400 - Colon Cancer Screening, Menopause and CVD, Required Vaccines

From the Literature and the USPSTF

1) Updated Guidance for Colon Cancer Screening

Colorectal cancer (CRC) is the third leading cause of cancer death for both men and women in the US. It is most frequently diagnosed among persons aged 65-74. However, it is estimated that 10.5% of new cases occur in persons younger than 50. Incidence of CRC (specifically adenocarcinoma) in adults aged 40-49 has increased by almost 15% from 2000-2002 to 2014-2016. In 2016, 26% of eligible adults had never been screened for CRC and in 2018, 31% were not up to date with screening.

The USPSTF recently updated their 2016 recommendation for CRC screening in asymptomatic adults 45 years or older at average risk of CRC (ie, no prior diagnosis of CRC, adenomatous polyps, or inflammatory bowel disease; no personal diagnosis or family history of known genetic disorders that predispose them to a high lifetime risk of colorectal cancer [such as Lynch syndrome or familial adenomatous polyposis]).

Updated recommendations include:

• Screen adults aged 50-75 for CRC. Grade A
• Screen adults aged 45-49 years for CRC. Grade B
• Selectively screen adults aged 76-85 years for CRC, considering their overall health, prior screening history, and patient’s preferences. Adults who have never been screened are more likely to benefit. Grade C

Several recommended screening tests are available. Clinicians and patients may consider a variety of factors in deciding which test may be best for each person. For example, the tests require different frequencies of screening, location of screening (home or office), methods of screening (stool-based or direct visualization), preprocedure bowel preparation, anesthesia or sedation during the test, and follow-up procedures for abnormal findings. Recommended screening strategies include:

• High-sensitivity guaiac fecal occult blood test (HSgFOBT) or fecal immunochemical test (FIT) every year
• Stool DNA-FIT every 1 to 3 years
• Computed tomography colonography every 5 years
• Flexible sigmoidoscopy every 5 years
• Flexible sigmoidoscopy every 10 years + annual FIT
• Colonoscopy screening every 10 years

Mark’s Comments:

We had covered the draft of this recommendation back in the fall due to it receiving so much press. So, though anticipated, the recommendation to start CRC screening at age 45 for all adults is practice changing. The Affordable Care Act requires that most private insurance plans provide coverage for the Grade A and B USPSTF recommendations. The American College of Gastroenterology updated their CRC screening recommendations in March of 2021 and recommended FIT or colonoscopy as the primary screening modalities, and made a “conditional” recommendation for screening in average risk adults age 45-49, so this is in line with the USPSTF conclusion. Remember that every colon cancer death in a previously unscreened individual is a tragedy that can be avoided, so let’s be sure to make those who have never been screened a top priority. There are screening options that are easy, affordable, and non-invasive. In other words, no real good excuses anymore.

References:

• USPSTF. Screening for Colorectal Cancer. Final Recommendation Statement. May 18, 2021. Statement

• USPSTF. Screening for Colorectal Cancer: USPSTF Recommendation Statement. JAMA. 2021;325(19):1965-1977. Link

From the Literature and the American Heart Association (AHA)

2) Primer on Menopause and Cardiovascular Disease (CVD) Risk

Data indicate that only 56% of women are aware that a) CVD is the leading cause of death in women; b) there is a notable increase in the risk for this disease after menopause, and; c) that women typically develop coronary heart disease several years later than men. This increase in risk led to the hypothesis that the menopause transition (MT) contributes to the increase in CVD risk. The latest 2011 AHA guidelines of CVD prevention in women did not incorporate the MT as a CVD risk factor.

The MT is a period of significant symptomatic, hormonal, menstrual, and other physiological changes that are relevant to CVD risk. Accordingly, the AHA recently released a statement intended to provide a contemporary synthesis of the existing data on the MT and how these data relate to CVD. Some notable highlights include:

