Caring for Your Patient with Cancer

FP SPRING 2022

MISSOURI FAMILY PHYSICIAN VOLUME 41, ISSUE 2

Caring for Your Patient with Cancer

FP MISSOURI FAMILY PHYSICIAN

EXECUTIVE COMMISSION BOARD CHAIR John Paulson, DO, PhD, FAAFP (Joplin) PRESIDENT John Burroughs, MD (Kansas City) PRESIDENT-ELECT Kara Mayes, MD, FAAFP (St. Louis) VICE-PRESIDENT Afsheen Patel, MD (Kansas City) SECRETARY/TREASURER Lisa Mayes, DO (Macon)

BOARD OF DIRECTORS DISTRICT 1

DIRECTOR ALTERNATE DISTRICT 2 DIRECTOR ALTERNATE DISTRICT 3 DIRECTOR DIRECTOR ALTERNATE DISTRICT 4 DIRECTOR ALTERNATE DISTRICT 5 DIRECTOR ALTERNATE DISTRICT 6 DIRECTOR ALTERNATE DISTRICT 7 DIRECTOR DIRECTOR ALTERNATE DISTRICT 8 DIRECTOR ALTERNATE DISTRICT 9 DIRECTOR ALTERNATE DISTRICT 10 DIRECTOR ALTERNATE DIRECTOR AT LARGE

Arihant Jain, MD (Cameron) Mike Feuerbacher, MD (Maryville) Robert Schneider, DO, FAAFP (Kirksville) Vacant Emily Doucette, MD, FAAFP (St. Louis) Dawn Davis, MD (St. Louis) Lauren Wilfling, MD (St. Louis) Jennifer Scheer, MD, FAAFP (Gerald) Jennifer Allen, MD (Hermann) Natalie Long, MD (Columbia) Amanda Shipp, MD (Versailles) David Pulliam, DO, FAAFP (Higginsville) Justin Cramer, MD, FAAFP (Marshall) Beth Rosemergey, DO, FAAFP (Kansas City) Afsheen Patel, MD (Kansas City) Wael Mourad, MD, FAAFP (Kansas City) Andi Selby, DO (Joplin) Barbara Miller, MD (Buffalo) Douglas Crase, MD (Licking) Vacant Vicki Roberts, MD, FAAFP (Cape Girardeau) Gordon Jones, MD (Sikeston) Jacob Shepherd, MD (Lees Summit) Josephine Glaser, MD (St. Louis) Krishna Syamala, MD (St. Louis)

RESIDENT DIRECTORS Morgan Murray, MD, UMKC Wesley Goodrich, MD, UMKC (Alternate)

STUDENT DIRECTORS Kelly Dougherty, UMC Karstan Luchini, KCU Joplin (Alternate)

AAFP DELEGATES Keith Ratcliff, MD, FAAFP, Delegate Kate Lichtenberg, DO, MPH, FAAFP, Delegate Sarah Cole, DO, FAAFP, Alternate Delegate Peter Koopman, MD, FAAFP, Alternate Delegate

MAFP STAFF EXECUTIVE DIRECTOR Kathy Pabst, MBA, CAE ASSISTANT EXECUTIVE DIRECTOR Bill Plank, CAE MEMBER COMMUNICATIONS AND ENGAGEMENT Brittany Bussey The information contained in Missouri Family Physician is for informational purposes only. The Missouri Academy of Family Physicians assumes no liability or responsibility for any inaccurate, delayed, or incomplete information, nor for any actions taken in reliance thereon. The information contained has been provided by the individual/organization stated. The opinions expressed in each article are the opinions of its author(s) and do not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries no respsonsibility for the opinion expressed thereon.

