Ages 19-40 Cardiovascular Disease Prevention and Cancer Prevention

Behavioral Counseling Intervention Population

Adults with cardiovascular disease risk factors

Behavioral Counseling Intervention Recommendation

Offer or refer adults with cardiovascular disease risk factors to behavioral counseling interventions to promote a healthy diet and physical activity

Behavioral Counseling Intervention USPSTF Grade

B

Behavioral Counseling Intervention High Risk

adults 18+ with ≥1 of the following: hypertension, dyslipidemia, mixed or multiple risk factors such as metabolic syndrome or estimated 10-year CVD risk of ≥7.5%

Behavioral Counseling Intervention - Dietary Counseling

- dietary advice: reductions in saturated fats, sodium, sweets and sugars. Increased consumption of fruits, vegetables, and whole grains

Behavioral Counseling Intervention - Physical Activity Counseling

- physical activity: 90 to 180 minutes of exercise per week of moderate to vigorous activity

CVD Risk Factors

- Diet

- Physical Activity

- Hypertension

- Dyslipidemia

- Obesity

- Smoking

- Diabetes

Hypertension Population

Adults 18+ without known hypertension

Hypertension Recommendation

Screen for hypertension in adults 18+ with office blood pressure measurement (OBPM)

Hypertension USPSTF Grade

A

Hypertension Prevalence

45% US adults

Hypertension Risks of Untreated HTN

- asymptomatic usually

- heart failure, MI, stroke, chronic kidney disease

Blood Pressure Categories - Normal

- Systolic < 120

AND

- Diastolic < 80

Blood Pressure Categories - Elevated

- Systolic 120-129

AND

- Diastolic < 80

Blood Pressure Categories - Stage 1

- Systolic 130-139

OR

- Diastolic 80-89

Blood Pressure Categories - Stage 2

- Systolic > 140

OR

- Diastolic > 90

Blood Pressure Categories - HTN Crisis

- Systolic >180

AND/OR

- Diastolic > 120

Dyslipidemia (AAP) Population

Ages 20-21

Dyslipidemia (AAP) Recommendations

All adolescents and young adults should undergo lipid screening once during this age range

Dyslipidemia (AAP) Risk of untreated

CVD, problems with heart, brain, kidneys, peripheral circulation

Dyslipidemia (AAP) Risk Factors

family history of premature CVD (female pre 65, male pre 55)

Dyslipidemia (AAP) Intervention

assess risk, provide behavioral counseling for for healthy diet and physical activity

Dyslipidemia (ACC/AHA) Population

Ages 20-39

Dyslipidemia (ACC/AHA) Recommendation

Estimate lifetime risk and consider statin if there is family history of premature ASCVD and LDL-C ≥160 mg/dL

Dyslipidemia (ACC/AHA) - Risk Calculator

- ASCVD risk calculator

- Current 10 year risk: 40-75 y.o.

- Lifetime risk assessment: less than 40 y.o.

10 year ASCVD Risk Percent Intervention - 5% (low risk)

risk discussion, emphasize lifestyle to reduce risk

10 year ASCVD Risk Percent Intervention - 5-7.5% (borderline risk)

if risk enhancers present then risk discussion regarding moderate-intensity statin therapy

10 year ASCVD Risk Percent Intervention - 7.5-20% (intermediate risk)

if risk estimate + risk enhancers favor statin, initiate moderate intensity statin to reduce LDL-C by 30-49%

10 year ASCVD Risk Percent Intervention - > 20% (high risk)

initiate statin to reduce LDL-C by >50%

Dyslipidemia (ACC/AHA) - Interventions

consider statin if family history of premature CVD and LDL-C ≥160

Dyslipidemia (ACC/AHA) - Lipid Panel Recommendations

- LDL-C ≥190: high intensity statin and genetic counseling

- diabetes and 40-75yrs: moderate intensity statin

- diabetes and 40-75 yrs with high risk: high intensity statin

LDL > 190

high intensity statin and genetic counseling

Diabetes and 40-75 y.o.