• The median age of natural menopause is 50 years.
• Because of the trends for increases in overall life expectancy in the US, a significant proportion of women will spend up to 40% of their lives postmenopausal.
• Earlier age at natural menopause is generally reported as a marker of greater CVD risk and linked to being Black or Hispanic, having a short menstrual cycle length, having a low parity, being a smoker, and having a worse CV health profile during reproductive life.
• Iatrogenically induced menopause (ie, BSO) during the premenopausal period is associated with higher CVD risk. Guidelines from the North American Menopause Society endorse menopausal hormone therapy (MHT) use among women with premature or early natural or surgical menopause, with treatment until at least the median age of menopause (in the absence of contraindications).
• Vasomotor symptoms are associated with worse CVD risk factor levels and measures of subclinical atherosclerosis.
• Sleep disturbance, a common complaint during the MT, is linked to a greater risk of subclinical CVD and worse CV health indexes in midlife women.
• Depression occurs more frequently during the perimenopausal and postmenopausal years and is related to both vasomotor symptoms and incident CVD.
• The perimenopause stage begins with the onset of intermenstrual cycle irregularities or other menopause-related symptoms and extends 12 months after menopause. It has been identified as a stage with significant alterations in several cardiometabolic and vascular health parameters strongly linked to higher CVD risk.
• Central/visceral fat increases and lean muscle mass decreases are more pronounced during the MT. The increased central adiposity is associated with an increased risk of mortality, even among those with normal BMI.
• Novel data show a reversal in the associations of HDL-C with CVD risk over the MT, suggesting that higher HDL-C levels may not consistently reflect good CV health in midlife women.
• According to limited data, only 7% of women traversing menopause report a physical activity level that matches the current recommendation, and <20% consistently maintain a healthy eating diet.
• Although the data are limited, randomized trial results suggest that a multidimensional lifestyle intervention can prevent weight gain while reducing triglycerides, SBP, and DBP, as well as blood glucose, insulin, and subclinical carotid atherosclerosis, among women undergoing the MT.
• Regardless of the strong line of observational evidence showing the MT as a period of accelerated cardiovascular risk, RCTs of lifestyle and behavioral interventions have not adequately represented this high-risk population.
• The literature supports a critical role for the time of initiation of MHT use relative to menopause, with initiation at <60 years of age or within 10 years of menopause appearing to be associated with reduced CVD risk.

• Data for primary and secondary prevention of ASCVD and improved survival with lipid-lowering interventions remain elusive for women, with further study required for evidence-based recommendations to be developed specifically for women.

Mark’s Comments:

This was a very helpful review and provided a significant “reframe” for me in the context of the menopausal transition period and the potential prevention of ASCVD. Because of limited research trial data for this population, there is still great uncertainty as to how to guide women during this period with interventions such as lipid lowering medications and menopausal hormone therapy to reduce their CV risk. At the same time, because present data indicate the MT is a period of significant detrimental changes in risk factors noted above, clinicians might consider an aggressive prevention-based approach for women in this stage, starting with lifestyle changes, to decrease the probability of a future CVD event. A reasonable initial lifestyle intervention would be to target ideal body weight with low central adiposity and maintenance of skeletal muscle mass.

Reference:

Khoudary S, et al. Menopause Transition and Cardiovascular Disease Risk: Implications for Timing of Early Prevention: A Scientific Statement From the American Heart Association. Circulation 142(25): e506-3532. Link

From the Code of the Commonwealth of Virginia (VA)

3) Required Vaccines for School (Do You Know Your State’s Code?)

In the summer of 2020, the Virginia General Assembly enacted a new law that requires that each child attending school be completely vaccinated according to the CDC Advisory Committee on Immunization Practice (ACIP) Child and Adolescent Immunization Schedule (Link). The new law was written in two versions – one to apply from July 1, 2020 to June 30, 2021, and one for July 1, 2021 and after. The law currently in effect (July 2020-June 2021) begins to update the requirements, and the one starting in July 2021 completes the update. The text of the law includes a list of the ACIP-recommended “general recommendation” vaccinations.

The final list of vaccination requirements is notable for a few exceptions that deviate from the full ACIP recommendations.

• Influenza vaccine is not mentioned as required, nor is it specifically exempted.
• Hib vaccine is mentioned as exempted in one section of the law, but not mentioned in the section covering specific vaccination requirements. The ACIP does not recommend Hib vaccine (initial or catchup) beyond age 4, so that may be why.

Because HPV is not transmitted in the school setting (hopefully …), parents can “opt-out” of HPV vaccination for their child after reviewing specific information (available at the VA Department of Health link below) about the association between HPV and CA.

John’s Comments:

This new legislation updates what was a pretty outdated and incomplete vaccination requirement list in the previous version of the law. Both religious and medical exemptions are still allowed. The opt-out for HPV vaccination represents an approach to the tension between public health law to advance health generally and its specific mandate to protect the public health from the imminent threat of communicable disease. In this case, Virginia decided on the more conservative latter approach. For our Take 3 readers who do not reside in Virginia, be sure to stay updated on your State’s statutes.

References:

• School Requirements – Immunization [Internet]. [cited 2021 May 17]. Link
• 2. § 22.1-271.2. Immunization requirements [Internet]. [cited 2021 May 18]. Link
• 3. § 32.1-46. (Effective July 1, 2021) Immunization of patients against certain diseases [Internet]. [cited 2021 May 18]. Link

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org