- Written By: Braedon Paul, FM PGY2, Victoria BC
- Peer Review By: Alysha Thomson, FM PGY2, Victoria BC
- Audio Production: also Braedon Paul!
Like the 2020 guideline update publication, we’re gonna break things down into a few subtopics, which are:
- Education and counselling
- Physical examination
- Functional inquiry
- Lab tests & investigations
- and finally, immunizations.
But before we dive too deeply into things, it’s helpful to know what the Periodic health exam actually is.. And what it isn’t.
The term “periodic” is kind of vague, and that’s actually intentional. According to the canadian task force on preventive health care, and I quote “The traditional annual physical examination of asymptomatic adults is not supported by evidence of effectiveness and may result in harm. There is better value in a periodic (i.e., according to age, risk, and specific test intervals) preventive visit to provide preventive counseling and screening tests proven to be of benefit. Periodic preventive visits are particularly useful for people older than 65 years of age.” citation
Their recommendation is based on a systematic review of 14 RCTs, which indicated that the traditional annual check-up didn’t reduce total mortality, cardiovascular mortality, or cancer mortality.
In comparison, the periodic preventative health visit is associated with a decrease in mortality and increased likelihood of living independently in the community among adults aged 65 and older, based on a meta-analysis of 19 trials.
They didn’t have as much evidence to support the under 65 population, which , as you would suspect, is a relatively healthier demographic at a baseline – and would probably take a massive trove of data to show benefit. But that’s of course where the periodic part comes in. Younger, healthier people will generally require fewer periodic exams, based on their overall risk profile.
PART 1 – EDUCATION AND COUNSELING
Alright alright alright. This sounds a lot like lifestyle stuff. So, Caleb, what specifically should we be discussing with our patients?
So we’re talking about a few things here. First off is Alcohol. So for this, we’re particularly looking for high risk drinking. You can use standardized tools like the CAGE or AUDIT questionnaires, or just straight up ask your patients about their alcohol consumption and risky behaviors related to alcohol use.
Remember those Canadian low risk drinking guidelines? Ya know, the things that change every week? Anyone remember them? Pause here if you need to. [BRIEF PAUSE]. We’re looking at ≤15 drinks/w (≤3/d) for men (no more than 3 in 1 day), and ≤10 drinks/w for women (no more than 2 in 1 day). Seems kind of random, but don’t shoot the messenger. And of course, zero alcohol is safest if pregnant or planning pregnancy. For the adolescents, this is part of the HEADSSSS screening exam, which we talk about in our recent “In Children” episode, which they really need to change the topic name for.
Next is smoking. Obviously smoking cessation is the most optimal, but you’ve gotta meet people where they’re at. Figure out that stage of change and take things from there. You can refer to validated smoking cessation programs, discuss pharmacotherapy with nicotine replacement or other drugs like bupropion and varenicline. For those who actively smoke, it’s extra important to discuss diet, with increased green leafy vegetables and fruit consumption to reduce the risk of lung cancer.
For the British Columbians, I refer patients to quitnow.ca for free smoking cessation counseling and pharmacotherapy. Other provinces probably have their own equivalent, which you should be able to find on the Health Canada site www.gosmokefree.ca. RxFiles also has a great PDF on smoking cessation pharmacotherapy.
On a similar page is diet. Here we’re talking about increased fiber, veggies and whole grains, low sodium, and limiting trans and saturated fats. I like the Mediterranean, but the important part is finding nutritional habits that work for you and sticking to it. Some patients may even benefit from a referral to a dietician.
Next up is exercise. Official recommendations are 150 min/w (30 min/day) of moderate to vigorous aerobic exercise and at least 2 sessions of resistance training per week. Those are the numbers, but as with all counseling, meet people where they are. If they drive to work every day, maybe encourage them to park a few blocks away and walk the rest. Anything is better than nothing, and having people incorporate exercise into their pre-existing habits will maximize their likelihood of actually doing it. Shout out to Atomic Habits by James Clear for that tidbit.
To finish this section off, we’re gonna rapid fire list the remaining elements of the Education & Counselling section with some call and response.
Let’s try and get a bit of active recall going here. One of us will list off an element of recommended counseling, and then we’ll give a brief pause to see if you can think of the specific recommendation, then we’ll give you the official recommendation. Clear as mud? Let’s go.
Recommended intake of calcium and vitamin D?
- 1000 mg/day of calcium,
- 1200 if you’re over 50,
- 1500 if you’re postmenopausal.
- Most, if not all, of this should be dietary (which is about 3 servings of dairy per day).
- Vitamin D,
we’re looking at
- 400-1000 IU daily,
- which can be safely increased up to 2000 daily, especially if you’re over 50 and/or at increased risk of vitamin D deficiency. I’m looking at you, northern Canada.