Missouri Academy of Family Physicians, 722 West High Street Jefferson City, MO 65101 • p. 573.635.0830 • f. 573.635.0148 Website: mo-afp.org • Email: office@mo-afp.org

CONTENTS 6 Current Breast Imaging Management: An Introductory Primer 10 Human Papillomavirus: Lung and Oropharyngeal Cancers 13 Colorectal Cancer Screening: Updated Recommendations from the USPSTF 15 Update on USPSTF’s Cancer Screening and Prevention Recommendations 19 A Day in the Life of a Family Physician - A Student Series 20 Your Voice, Your Message 22 MAFP Priority Issues and Messages 24 Support for Preceptor Workforce Program Bill 25 2021 Congress of Delegates - Part 2 26 Virtual CME Addresses the Science of Key Family Medicine Topics 27 Members in the News 30 References

MARK YOUR CALENDAR April 21 Spring Scientific CME Series (virtual) - Cancer www.mo-afp.org/cme-events/spring-cme/ May 19 Spring Scientific CME Series (virtual) – Musculoskeletal www.mo-afp.org/cme-events/spring-cme/ June 10 Transition to Practice Conference for Residents and Students Lodge at Old Kinderhook, Camdenton https://www.mo-afp.org/transition-to-practice/ June 11-12 Board of Directors Meeting and Strategic Planning Session Lodge at Old Kinderhook, Camdenton November 11-12 30th Annual Fall Conference - Big Cedar Lodge, Ridgedale November 13 Board of Directors Meeting - Big Cedar Lodge, Ridgedale MO-AFP.ORG 3

Caring for Cancer Patients

I John Paulson DO, PhD, FAAFP Board Chair, Joplin

t’s probably safe to say that we have all treated patients with cancer.

According to Doctor Google, the world’s oldest documented case of cancer was in ancient Egypt around 1500 BC. It described a tumor in a breast that was treated by destroying the tissue with a hot instrument called “the fire drill.” Need I mention that the first anesthesia was not recorded until around the mid-1800s? We have come a long way from “the fire drill” with the invention of radiation therapy in the 1900s and chemotherapy in the 1940s. Cancer prevention and treatment efforts continue to advance, and with the new mRNA technology, we are seeing some promising early results.

How many of us have referred a patient to an oncologist to treat a newly diagnosed cancer and never saw that patient again until their cancer was in remission or possibly ever? Candidly, I can’t help but be frustrated when I have potentially cared for that patient for years, and then they are lost to the Cancer center for weeks to months before I see them again. I have come to grips with

PS -

the fact that they are well cared for during that time. Once these patients start treatment, they will likely be getting daily, weekly, or monthly chemo and/or radiation for weeks. They may see their oncology team more in those three months than my team has seen them in a decade, knowing that I may only see my chronic folks 3-6 times per year.

We are far better at cancer screening and treatment these days, and despite the high incidence of cancer, we see people live longer with cancer. We are dedicating this issue to a variety of cancer topics that address screening, prevention, and the care of our patients after the diagnosis of cancer.

We hope this issue will provide you a little more information that might help boost your confidence to answer questions from patients, friends, and family or teach you something you may not have known.

MAFP is publishing an issue of this magazine dedicated to the Joy of Family Medicine that will be a collection of inspirational stories from our members.

Please send your stories, photos, and reasons why you love Family Medicine to marketing@mo-afp.org.

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MISSOURI FAMILY PHYSICIAN April - June 2022

Today more than 3,500 children will try their first cigarette.

Stop kids from starting.

Volunteer to be a Tar Wars presenter. www.tarwars.org

Supported in part by a grant from the American Academy of Family Physicians Foundation.

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Current Breast Imaging Management: An Introductory Primer

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Amy K. Patel M.D. Liberty, MO 6

MISSOURI FAMILY PHYSICIAN April - June 2022

he specialty of breast imaging is rapidly evolving in all aspects, including practice standards and parameters.

Oftentimes, it can be confusing for a primary care provider when wanting to order the appropriate breast imaging for a patient. As breast imaging specialists, we ultimately follow the American College of Radiology (ACR) Appropriateness Criteria Guidelines. These guidelines are evidence-based and regularly reviewed by expert panels to ensure we are recommending the correct breast imaging studies as well as modifying guidelines as research evolves [1].

the National Comprehensive Cancer Network [4]. If a woman is above average risk from the ages of 25-29, annual breast MRI is recommended. If a woman is 30 years of age and above, annual screening mammography is recommended with supplemental screening in the form of breast MRI or ultrasound alternating every six months. However, it is important to note that MRI is more sensitive of an examination than ultrasound [2].

