Cancer Screening Recommendation

A 52-year-old man presents for an initial primary care visit at the nurse practitioners practice period he has not seen any health care providers since age 38, stating that he has been in good health. Social history, drinking approximately 2 beers per night over the weekend, two nights per week, has a 5 pack year cigarette smoking history, having taken up smoking when he was in college, and quit at age 22. He reports feeling well and without chief complaint or chronic health problems.  He asks about what kind of cancer screening he should have. The NP advisors which of the following?

A. Colonoscopy 

B. Prostate specific antigen (PSA) 

C. Low dose chest CT

D. Given his history, no routine cancer screening is advised. 

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Transcript

Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Doctor Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question, so you can better understand how to arrive at the correct test answer. 

So, if you're ready, let's jump right in. 

Margaret Fitzgerald: A 52-year-old man presents for an initial primary care visit at the nurse practitioner’s practice. He's not been seen by another health care provider since age 38, stating he's been in good health. Social history: drinks approximately 2 beers per night over the weekend, usually 2 nights per week; has a 5-pack year cigarette smoking history. 

Having smoked while he was in college and quit at age 22, he reports feeling well and is without chief complaint or chronic health problems. 

He asks the NP about what kind of cancer screening he should have. The NP advises which of the following: 

A: Colonoscopy. 

B: Prostate specific antigen aka PSA. 

C: Low dose chest CT. 

D: Given his history, no routine cancer screening is recommended. 

Yeah, routine cancer screening is advised and the correct answer is A: Colonoscopy. Where should we start with a question like this? First, decide what type of question it is. Given his 52-year-old man who's had no health care for a number of years and does not have any alarming report on H&P and a very brief health history. 

This is a plan question. Cancer and other health screenings are critically important part of providing primary care. When I look at a question like this, the first thing I want to say is yes, but please give me more of a health history on this guy. 

Yes, but tell me more about his health habits and actual practice. There's a lot of information that should be gathered about this patient. He's new to your practice, and he's coming in like a tabula rasa or a black blank slate, if you will. 

However, on the NP boards, you're going to find this. You're going to get just enough information about the patient and really not any more than that. 

And as a result, what you have to do is pull out all the information that you can have. I've mentioned this before, but if it says in the health history that the patient's a nonsmoker or they’re smoker or in this case we have a really remote history of tobacco use-if it says he only drinks 

a couple of beers a couple of nights a week, then that's all he drinks, right. 

We just have to go with that and not do any second guessing. So, with that as background, let's go and think about cancer screenings. 

Cancer screening using the recommendations based on population risk and best evidence of nationally recognized clinical guidelines should guide the choice of the correct answer to this question. 

All screening tests are examples of secondary prevention focused on early case finding of asymptomatic disease. With this in mind, let's take a look at the options and why colonoscopy is the best choice. 

A 52-year-old man presents for an initial primary care visit 

at the NP’s practice. He's not seen any health care provider since age 38, stating he's been in good health. 

Okay, as an aside here, you hear this a lot about guys, middle aged men in particular, that they will have long gaps without being involved in health care if they haven't had any health problems. 

Social history: he drinks approximately 2 beers per night over the weekend, 2 nights per week; has a 5-pack cigarette smoking history, having taken up smoking when he was in college and quit at age 22, he reports feeling well and is without chief complaint or chronic health problems. 

He asks about what kind of cancer screening he should have. The FNP advises which of the following options: 

A: Colonoscopy. This is, of course, the correct answer. Colorectal cancer screening is recommended to start at age 45, and the average risk person 

and even earlier in people with select risk factors, including inflammatory bowel disease and strong family history of colorectal cancer. 

You're right. We don't know whether he has strong family history of colorectal cancer, although he does say he's generally in good health with no chronic health problems. 

So that pretty much eliminates the risk of inflammatory bowel disease. 

But we should assume that he doesn't. In other words, if there was a very strong family history of colorectal cancer, particularly at a young age, 

we would have been told that because that's pertinent to the correct answer. 

If he had inflammatory bowel disease, that would be pertinent again, and we would have been given that information. In real life, of course, we're going to get more history on him, but we have to answer with the best choice that we have and not, and not possibly one where there is another choice. 

By the way, it was not that long ago that the initial time to start colorectal cancer screening was age 50, but that threshold was brought down to age 45 based on a number of factors, including increased levels of this cancer type being seen in individuals less than 50 years old. 

I believe that change was within perhaps the last 5 years or so. It wasn't all that long ago. So, you might even-and the reason I bring that up is you might hear some providers still talked about starting colorectal cancer screening at age 50. But best evidence now by ACS and U.S. Preventive Services Task Force is starting at age 45. 

So, another way of looking at this, this guy's already 7 years overdue for his initial colonoscopy. Now, B: Prostate specific antigen. PSA. Yes. He is assigned male at birth. Yes. He has a prostate. 

So why wouldn't prostate cancer screening be the best answer? And here is the reason why. For men age 50 to 69 years of age, PSA can be offered for prostate cancer screening as part of shared decision-making where the provider and the patient have a dialogue about the possible benefits 

and risks of the test. 

This is a great example of an answer that is technically correct, but it is not as strong an option as A. So, in other words, PSA is a US 

Preventive Services Task Force grade C recommendation, and colonoscopy for colorectal cancer screening is a grade A recommendation. 

In other words, everyone in his age group-indeed anyone, everyone 

starting at age 45, should be encouraged to get colorectal cancer screening with a colonoscopy. And there are other there are other tests that can be offered as well, such as the fit and the like. 

But here we're just talking about colonoscopy. And so routinely colonoscopy for colorectal cancer screening should be offered starting at age 45. 

However, it is not routine, like everyone in included for men age 50 to 69 to have a PSA done. Option C: Low-dose CT. This is incorrect as he doesn't qualify for a low-dose CT, which is of course used for lung cancer screening. 

So who should be screened for lung cancer? He does have a smoking history, albeit quite remote and quite short. So who should be screened? 

People age 50 to 80 years with a 20-pack year or more smoking history 

who are currently smoking or have quit within the last 15 years. All right. 

So he is between 50 to 80. So we would check that off. Yep. Consider screening. But his pack year history was 5 pack years, not 20. And he quit smoking more than 15 years ago. And he's not currently smoking. 

So he does not qualify. By the way, when do you stop lung cancer screening? Once the person has not smoked for 15 years. 

Check. He quit about 30 years ago. Or develops a health problem 

that substantially limits the life expectancy or the ability or willingness to have curative lung cancer surgery. 

So in other words, he doesn't qualify now for low-dose CT, even with his smoking history, nor will he qualify in the future as we know the guidelines at this point. And then option D: Given his history, 

no routine cancer screening is advised. 

Obviously that is incorrect because he qualifies for colorectal cancer screening. Plus you'd have the dialogue with him about getting PSA done or not done. 

Key takeaway: Cancer screenings helps save lives by finding disease before it's clinically evident. Providing advice on when to screen and, what to screen for is based on epidemiologic principles. That and best evidence and is a key part of providing primary care. 

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