moderate intensity statin and risk assessment to consider high-intensity statin

Family hx of premature CVD and LDL > 160

consider statin

High Intensity Statins

- atorvastatin 40/80mg

- rosuvastatin 20/40mg

Moderate Intensity Statins

- atorvastatin 10/20mg

- rosuvastatin 5/10mg

- simvastatin 20-40mg

Obesity Population

Adults

Obesity Recommendations

Offer or refer adults with BMI ≥30 to intensive, multicomponent behavioral interventions

Obesity USPSTF Grade

B

Obesity - Risks of Untreated

atherosclerotic heart disease (ASHD), Type 2 diabetes, cancer (liver, kidney, breast, endometrial, prostate, colon), gallstones, increased risk of death

Obesity Prevalence

>40% women, >35% men

Obesity Intervention

refer to weight management or nutrition providers

BMI < 18.5

Below normal weight

BMI > 18.5 and < 25

normal weight

BMI > 25 and < 30

overweight

Class I Obesity

>30 and <35

Class II Obesity

>35 and <40

Class III Obesity

>40

Tobacco Use Population

Nonpregnant adults

Tobacco Use Recommendations

Ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and FDA approved pharmacotherapy for cessation

Tobacco Use USPSTF Grade

A

Tobacco Use Prevalence

1.1 billion smoked (7% women / 33% men), US 21% of population

Tobacco Use Mortality

leading preventable cause of disease, disability, and death in the US; up to 50% of those who smoke regularly can be expected to die from a tobacco-related illness (atherosclerotic CVD, cancer, COPD)

Tobacco Use - How to Implement Recommendation

- use 5 As: Ask, Advise, Assess, Assist, Arrange follow up

- treat smoking status as a vital sign

Tobacco Use Intervention

- provide cessation interventions to persons who use tobacco

- behavioral counseling

- FDA approved pharmacotherapy (varenicline, NRT, bupropion)

- or both of above

Tobacco Use - First line tx

- varenicline

OR

- combination of nicotine replacement products

Tobacco Use - Second line tx

- single nicotine replacement product

OR

- bupropion

Tobacco Use - Treatment if single agent is not sufficient

- varenicline + nicotine replacement

- varenicline + buproprion

- buproprion + nicotine replacement

Diabetes Population

Asymptomatic adults 35-70 who are overweight or obese

Diabetes Recommendation

Screen for prediabetes and type 2 diabetes in adults 35-70 who are overweight or obese. Offer or refer patients with prediabetes to effective preventive interventions

Diabetes USPSTF Grade

B

Diabetes - High Risk

AIAN, NHPI, Black, and Hispanic/Latino populations, overweight (BMI 25-30) or obese (BMi 30+) patients

Diabetes Screening Timeline for People w/ normal glucose

every 3 years is a reasonable approach

Diabetes Testing

fasting plasma glucose, HbA1c, or oral glucose tolerance test

HbA1c Prediabetes Level

5.7-6.4%

HbA1C Diabetes Level

> 6.5%

Fasting Glucose Prediabetes Level

100-125 mg/dL

Fasting Glucose Diabetes Level

> 126 mg/dL

Cervical Cancer Populations

- Patients with a cervix 21-65

- Patients with a cervix under 21 or above 65

- Patients who have had a hysterectomy

Cervical Cancer Recommendation for Patients with a cervix 21-65

- 21-29: Screen every 3 years with cervical cytology alone

- 30-65: Screen every 3 years with cervical cytology alone or every 5 years with high-risk HPV testing alone or both every 5 years

Cervical Cancer Recommendation for Patients with a cervix under 21 or above 65, Patients who have had a hysterectomy

Cervical cancer screening NOT RECOMMENDED

Cervical Cancer USPSTF Grade for Patients with a cervix 21-65

A

Cervical Cancer USPSTF Grade for Patients <21 and >65, or patients with a hysterectomy

D

Cervical Cancer Prevalence

- 11,500 new cases/year, 4,000 deaths/year, 4th most common cancer in women and for cancer deaths