If a patient is average risk with dense breasts, then some breast centers may recommend supplemental screening such as ultrasound or a newer MRI protocol called “Abbreviated,” where the imaging time is typically reduced to half the time of a full MRI. Dense breasts are defined as breast tissue components visualized on mammography that are denser than adipose tissue, appearing “white” on a mammogram. There are now many breast imaging centers recommending this in average-risk women with dense breasts because it is widely accepted that breast density is in and of itself a risk factor that contributes to one’s overall risk percentage and with a four-sixfold increased relative risk [5]. Since imaging of average risk women with dense breasts varies per breast imaging center, be sure to contact your breast imaging center where you are sending the referral to inquire to see if this practice is performed if you have a patient who desires this.

If a woman presents with a palpable abnormality or pain and is under the age of 30, typically, many breast imaging centers start with ultrasound. If the area evaluated looks suspicious or indeterminate, then diagnostic mammography may be ordered as well for correlation of the two modalities. If the patient is 30 and above, the majority of breast imaging centers will start with diagnostic mammography followed by targeted diagnostic ultrasound [1].

Male Breast Imaging

Opposed to breast cancer affecting 1 out of 8 women, breast cancer affects 1 out of 800 men [8]. However, more research is needed to fully understand risk in men as well as to ensure we, as a breast cancer community, are recommending the correct surveillance. As of now, if a man is considered above-average risk for breast cancer, the breast imaging recommendations vary per practice and institution. Therefore, it is important to discuss with your breast imaging center where you are sending the referral to see if there are any protocols in place for male breast imaging.

Female Breast Imaging

In 2018, recommendations for women who are above average risk for breast cancer were released by the ACR and Society of Breast Imaging (SBI). The recommendations include a statement that any woman of any color needs to be risk assessed by age 30 [2]. Higherthan-average or above-average risk constitutes a ≥20% lifetime percent risk for breast cancer and is usually determined by a breast cancer risk assessment tool such as Tyrer Cuzick or the Gail Model [3]. If a woman is average risk, annual screening mammography beginning at age 40 is recommended by many organizations such as the ACR, SBI, the American Society of Breast Surgeons, the American College of Obstetricians and Gynecologists, and

BREAST CANCER AFFECTS 1 OUT OF 800 MEN MO-AFP.ORG 7

In my practice, for example, if a male patient is deemed high risk, we recommend annual mammography screening.

We are more likely to see men for a symptom, such as a palpable abnormality or pain. If the patient is younger than 25 years of age, diagnostic ultrasound is performed. If the finding is suspicious or indeterminate, diagnostic mammography may be performed.

If the patient is above the age of 25, then mammography is usually appropriate with targeted diagnostic ultrasound to follow.

If the patient is of any age with a suspicious palpable (i.e. not gynecomastia), axillary lymphadenopathy, nipple discharge, or retraction, diagnostic mammography and ultrasound are recommended [1].

Transgender Breast Imaging

As of November 2021, guidelines have been established for breast imaging in transgender patients. Currently, in the United States, .39-2.7% percent identify themselves as transgender and non-binary, so it is important we have a general understanding of these guidelines to meet the unique needs of these patients [6].

Breast cancer screening recommendations in these patients is based on the sex assigned at birth, exogenous hormone use, and other risk factors.

The recommendations are as follows: • Mammography may be appropriate for breast cancer screening in an average risk transfeminine (male-to-female) patient who is 40 years of age or older with past or current hormone use for ≥5 years.

• Mammography is usually appropriate for breast cancer screening in above-average risk transfeminine patients who are 25

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MISSOURI FAMILY PHYSICIAN April - June 2022

to 30 years of age or older with past or current hormone use for ≥5 years. Patients in this risk category include a personal history of breast cancer or chest irradiation at 10 to 30 years of age, having a genetic predisposition to breast cancer, having a family history of breast or ovarian cancer, or are untested with a first-degree relative with a genetic predisposition to breast cancer.

• Imaging is usually not appropriate for mammography screening in an average risk transfeminine patient of any age with no hormone use or <5 years of hormone use.

• Mammography may be appropriate for breast cancer screening in an above-average risk transfeminine patient who is 25 to 30 years of age or older with no hormone use or <5 years of hormone use.

Patients in this risk category have a personal history of breast cancer or chest irradiation at 10 to 30 years of age, a genetic predisposition to breast cancer, a family history of breast or ovarian cancer, or is an untested patient with a first-degree relative with a genetic predisposition to breast cancer.

