneiderbaum? Your examples are quite well presented. And on a couple of them, the update in progress is to be noted. And I'm just wondering, biggest obstacle some of us have in trying to put forth the USPSF recommendations is running into the positions of the specialist societies, particularly gastroenterology versus the USPSF task force. And the same sort of a situation for breast and prostate. So the notion now becomes whose criteria does one employ? One, because one might be self-aggrandizing finances, particularly in GI, similarly in imaging with breast. And I was going to ask our AI rep, and I'm sorry to dump on you, it's a medical term. What would improve, and it seems to me that all of these lie on improved diagnosis to reduce false positives. That's the end in view. Yes. And my understanding is that AI, for example, is better at diagnosing breast cancer than many radiologists. At least that's been published. So, I mean, your slide suggests that. When the update's in progress, does one default to the specialists or to the USPSF task force? How should one present? Or is there new features coming in? Let me give you the mic. Well, that's the issue. Yeah, comment is it depends on what the insurance is going to pay for. And because insurance is required to pay for A and B recommended services, PSA is not recommended. So quick comment on that last comment. Yeah, I think the power of AI, and one of the promises of AI is the ability to look at immeasurably vast data sets that we've had for a long time and discern new trends because of the ability to process that amount of data that humans just can't. Which will get us to the place that was mentioned where like the real thing that we need to do with this is figure out which of these prostate cancers become metastatic and we should do something about and which end up not being that big a deal. And that's a very similar paradigm in breast cancer as well. So that's really the benefit of, in the future AI can look at data sets that we already have in aggregate and possibly discern new trends. What I'm gonna do is I'm gonna, it'll probably muddy the water, but it kind of gives you some food for thought and there are some references in here to kind of follow up on later. And I certainly would like to see what happens with screening recommendations. What the task force has done with prostate cancer all the way back to 96, D, do not recommend. 2002, inconclusive. 2008, inconclusive. That's in the younger age group. 2012, went back to do not recommend and the urologist had a fit. Because again, the same, it's just a little bit about the PSA, I might jump back to that. But these are the randomized clinical trials that were used and there are still, some of them are still ongoing. These are from the two main ones were looked at. PLCO, this is in the U.S. Screening versus control. Screening was PSA, digital rectal exam. Control was usual care. So the big criticism from the urologist on this is that usual care, well, a lot of the usual was intention to screen. So usual care people got screened too. So they felt that kind of muddied the water there in terms of their findings and this is their early findings, seven to 10 years. There's more follow up now that prostate cancer mortality did not differ significantly between the two study groups. Again, seven to 10 years, not very long. They felt the other criticism was that this was not long enough follow up to make that conclusion. The other criticism is the second study, European study, did find 20% decrease in mortality. So they did show a decrease in mortality but it was felt to be offset by over-diagnosis and over-treatment. So again, I think we've all come back to the real question is who do we wanna diagnose and treat and who do we wanna leave alone because we would diagnosing them and treating them would cause more harm than good. And then the other one, Europe, one study, again, found basically the same thing as the European study. Yes, it decreased prostate cancer mortality but was associated with over-diagnosis. So takeaway again, we've kind of hashed this out among ourselves. Again, the rationale for screening as we brought up, prostate cancer does kill a lot of men. Some of it's very aggressive. We wanna find those aggressive cancers and treat them, especially in younger men because more benefit increase quality of life and not so many years of life lost and so forth. Against PSA, very low specificity, most elevated PSA is not prostate cancer. It tends to fluctuate. Are there other, and then other comments, there are other studies, right? Urologists like to look at PSA velocity. In other words, how fast is it going up? PSA density, which requires imaging of the prostate. So determine its volume and then what's the PSA relative to the volume of the prostate. So lots of other potential tools out there that could be used. Big one now is MRI, right? So biopsies, right? Instead of just going and randomly biopsy, of course it's done, needle biopsy, through the rectum into the prostate, random biopsies. Not very, I don't know, yeah. Now it's MRI directed, targeted biopsy. So techniques are really, they are improving. And so it's just a very interesting, it's a subject that is hopefully going to improve through better diagnosis, better screening. Just told my students, statistics guide physicians. But the problem is, well, there are many examples. I know a retired admiral and he had a high normal PSA for years and Walter Reed refused to work him up because he said he had a normal PSA. And finally he got in their face and demanded that something, you know, at least they take a look at it. Well, he did an MRI and he had prostate cancer. So, you know, statistics guide us, you know? And so, you know, for cancer patients, you know, the survival rate might be 1%. But if you're that 1%, it's 100%. Yeah, so when you look at individual, and I remember when I was an intern in the army, I watched a 19-year-old soldier die of colon cancer. You know, it's like, you know who screens 19-year-olds for colon cancer? And so I understand the reasoning behind screening recommendations, but still as physicians, we need to look at the individual patient. And just because not many people get hit by lightning doesn't mean people don't get hit by lightning. And you have to listen to your patients, you know? So I think sometimes some of the younger doctors maybe put too much weight on the screening recommendations. Maybe some of the insurance companies put too much weight on the screening recommendations because, you know, somebody who's got symptoms and you're suspicious, you need to work them up, you know? You don't want to miss something and have one of your patients die. Yeah, good point. Yeah, bottom line, listen to our patients. You know, each case, absolutely look at guidelines, but then apply them, you know, listen. So apply them to your patient, listen to your patient. So, Rhys, I think we've kind of hashed this out also, research needs and gaps. Basically, how do we identify the men that are going to be at highest risk of metastatic disease? And, okay, and last slide, this is actually from, and there's a link here, Memorial Sloan Cancer Center Grand Rounds. They have some very nice grand rounds in urology. And of course they are the subject matter. You know, we were talking about primary care recommendations versus when the subject matter experts or the specialists weigh in. Well, but they do have a very nice grand rounds on this. And basically they sum it up, share clinical decision-making as was suggested. Don't screen men who won't benefit. Don't biopsy, that was a big one. Don't just biopsy everybody with an elevated PSA. I have a reason to biopsy, and of course other, you know, there are other more better techniques now for biopsy, don't treat low-risk disease. And if treatment's indicated, really look at who is going to provide that treatment because that can affect outcomes. They did feel that the high incidence, reported incidence of these side effects, you know, maybe are not so high in the right hand. So I won't go into the last one. I'll just, maybe I'll give two bullet points on this. Lung cancer screening is probably the, just going to jump right in, lung cancer screening exists and people don't seem to know about it. The, this is among people that are recommending, people that currently smoke or have quit smoking within so many years for the recommendations, very, very low. So just kind of keep that in mind, that is something, it's out there. It's not really a new recommendation. So keep that in mind for patients who smoke or who have smoked. So other than that, I'll skip over that one. Any, yeah, we'll skip that one too then.

preventive medicine

U.S. Preventive Services Task Force

Healthy People 2030

screening recommendations

cervical cancer

breast cancer

colorectal cancer

prostate cancer

lung cancer