Preventive Care is Your Best Bet

“It is better to prevent than to remedy” is a popular saying in Brazil where I was born which in English would correspond to “better safe than sorry” or even “prevention is better than cure”.

Everyone knows that it is better to prevent than to treat, to avoid bad things happening rather than trying to fix something after it happens.

Although of course we cannot prevent every single disease and avoid all risks in life, we can definitely reduce the risk considerably by taking some measures.

In general, physical exercise, healthy eating, keeping our weight under control, avoiding tobacco, moderate consumption of alcohol, using sunscreen when outside, using a seat belt when in the car, using a helmet when cycling, and having a safe sex life are some ways to prevent diseases and injuries.

But there are other specific ways of prevention which are:

Prevention of Cardiovascular Disease

Cardiovascular disease, especially heart attacks and strokes, is the main cause of mortality in developed countries.

A commonly used tool to evaluate cardiovascular risk is the Framingham Risk Score, which provides a 10-year CVD risk (the risk of having a heart attack or stroke in the next 10 years). Another available calculator is the American College of Cardiology/American Heart Association risk calculator (ACC/AHA), which provides both a 10-year and a lifetime CVD risk.

After 20 years of age we should have a cardiovascular risk assessment every three to five years.

Hypertension (high blood pressure) screening is also a very important measure for prevention of cardiovascular disease. We recommend for all adults 18 years of age and above to measure their blood pressure. If it’s normal (<130/85 mmHg) and there are no other risk factors they should be rescreened every three to five years between the ages of 18 and 39.

If the blood pressure is between 130 to 139/85 to 89 mmHg, if the person is overweight or obese, if African-American or if he or she is 40 years of age or more, blood pressure should be checked at least annually. Source: 2015, US Preventive Services Task Force (USPSTF).

Hyperlipidemia (high cholesterol or triglycerides)

We suggest a one-time screening for hyperlipidemia from 17 to 21 years of age.

• If the screening is normal under 21 years of age but risk factors are present – such as diabetes, hypertension, smoking, family history – we suggest regular screening for lipid abnormalities starting at age 25 for men and 35 for women.
• If the screening is normal over 21 years of age and there are no risk factors, we suggest screening for lipid abnormalities starting at age 35 for men and 45 for women.

If the lipid measurements are clearly below an appropriate threshold for treatment, we suggest repeating measurements every five years.

Diabetes mellitus — 

For adults with hypertension or hyperlipidemia, or who are overweight or obese, we suggest screening for type 2 diabetes between the ages of 40 and 70.

Vascular Disease

• Abdominal aortic aneurysm (AAA) is a dilatation of the big artery in the abdomen called the aorta. It is a common and potentially life-threatening condition. Without repair, ruptured AAA is mostly fatal. Of the 50 percent of patients with ruptured AAA who reach the hospital, between 30 and 50 percent will die in the hospital.
• We recommend a one-time ultrasound screening for AAA in men aged 65 to 75 who are current or former smokers, or who have a first-degree relative who had AAA.

If you eat healthy, exercise, have a normal weight and don’t smoke, you reduce by 80% your risk of having heart attack or stroke. You can also reduce risk even more by controlling your blood pressure, cholesterol, and glucose level.

Cancer Prevention

The key factor in the treatment of cancer is early detection. Detecting cancer in an early stage can save lives.

Breast cancer screening

Between 40 and 50 years of age we should discuss the risks and benefits of breast cancer screening, but during this decade of life it is a shared decision-making process. In younger women, the risk of breast cancer is lower, so there is more chance of false positive results and consequently there is more harm than benefit in screening. The older she becomes, the risk of cancer increases and there is more benefit in screening than not screening.

Between 50-74 years of age a mammography is clearly recommended every two years.

Cervical cancer screening

• For average-risk women aged 21 to 29, we suggest Pap smear screening every three years.
• For average-risk women aged 30 to 64, we suggest either Pap smear screening every three years or co-testing (Pap smear and human papillomavirus [HPV] testing) every five years.

Colorectal cancer screening

• Screening for colon cancer is recommended to start at 50 years old for average-risk patients.
• Colonoscopy every 10 years is the preferred method of screening (American College of Gastroenterology).
• Other option is yearly FOBT (fecal occult blood test) and FIT (fecal immunochemical test).

Lung cancer screening

We suggest annual screening with low-dose computed tomography (CT) for patients aged 55 to 77 years old with a history of smoking – at least 30 pack-years or who have quit within the previous 15 years. Source: (USPSTF, 2013)

Prostate cancer screening

In the past, there was a tendency to screen everyone after 40 years old for prostate cancer, but aggressive screening caused more harm than benefit. This happened because although prostate cancer is very common, usually the growth is very slow, so slow that most people die of other causes. In an autopsy report, 30 percent of men who died at 50 years old were found to have prostate cancer and 70 percent of those who died at 70 years of age. For these men screening would be unnecessary and could even be potentially harmful.

We suggest that discussions about screening should begin at age 50 in asymptomatic average-risk men and at age 40 to 45 in men at high risk for prostate cancer (including black men, men with a family history of prostate cancer, and men who are known to have the BRCA1 or BRCA2 mutations).