• Imaging is usually not appropriate for breast cancer screening in a transmasculine (female-to-male) patient of any age and any risk who has had bilateral mastectomies (i.e., “top surgery”).

• Mammography is usually appropriate for breast cancer screening in an average risk transmasculine patient who is 40 years of age or older with reduction mammoplasty or no chest surgery.

Patients in this risk category have a <15% lifetime risk of breast cancer.

• Mammography is usually appropriate for breast cancer screening in an intermediate risk transmasculine patient who is 30 years of age or older with reduction mammoplasty or no chest surgery. Patients in this risk category have a personal history

of breast cancer, lobular neoplasia, atypical ductal hyperplasia, or a 15% to 20% lifetime risk of breast cancer.

• Mammography is usually appropriate for breast cancer screening in an above-average risk transmasculine patient who is 25 to 30 years of age or older with reduction mammoplasty or no chest surgery. Patients in this risk category may have a genetic predisposition to breast cancer, a history of chest irradiation between 10 and 30 years of age, a ≥20% lifetime risk of breast cancer, or are untested patients with a first-degree relative with a genetic predisposition to breast cancer. MRI with and without IV contrast is recommended as an adjunct to mammography for screening. *The word mammography in this section refers to both digital breast tomosynthesis (i.e., 3D mammography) and full-field digital mammography (i.e., 2D mammography) as either is acceptable when ordering this imaging based on appropriateness criteria guidelines.

However, regardless of these recommendations and guidelines, if you seek additional guidance, reach out to your local breast imaging center or a breast imaging specialist for assistance.

Amy Patel, MD is a Breast Radiologist in Liberty, MO. Dr. Patel is the Medical Director of The Breast Care Center at Liberty Hospital, Chairwoman of the Liberty Hospital Cancer Committee, Assistant Professor of Radiology at UMKC School of Medicine, and President Elect of the American Association for Women in Radiology.

References found on page 30.

Shape the Future of Family Medicine Our Medical Students Need You Our state has a critical need for clinical training sites for students. Share your knowledge and skills.

To volunteer to host clinical rotations, contact the department of family medicine at a medical school near you.

MO-AFP.ORG 9

John Paulson, DO, PhD, FAAFP Joplin, MO

Scott McClintick, DO Joplin, MO

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MISSOURI FAMILY PHYSICIAN April - June 2022

Human Papillomavirus: Lung and Oropharyngeal Cancers

About HPV

M

ost family physicians are acutely aware that certain human papillomavirus (HPV) infections are important risk factors for cervical cancer. Oncogenic DNA viruses include HPV, Epstein-Barr virus (EBV), Hepatitis B virus (HBV), human herpesvirus-8 (HHV-8), and Merkel cell polyomavirus (MCPyV). Since the first identification of HPV, over 200 different subtypes have been identified. Sexually transmitted HPV types are traditionally classified into high-risk HPV types (16, 18, etc.) and lowrisk HPV types (6,11, etc.) (1). Overall, HPV is responsible for almost 4.5% of all cancers diagnosed worldwide (2).

HPV is spread through vaginal, anal, or oral sex. These infections occur in both males and females. Nearly all sexually active people are infected with HPV within months to a few years after becoming sexually active with around half of these infections being the high-risk HPV type. Despite most people being infected with HPV at some point in their lives, only persistent infections will cause pathological changes. In response to harmful and invading pathogens, the innate immune system becomes activated, generating an acute inflammatory response. This inflammatory response aids in the removal and clearance of the pathogen.

However, should the pathogen fail to be removed, the development of chronic inflammation occurs, which is strongly associated with cancer (3). When a high-risk HPV infection persists for many years, it can lead to cell changes that, if untreated, may worsen over time and become cancerous. Chronic inflammation as a result of viral infection is responsible for an estimated 25% of all human cancer (4).

While HPV is recognized as the primary etiological factor of cervical cancer, there is widespread evidence that this virus is detected not only in gynecological carcinomas, but also in tumors of other organs, in particular the upper and lower respiratory tract which will be discussed below.