Cervical Cancer Screening DOES NOT apply to

to those who have been diagnosed with a high-grade precancerous lesion or cervical cancer

Cervical Cancer Screening DOES apply to

patients with a cervix regardless of sexual history or HPV vaccination status

Cervical Cancer Tests

- cervical cytology (high specificity, fewer false positives): pap smear

- hrHPV testing (high sensitivity, less false negatives): looks for DNA/RNA from certain high risk types of HPV in samples of cells taken from cervix

- cotesting: both HPV test and pap are done at the same time

cervical cytology

(high specificity, fewer false positives): pap smear

hrHPV testing

(high sensitivity, less false negatives): looks for DNA/RNA from certain high risk types of HPV in samples of cells taken from cervix

Cervical Cancer Testing Recommendation for ages 21-29

Screen every 3 years with cervical cytology alone

Cervical Cancer Testing Recommendation for ages 30-65

Screen every 3 years with cervical cytology alone or every 5 years with high-risk HPV testing alone or both every 5 years

Cervical Cancer AAP Recommendation

start screening at 21

Breast Cancer Populations

- Women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or an ancestry associated with BRCA-1/2 gene mutation

- Women whose personal or family history or ancestry is not associated with potential harmful BRCA-1/2 gene mutation

- Women at increased risk for breast cancer aged 35+

- Women not at increased risk for breast cancer aged 35+

Breast Cancer Recommendation - personal or family hx or ancestry of BRCA 1/2 mutation

Primary care clinicians should assess women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with breast cancer susceptibility 1 and 2 (BRCA-1/2) gene mutations with an appropriate brief familial risk assessment tool. Women with a positive result on the risk assessment tool should receive genetic counseling and, if indicated after counseling, genetic testing

Breast Cancer USPSTF Grade - personal or family hx or ancestry of BRCA 1/2 mutation

B

Breast Cancer Screening - personal or family hx or ancestry of BRCA 1/2 mutation

screen with Gail model 2 (BRCAT), breast cancer surveillance consortium risk calculator, or Tyrer-Cuzick

Breast Cancer Recommendation - no personal or family hx of BRCA 1/2 mutation

Routine risk assessment, genetic counseling, or genetic testing is not recommended for women whose personal or family history is not associated with BRCA-1/2 mutations

Breast Cancer USPSTF Grade - breast cancer screening for people with no personal or family hx of BRCA 1/2 mutation

D

Breast Cancer Screening - people with no personal or family hx of BRCA 1/2 mutation

- breast cancer screening is NOT recommending for this population

Breast Cancer Recommendation - women with increased risk aged 35+

Offer to prescribe risk-reducing medications such as tamoxifen, raloxifene, or aromatase inhibitors to women who are at increased risk for breast cancer and at low risk for adverse medication effects

Breast Cancer USPSTF Grade - women with increased risk aged 35+

B

Breast Cancer High Risk - women with increased risk aged 35+

women with BRCA-1/2 mutations or family history of breast cancer

Breast Cancer Intervention - women with increased risk aged 35+

prescribe tamoxifen, raloxifene, or aromatase inhibitors

Breast Cancer Other Options - women with increased risk aged 35+

intensive screening and risk reducing mastectomy/salpingo-oopherectomy

Breast Cancer Recommendation - women NOT at increased risk aged 35+

Prescribing risk-reducing medications such as tamoxifen, raloxifene, or aromatase inhibitor is not recommended for women who are not at increased risk for breast cancer

Breast Cancer USPSTF Grade - women NOT at increased risk aged 35+

D

Breast Cancer Screening - women NOT at increased risk aged 35+

NOT recommended for those not at increased risk for breast cancer

Skin Cancer Populations

- Young adults, adolescents, children, and parents of young children

- Adults older than 24 years with fair skin type

Skin Cancer Recommendations - young adults, children, parents

Counsel young adults, adolescents, children, and parents of young children about minimizing exposure to UV radiation for persons aged 6mos-24yrs with fair skin types to reduce their risk of skin cancer

Skin Cancer USPSTF Grade - young adults, children, parents

B