When a decision is made to screen, we suggest that screening be performed with prostate-specific antigen (PSA) tests at intervals ranging from every two to four years if normal. If PSA is elevated – in the 4-7 range – repeat after six to eight weeks. If above 7, an urologist should be consulted.

Melanoma screening

• We recommend that individuals at high risk, such as those with a family history of melanoma or with multiple atypical nevi (nevi), have a yearly full-body skin examination by a clinician with skin expertise. We also suggest educating high-risk patients about the appearance of melanoma and advising them to look at their skin monthly and alert their doctors if they note any changing moles or other suspicious lesions.

A number of measures can be taken to prevent cancer, including:

• Avoidance of tobacco
• Being physically active
• Maintaining a healthy weight
• Eating a diet rich in fruits, vegetables, and whole grains, and low in saturated/trans fat
• Limiting alcohol consumption
• Protecting against sexually-transmitted infections
• Avoiding excessive exposure to direct sun
• Getting regular screening especially for breast, cervical, and colorectal cancer

More Prevention

Vaccinations

Vaccines can prevent many disease such as tetanus, diphtheria, pertussis, hepatitis A and B, measles, mumps, rubella, varicella, Haemophilus influenza, pneumococcus, meningococcal, polio, rotavirus, HPV, influenza, Japanese encephalitis, rabies and typhoid. The incidence of many diseases has been reduced significantly through vaccination programs. For example, Polio is a highly infectious disease caused by a virus that invades the nervous system, and can cause total paralysis in a matter of hours. Among those paralyzed, 5-10 percent die when their breathing muscles are immobilized. Since the Global Polio Eradication Initiative (GPEI) was launched in 1988, the number of cases has fallen by over 99%. In 2012, only three countries in the world remain polio-endemic. With continued effort, there is hope that in a few years polio will be eradicated completely.

Another example of success is the HPV vaccine. Cervical cancers can be preventable with HPV vaccine and routine Pap smear testing. Therefore, a routine 3-dose HPV vaccine is recommended for all females to help prevent not only cervical, but also vaginal, vulvar, and anal cancer. This very important HPV vaccine is now available in China but it is in high demand. At Shanghai United Family Hospital you need to look for availability on the hospital’s website homepage: HPV 2 is for women 9-45 years old, HPV 4 for 20-45 years old, and HPV 9 for 16-26 years old.

Influenza vaccinations for children over 6 months of age and adults will start soon at United Family Hospital.

Prevention of sexually transmitted disease

Sexually transmitted disease (STD) is a major public health problem and frequently is asymptomatic. Screening for STD is a way to detect early, treat and prevent transmission and serious complications. Most common STD are hepatitis B and C, chlamydia, gonorrhea, herpes, syphilis, and HIV. Using condoms is one good way to reduce the risk of sexually transmitted diseases.

Prevention of Depression

The USPSTF recommends screening for major depressive disorder in adolescents aged 12 to 18 years and the general adult population, including pregnant and postpartum women.

PHQ-2 is a good tool to screen for depression.

With two questions we can screen for depressive symptoms:

• During the last month, have you often been bothered by feeling down, depressed, or hopeless?
• During the last month, have you often been bothered by having little interest or pleasure in doing things?

PHQ-9 is also a good tool for diagnosis that also has a calculator to grade severity of depression.

Prevention of Unhealthy Alcohol Use

Unhealthy alcohol use is a very common cause of preventable death and is often unrecognized. Alcohol Use Disorder Identification Test (AUDIT) is a simple questionnaire that can be used. A score above 8 in this test is positive for unhealthy alcohol use. And it is also in a calculator form.

Another way to screen for unhealthy drinking is by asking how many “standard drinks” a person drinks. A “standard drink,” is defined as 12 grams of ethanol or 150 grams or a glass of wine, or 360 grams or a can of beer, or 45 grams of spirits.

• More than 14 standard drinks per week or more than 4 drinks on any day, for men and;
• More than 7 standard drinks per week or more than 3 drinks on any day, for women are considered at increased risk.

Prevention of Tobacco Use

Smoking increases the risk of stroke, heart attack, and lung cancer.

Smoking cessation is a good and effective way to prevent disease and death.

There are medications such as varenicline and bupropion that can help smoking cessation.

Prevention of Osteoporosis

We suggest osteoporosis screening in the following groups:

• All women aged 65 years or over
• All men over 70.
• Postmenopausal women under 65 years old with risk factors for osteoporosis (steroid therapy, low body weight, smoking, excessive alcohol intake, rheumatoid arthritis, previous fracture)
• Men with clinical manifestation of low bone mass, history of low trauma fracture, risk factors for fracture (such as androgen deprivation therapy for prostate cancer, hypogonadism, or primary hyperparathyroidism).

References from UpToDate:

• Preventive care in adults: Recommendations

H Nancy Sokol,  Joann G Elmore,  Judith A Melin,

This topic last updated: Jun 04, 2019.

• Preventive care in adults: Strategies for prioritization and delivery

Anthony J Viera, Joann G Elmore, Judith A Melin

This topic last updated: Jan 23, 2018.

• Screening for unhealthy use of alcohol and other drugs in primary care

Richard Saitz, Andrew J Saxon, Richard Hermann,  

This topic last updated: Mar 15, 2018.