About HPV and Lung Cancer

Lung cancer is one of the leading causes of cancer mortality and morbidity worldwide (5). Primary lung cancers are divided into two main groups: small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC). NSCLC is further divided into three common types: squamous cell carcinoma (SCC), large cell carcinoma (LCC), and adenocarcinoma (AC). Smoking, by far, has been identified as the most important risk factor for lung cancer. However, other interactions with environmental, genetic risk factors, and infectious diseases also contribute to the pathogenesis of lung cancer. HPV infections have been identified as a potential contributor to the pathogenesis of lung cancer in certain populations, such as those who have never smoked.

Considerations for how this could occur include hematologic spread from cervical lesion to lung, high-risk sexual behaviors, and airborne transmission to the lungs. It remains clear that HPV16 and HPV-18 are the most common HPV subtypes associated with lung cancer.

Additionally, AC and SCC appear to be associated with a higher prevalence of HPV. Overall, NSCLC is the most common form of lung cancer, accounting for 80 to 85 percent of cases, according to the American Cancer Society (ACS), with AC being the most common type of lung cancer, accounting for 30 percent of all cases and about 40 percent of all NSNLC occurrences.

Meanwhile, SCC is responsible for about 30 percent of all NSCLC cases and is generally linked to smoking. Recent research has

identified AC with HPV 16/18 infections as having significantly higher survival rates vs. HPV negative tumors (6). Furthermore, some studies have suggested that HPV vaccination might not only be useful for cervical cancer prevention but also in the reduction of lung cancer risk (5).

About HPV and Head and Neck Cancer

Head and neck cancers are the seventh most common tumors worldwide (7). Head and neck squamous cell carcinoma (HNSCC) is a heterogeneous group of malignancies that arise in the mucosal epithelium of the oral cavity, oropharynx, hypopharynx, and larynx.

The oropharynx includes the back third of the tongue, the soft palate, the side and back walls of the throat, and the tonsils (8). Almost 90% of all head and neck cancers are HNSCC, and 72% of those are attributable to alcohol and tobacco consumption (9). Of all HNSCC, those involving the oral cavity and oropharynx seem to have the greatest association with HPV infections. The rate of oropharyngeal cancer (OPC) began to rise in 1999 and has been increasing ever since (7). There are three known causal factors related to OPC: tobacco use, alcohol, and HPV infection. (8).

We have seen increasing rates of OPC among males with no real change in rates among females. Additionally, we have also documented an increase in OPC in those 50-79 years of age compared to a decrease in OPC rates among those 40-49 (10). HPV positivity has also been associated with improved survival outcomes both in patients with OPC and AC with HPV 16/18 infections (6, 9, 11).

Role of Family Physicians in HPV Associated Cancers

Family physicians are already working to reduce the number of lung and oropharyngeal cancers with their efforts to screen for and reduce alcohol and tobacco use. Additionally, efforts to reduce HPV-associated cancers are supported by United States Preventative Services Task Force (USPSTF) recommendations with specific guidance on cervical cancer screening. Currently, however, there are no FDA-approved tests to detect HPV infection or HPV-caused cell changes in anal, vulvar, vaginal, penile, or oropharyngeal tissues.

Some research has found benefits with anal cancer screening in highrisk populations. The USPSTF has found that evidence is insufficient

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to recommend screening for oral cancers in asymptomatic adults.

However, the American Dental Association (ADA) does recommend dentists screen all patients as a part of their routine dental check-ups.

Despite the best evidence for HPV vaccine prevention of cancer coming from anal and cervical cancers, it is reasonable to be hopeful that HPV vaccination will also reduce and prevent other HPVassociated cancers. HPV vaccination recommendations from the Advisory Committee on Immunization Practices (ACIP) are included in Table 1.

Efficacy studies have indicated HPV vaccines are a highly effective prevention tool prior to HPV exposure (12, 13). However, gender, religiosity, political ideology, and education policies are predictors of HPV vaccine completion. In 2016, the US HPV vaccine completion by state showed a range of 26.7% to 70.8%, with Missouri falling

Conclusion

Current data continues to support the belief that HPV infection may increase the risk of developing lung and oropharyngeal cancer.