Any other supplements?
For women planning pregnancy, you can throw folic acid onto that list, 0.4-0.8 mg daily, more if they’re at higher risk of neural tube defects due to personal or family history
What are some forms of protection that we should discuss with patients?
Vague as ever. I’m thinking about:
- sun protection,
- safe sex practices with contraception and STI counselling
- hearing protection,
- and I’ll throw in a bit of oral hygiene with brushing/flossing and fluoride-containing toothpaste.
What about for the young and old?
In the elderly, I’m thinking about a falls assessment,
and for the young, we of course have our HEADSSS assessment, and then counselling parents on home safety – which is highlighted in detail on the Rourke baby records.
PART 2 – PHYSICAL EXAM
This section is pretty brief. Gone are the days of the head-to-toe screening exam. A shell of its former self, the evidence-based physical exam for the periodic screening assessment includes but one element.
Any idea what that could be?
good old blood pressure.
That was my second guess. We covered hypertension back in May of this year, so go check out that episode for a deep dive, but in short, here are the numbers to know, according to the Hypertension Canada 2020-2022 guidelines. Same as before, I’d encourage you to rattle these numbers off during pauses.
For most patients (AKA low risk), our treatment target is < 140/90.
That’s confusing. Let’s make it even more confusing. The diagnostic criteria of HTN will also be slightly different, based on the method of measurement, whether this is ambulatory 24-hour cuff vs intermittent home BP versus in-office, etc. Once again, check out our wonderfully done HTN episode for more on that. We’ll also post the HTN Canada guidelines in the show notes.
Alright, next up. For diabetics, our treatment target is < 130/80.
For high risk patients:
- over 50 with one of
- 10-year risk > 15% or
- over age 75 alone.
you can consider (emphasis on consider) a treatment target of [pause] sBP < 120. No diastolic recommendation for these folks. That’s obviously quite aggressive and should be balanced against other risks, like the risk of falling for example.
The preventative care checklist also includes a BMI measurement, which you can also consider as part of your physical exam, plus or minus waist circumference.
Before moving on, you can also consider screening for hearing impairment in the elderly, although there’s really no great evidence so this gets a Grade B recommendation. As part of your functional inquiry, you could instead just ask about hearing difficulties if you’re concerned for any reason. When it comes to vision, the CTF recommends against screening for impaired vision in the primary care setting.
PART 3 – FUNCTIONAL INQUIRY
This is basically just a “how ya doin?” for patients, giving them a chance to bring up any specific symptoms or health concerns they may have. It’s essentially a review of systems.
The Preventative care checklist includes a heading for each major system, HENT, CV, Resp, GI, GU, Mental health, constitutional symptoms, et cetera. Nothing too special or complicated. With that, we continue our journey into part 4 – lab tests and investigations.
PART 4 – LAB TESTS & INVESTIGATIONS
Alright everyone, this is where the money is. We are in high-yield territory folks. Time to zone back in. Same with above, this’ll be a bit of Q and A, with some pauses thrown in so you can try and come to the answer yourself. Let’s start with colorectal cancer screening. We’ll break down the screening guidelines into two questions each, who gets it (ie, age/demographic) and how do we do it (ie, frequency and type of investigation). Easy enough? Let’s start with Colorectal Cancer.
Colorectal Cancer Screening
- Who gets screened?
Adults aged 50-74 with average risk (in other words, no personal or familial risk factors).
This is a weak recommendation from ages 50-59, so you can offer screening after discussing harms and benefits, and a strong recommendation from 60-74.
Keep in mind that screening is for asymptomatic individuals – ie, NOT displaying s/sx of CRC. This applies to all screening tests as a rule. So if they have symptoms, none of this applies.
- How do we do it?
There are two ways to screen.
- Method 1 is with FOBT (either fecal immunochemical testing (FIT) or high sensitivity guaiac-FOBT – depending on your province) every 2 years.
- Method 2 is flexible sigmoidoscopy every 10 years, NOT colonoscopy, every 10 years. It’s almost always going to be FOBT, though.
In either case, positive screens should get follow up with colonoscopy.
Bonus question, who would we consider high risk and thus not eligible for routine screening?
High risk includes:
- previous CRC or polyps,
- inflammatory bowel disease,
- history of CRC in one or more first degree relatives, or
- adults with hereditary syndromes predisposing to CRC (e.g. familial adenomatous polyposis, Lynch Syndrome).
The exact definition changes from province to province, as does the screening
For these folks, follow your provincial guidelines or connect with your local gastroenterology team, but a common strategy is to start screening at age 40 (or 10 years earlier than the youngest affected relative) with a colonoscopy every five years for those who have a 1st degree relative with colorectal cancer (at age <60 years).
