Shifting Focus on Preventive Medicine

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The presidential campaign has once again brought health care, and especially its cost, to the surface.  Each candidate has a plan to reform the nation’s health
care system. 
Many of us in the medical community believe that the most important change would be to shift the emphasis in US medicine, focusing more on disease prevention.  Disease screening can both identify health and environmental conditions that adversely affect large number of people, and effectively reduce both the frequency and severity of diseases.  Screening must be individualized; everyone should see a primary care provider periodically for physical examinations and to discuss any specific concerns or history. 
More specifically, the US Preventive Services Task Force (USPTF) reviews the current evidence from various studies and makes general recommendations. I have outlined below some of the principles they suggest regarding prevention of the most common diseases we see in our country.
Cardiovascular Disease (Cv)
CV disease is the most common cause of death in the US.  Everyone should be counseled and screened at age 35.  Primary prevention aims to avoid development of the disease.  According to the Nurses’ Health Study, there is good evidence that avoiding obesity,  regular exercise,  eating a healthy diet, and not smoking can reduce cardiovascular risks to the heart and brain by up to 84 percent.  The Women’s’ Health Study showed this lifestyle could reduce the risk of stroke by up to 55 percent.  For people with a moderate risk of heart disease, controlling blood pressure, treating abnormal cholesterol, and taking low dose aspirin (81 mg) on a daily basis can effectively reduce the risk of cardiovascular disease.
CV disease sometimes manifests itself as a ruptured abdominal aortic aneurysm.  Although rare, this is a potentially catastrophic event where the  largest blood vessel in the abdomen is dilated, and subsequently tears.  These often fatal events occur most in current or former male smokers between the ages of  65 and 75.  These men are advised to consider having a one time abdominal ultrasound to check for aneurysm.
Cancer
1. Breast cancer – The USPSTF recommends that women begin annual mammography and clinical breast exams at age 50; the American Cancer Society recommends beginning yearly mammograms at age 40. Mammography and clinical exams should be continued until a woman’s life expectancy is less than 10 years – meaning well into old age.
2. Cervical cancer- Women should be screened with pap smears beginning three years after the onset of sexual activity or at age 21, whichever comes first, and should have a pap smear every 1-3 years depending on previous results and risk factors that include history of sexually transmitted infection, immune status, and number of
sexual partners.
3. Colorectal cancer – This is an eminently preventable disease. Screening for most people should begin at 50 years of age, or 10 years before a first degree relative was diagnosed, and should continue until life expectancy is less than 10 years. Screening options include a colonoscopy every 10 years, CT colonography (virtual colonoscopy) every five years, flexible sigmoidoscopy every five  years, or double contrast barium enema every five years. There are benefits and risks to each method and the choice should be tailored to the individual patient.
4. Lung cancer – All patients should be screened for tobacco use, and counseled on the need to stop smoking and the various methods available to help them accomplish it.   Stopping smoking is the one most important change a person can make to positively influence his or her health.  Within one year of quitting, the risk of heart attack or death is reduced by up to 50 percent, and after several years, the risk declines sufficiently to approach that of a non-smoker. The risk of stroke approaches that of a non-smoker within several years of the end of smoking.  Chest x-rays in asymptomatic people, regardless of their smoking status, do not detect lung cancer in enough time to help them beat the disease, so they are not recommended.  Studies are currently underway looking at the effectiveness of CT scans to detect lung cancer early enough to positively influence treatment and the patient’s subsequent quality of life.
5. Prostate cancer – This is a controversial topic because the benefits of treatment with regard to improving a person’s life expectancy  are uncertain, and there are potential risks associated with treatments that can strongly affect one’s quality of life.  At 50 years of age, men should be counseled as to the risks and benefits of screening.  If a man elects to be screened, a digital rectal exam and a blood test should be performed.  Some recommend stopping screening at age 65, but this decision needs to be made on an individual basis.
Diabetes
The USPSTF recommends screening all people with blood pressure over 135/80 with a yearly blood sugar test.  The American Diabetes Association recommends screening everyone at age 45 and over.
Other Preventable Diseases
1. Influenza – A yearly vaccine is recommended for everyone beginning at age 50, as well as for all women who are pregnant during flu season, for children ages 6 months through 18 years, for people with chronic lung, heart, kidney, liver, hematologic or metabolic disease, for people who are immune suppressed, for residents of nursing homes, and for anyone who has contact with someone with any of the above conditions, particularly health-care personnel.  This means that most of us should be getting flu shots every year.
2. Pneumococcal disease – A one-time vaccine is recommended at age 65; younger patients with chronic diseases also should
be vaccinated.
3. Shingles- The Advisory Committee on Immunization Practices recommends a zoster (shingles) vaccine at age 60, regardless of whether one has had shingles in the past.
So here’s my political pitch: periodic health maintenance exams are easy. Your job is to see a primary care provider.  It is that health care provider’s responsibility to make recommendations based on your age, personal and family history, and — crucial for him or her — to explain the risks and benefits of any testing that may be recommended, so that you are armed to make the best decisions appropriate for you.  Together, health care providers and patients can sharply reduce the onset of widespread diseases from which million of us might otherwise suffer.  This not only avoids needless pain, suffering and early deaths, but can greatly reduce the financial burden of health care we all share.

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