While research efforts continue to develop a better understanding of the pathogenesis and how to reduce this risk, family physicians should continue to screen for and work to reduce alcohol and tobacco use, continue cervical cancer screening, and recommend HPV vaccination in those individuals who meet criteria knowing that it will reduce their risk of anal and cervical cancer risk with the expectation that it may also reduce the risk of HPV associated oropharyngeal and lung cancers. We should also continue our efforts on vaccine ordering and administration to reduce all vaccine-preventable diseases.

John Paulson, DO, PhD, FAAFP is Chair of Primary Care at Kansas City University in Joplin, Missouri. Scott McClintick, DO is Adjunct Clinical Instructor, Otolaryngology Residency Faculty at Kansas City University in Joplin, Missouri.

References found on page 30.

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into the category of 29.1-39% (14). Early reports during the COVID-19 pandemic documented a marked decline in pediatric vaccine ordering and administration, placing US children and adolescents at risk for vaccine-preventable diseases. It is now time for us to work together and achieve our catch-up coverage, not only with HPV vaccination but with all of our vaccine-preventable diseases. Vaccine underuse may worsen in the near future with continued hesitancy from some in regards to the current COVID-19 vaccination efforts. If and when your COVID-19 vaccination recommendations are not successful, consider it a win if you are able to negotiate one of the many other successful vaccines that are still available and likely needing catch-up coverage.

MISSOURI FAMILY PHYSICIAN April - June 2022

Keep Your Career on the Move

Colorectal Cancer Screening: Updated Recommendations from the USPSTF

A

Scott Andelin, MD Kansas City University College of Osteopathic Medicine - Joplin

s the third most common cause of cancer death for both men and women in the United States(1), colorectal cancer (CRC) is of significant concern. Over the last two decades, there has been an increased incidence of CRC in people younger than 50, with 10.5% of new CRC cases now occurring in individuals younger than age 50.(2) In addition, 40-49 year olds have up to 5 times higher risk for CRC compared to 20-39 year olds.(3) Analysis of the changing frequency of CRC in younger individuals, along with a systematic review to evaluate the risks versus benefits of CRC screening led the US Preventive Services Task Force (USPSTF) in 2021 to update their CRC screening recommendations for average risk individuals, with recommendations now for screening all adults beginning at age 45.(1) Considering their pivotal role in preventive care, family physicians should have a global understanding of colorectal cancer including epidemiology and pathogenesis, screening modalities, and screening recommendations.

Epidemiology and Pathogenesis of Colorectal Cancer

Megan Anderson, OMSIII Kansas City University College of Osteopathic Medicine - Joplin

Adriana Kitchens, OMSIII Kansas City University College of Osteopathic Medicine - Joplin

Development of CRC has many risk factors, some of which include alcohol and tobacco use(4,5), obesity(6), diabetes(5), and increased intake of red and processed meat.(4) Increased prevalence of diabetes and obesity in the United States likely plays a role in the increasing number of CRC cases in persons younger than 50.(6) Men are at an increased risk of developing CRC compared with women(4) and African Americans are at the highest risk of developing CRC compared with other ethnicities in the United States.(4) While screening recommendations do not change based on nonspecific risk factors, gender, or race, individuals with specific risk factors including a prior history of colon cancer, adenomatous polyps, inflammatory bowel disease, or genetic disorders that increase risk of CRC (personal or family history) may require adjustment to their CRC screening regimen.(1) Colorectal cancer most frequently arises from benign polyps, which then transform to adenocarcinoma over the course of many years. Both tubular adenomas and serrated polyps are benign but have the potential for malignant transformation.(8) This typically occurs through specific mutation pathways that can lead to development of CRC(8,9). Adequate screening in the general population provides an opportunity to detect and remove the benign polyps before they become malignant as well as detect CRC in its early stages(10).

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Screening Modalities

CRC screening modalities can be divided into two main categories, including stool tests and direct visualization tests.

Available stool tests include high-sensitivity guaiac fecal occult blood test (gFOBT), fecal immunochemical test (FIT), and stool DNA test. The gFOBT screens for the chemical components of blood in the stool. The FIT uses antibodies to identify blood in the stool.