Check out the show notes for a link to a PDF from Colorectal Cancer Canada (Screening_Guidelines_in_Canada.pdf (colorectalcancercanada.com)) with tables showing average and high risk guidelines, screening test types, etc, all broken down by province.
Breast Cancer Screening
- Who gets screened?
Average-risk women aged 50 to 74 are conditionally recommended for screening.
Women aged 40-49 are conditionally recommended against screening, though this can be a shared decision.
- How and how often do they get screened?
This is screening mammography every 2-3 years.
So unlike CRC screening, the evidence to support breast cancer screening is a lot less robust, and the whole guideline is a conditional recommendation based on very low certainty evidence. In light of this, the CTFPHC recommends shared decision-making with women to discuss avoiding harms of screening vs. a modest absolute reduction in breast cancer mortality.
The CTFPHC has a great pictograph called the “1000 person tool” on their site that breaks things down in an easily digestible way, but really highlights how limited the actual benefit of screening actually is – with 1-2 deaths prevented per 1000 patients (based on the age group) and hundreds of false positives, 30-40 of which would go on to require unnecessary biopsy. The link for that PDF is in the show notes.
One final bonus question,
who would we consider high risk for breast cancer and thus not candidates for our average risk screening protocols?
This includes women at increased risk of breast cancer, which includes women with:
- a personal or family history of breast cancer,
- women who are carriers of gene mutations such as BRCA1 or BRCA2
- or have a first-degree relative with these gene mutations, and
- women who had chest radiation therapy before 30 years of age
- or within the past eight years.
Cervical Cancer Screening
Who gets cervical cancer screening, how often, and via what method?
- We screen average risk women aged 25 to 69 who are or have ever been sexually active.
- Screening is done via Pap smear every 3 years, which is a cytology based test.
- From age 25-29 is a weak recommendation
- whereas 30-69 is a strong recommendation with high quality evidence.
- You may also be familiar with the HPV test, which looks for HPV DNA from a sample of cells, which could certainly change the way we screen, but it’s not currently used a primary screening test in Canada and availability/cost varies from province to province, although that certainly could change in the coming years.
Next question is when do we stop screening?
Now the obvious answer would be age 70 since screening ages out at 69, but there is a caveat. The recommendation is that
– women aged ≥ 70 who have been adequately screened (i.e., 3 successive negative Pap tests in the last 10 years) no longer require screening.
However, for women aged 70 or over who have not been adequately screened, the CTFPHC recommends continued screening until 3 negative test results have been obtained.
Lung Cancer Screening
WHO qualifies for lung cancer screening?
This is a bit more nuanced with a few specifiers, and includes adults aged 55-74 yrs with
at least a 30 pack-year smoking history and are currently smoking or quit less than 15
How do these folks get screened, and how frequently?
Screening is done via annual low-dose CT up to a maximum of three consecutive times.
Remember that a chest x-ray is NOT recommended as a screening test. Another caveat is that screening should ONLY be carried out in health care settings with expertise in early diagnosis and treatment of lung cancer.
This guideline is another weak recommendation based on low quality evidence – meaning you really need to have a discussion with your patients about the benefits and harms of screening (including false positives, side effects of invasive follow-up testing, overdiagnosis, etc). As usual, check out the 1000-person tool on the CTFPHC website for a dive, but briefly: per 1000 people screened, you’re looking at 351 false positives, which includes 1 person who will die from invasive follow-up testing, and 3 fewer people who will die from lung cancer when compared to screening CXR. Not fantastic but not nothing – so have that discussion with your patients…
Prostate Cancer Screening
Moving right along, prostate cancer. So, right off the bat, a bit of controversy here. The CTF and Canadian urological association (CUA) both have differing opinions on the matter, with the CTF recommending against screening with prostate specific antigen (PSA) testing for men of all age.
Their recommendation is strong for men below 55 and above 70, but is only a weak recommendation for those in the 55-69 group, which is the one subgroup that may derive some “uncertain potential reduction in prostate cancer mortality”.
They also recommend against screening DRE. Interestingly, men with lower urinary tract symptoms in this cohort (ie, nocturia, urgency, frequency and poor stream) and men with known BPH are included in this cohort. Now, for exam purposes, that’s probably the guideline to know, but I would be remiss if we didn’t at least mention the CUA guidelines, which was just updated in September 2022. In contrast to the CTF, they recommend offering PSA screening by way of shared-decision making for men starting at age 50 with a life expectancy of greater than 10 years. To check out their full recommendation, they just published a pocket guide that contains their full recommendation as well as this handy algorithm to follow based on PSA results, which we’ve linked in the show notes.