The stool DNA test identifies cancer biomarkers in the stool. The only FDA-approved stool DNA test at this time is the “s-DNA-FIT” which is a stool DNA test and FIT test combined. Any positive stool test should be followed up with a colonoscopy. The gFOBT appears to have the lowest accuracy of all stool tests and can be most cumbersome for patients to administer as it requires three stool samples for test completion. Of the stool test, the sDNAFIT has been shown to have the highest sensitivity for identifying CRC. It should be noted that the sDNA-FIT is less specific for CRC as compared to FIT and does lead to more false positives and subsequent follow-up colonoscopies(1).

Direct visualization tests include flexible sigmoidoscopy (FS), flexible sigmoidoscopy with FIT, CT colonography, and coloscopy. FS uses a camera to visualize the rectum, sigmoid colon, and descending colon. CT colonography uses a series of XR images to visualize the colon.

Abnormal findings via FS or CT colonography should be followed up with colonoscopy. Colonoscopy uses a camera to visualize the entirety of the rectum and colon(1).

One meta-analysis found “colonoscopy had a 96.4% probability of being the most effective examination to reduce CRC mortality.” However, the same study did find that gFOBT, FIT, FS, and colonoscopy all prevented deaths from CRC(11). Overall patient adherence to screening is considered a significant predictive factor in screening effectiveness(12). The USPSTF does not recommend one specific screening modality as the “best” but recognizes that there are many factors that could impact choice, including local resources as well as individual patient factors(1).

Screening Recommendations

In May 2021, the USPSTF updated their previous 2016 guidelines for CRC screening and published their recommendations along with supporting evidence in JAMA(1). Additionally, details of

the 2021 USPSTF final recommendation on CRC screening can be found on the USPSTF website at https://www. uspreventiveservicestaskforce.org/uspstf/recommendation/ colorectal-cancer-screening (13). The most notable change in this 2021 guideline is the recommendation to start screening all average-risk adults at age 45(1). In March 2021, the American College of Gastroenterology made a similar suggestion to start CRC screening at age 45 but emphasized that the strongest evidence for CRC screening remains in individuals aged 50-75(10).

The previous recommendations to only selectively screen individuals aged 76-85 remain in place, with the recognition that in this age group, the risk of screening may outweigh the benefit.

In particular, as the benefit of screening for CRC may be delayed by several years, the patient’s overall health and life expectancy should be considered. Higher priority for screening should be given to those who have not previously been screened(1,10). It is universally accepted that CRC screening should not continue after the age 85(1). See attached Table 1 with a summary of current USPSTF CRC screening recommendations.

The updated USPSTF guidelines on CRC screening provide an opportunity for family physicians to reflect on our roles in the prevention and early detection of CRC in our communities. Due to the progressive nature of nonmalignant colon polyps to malignancy and the ability to intervene early on, screening can make a real difference in decreasing mortality due to CRC. Now with the change in age recommendations, family physicians should begin having discussions with patients earlier about options for CRC screening and the impact it can have on their lives.

References found on page 30.

The American College of Gastroenterology makes a strong recommendation for colonoscopy and FIT as the primary choices for CRC screening10.

• The recommended frequency of CRC screening modalities varies by type as listed below: gFOBT or FIT every year • sDNA-FIT every 1 to 3 years • CT Colonography every 5 years • Flexible sigmoidoscopy every 5 years • Flexible sigmoidoscopy every 10 years plus annual FIT • Colonoscopy every 10 years1 14

MISSOURI FAMILY PHYSICIAN April - June 2022

Update on USPSTF’s Cancer Screening and Prevention Recommendations

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he mission of the United States Preventive Services Taskforce (USPSTF) is to improve the health of people nationwide by making evidence-based recommendations on effective ways to prevent disease, promote health, and prolong life. Since it first published the Guide to Clinical Preventive Services (1) in 1989, the USPSTF has iteratively updated clinical prevention guidelines towards that mission. Cancer is the second leading cause of death in the United States; it’s no surprise that the USPSTF has almost 20 recommendation statements regarding cancer prevention and screening. I will review the current recommendations, focusing on recent updates.

The USPSTF uses a grading system to communicate the strength and direction of its recommendations. (See Table 1)

James J Stevermer, MD, MSPH, FAAFP Columbia, MO

Prevention

Tobacco use is a leading cause of morbidity and mortality in the US, and one contributing mechanism is the causal role tobacco use plays in multiple cancers. The USPSTF makes a grade A recommendation to ask all adults about their tobacco use, advise them to stop, and provide behavioral, and for all non-pregnant people, pharmacotherapy for cessation. (3) There is insufficient evidence to know whether this works for schoolaged children and adolescents. However, there is evidence to support (Grade B) providing education or brief counseling to this population to prevent initiation of tobacco use. (4) The USPSTF found insufficient evidence to recommend for or against the use of multivitamins to prevent developing cancer (Grade I); however, there was evidence to recommend against the use of beta-carotene or Vitamin E to prevent cancer (Grade D). (5) MO-AFP.ORG 15

Update on USPSTF’s Cancer Screening and Prevention Recommendations

People identified to be at increased risk of breast cancer should be offered risk-reducing medications. The best method for identifying these people is unknown, and clinicians may take several approaches, including using the risk assessment tool, family history or medical history (such as chest radiation, presence of BRCA mutations, or abnormal biopsy results) to establish their patients’ risk. (6) The USPSTF also recommends counseling young adults, adolescents, children and parents of young children to minimize exposure to UV radiation for people aged 6 months to 24 years with fair skin types (Grade B). There is some evidence to support making similar recommendations to selected adults over 24 years of age.

(Grade C). (10)

Recent Prevention Updates

Daily low-dose aspirin was recommended to help prevent colorectal cancer in people identified to be at a higher risk of cardiovascular disease. (7) However, a draft recommendation update from 2021 no longer identified colorectal cancer prevention as an identifiable benefit from daily aspirin use. (8) Primary prevention studies published in the last few years, as well as longerterm follow-up data from older studies, raised doubt about the strength of this association. (9) (There still is a role for using daily aspirin to prevent cardiovascular disease in some patients (Grade C).

Screening

The USPSTF has made recommendations about screening for 12 different cancers, using the full spectrum of recommendation grades. (See Table 2) Recommendations against screening (Grade

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D) were given to 4 cancers.

Two, thyroid and testicular, are uncommon and have a good prognosis, and what data was found demonstrated no clear additional benefit from screening. (20, 23) Ovarian and pancreatic cancers have much more serious prognoses, but both lack accurate, noninvasive methods of screening (21,22). Several cancers lack adequate evidence for the USPSTF to provide any other grade than I. (See Table 2) Prostate cancer screening remains a complex area, as it is a cancer with significant morbidity and mortality, but there is a significant risk of overdiagnosis, and treatments carry the risk of morbidity. The resulting balance between harms and benefits is fairly narrow, and so the USPSTF makes a recommendation towards using shared-decision making to discuss this balance with patients, thereby assisting them in making an informed, personal decision. (16) The USPSTF recommends for both cervical and breast cancer screening, in appropriate populations (see Table 2). (14,15) For both cancers, screening technology is changing rapidly; this includes digital mammography and 3-D imaging for breast cancer, and new methods of screening for cervical cancer, such as patient selfcollection for human papilloma virus (HPV) testing. In addition, the role of prior HPV vaccination is being assessed. The USPSTF is in the process of updating these recommendations, a process that usually takes several years.

Recent Screening Updates

In 2021, the USPSTF updated recommendations for lung cancer screening and colorectal cancer screening and expanded eligible populations for screening. For lung cancer screening, the USPSTF used their standard evidence review and incorporated modeling to help best identify what thresholds should be used for screening with low-dose CT. (13) The new recommendation moves the lower age for screening from 55 to 50, and keeps the upper age at 80 years. This includes all people who currently smoke or have quit in the last 15 years. Another change was to lower the cumulate packyear history from 30 to 20. The estimated effect is to almost double the eligible population for screening, with a disproportion increase in Black and Latinx/Hispanic populations. Since it appears that Black people who smoke have a higher risk of lung cancer than do White people, and this risk difference becomes wider at lower levels of smoking intensity, widening the eligibility criteria may reduce racial disparities.

Table 2 Cancer screening recommendations from the USPSTF

The USPSTF also commissioned a modeling study for its colorectal cancer screening recommendation. (11) In this case, modeling incorporated evidence of increasing incidence of colorectal cancer in adults younger than 50. The resulting modeling outputs suggest a small but important reduction in cancer cases and cancer mortality in this younger population. Given these findings, a separate recommendation was made for people aged 45-49 years (Grade B), along with the prior recommendation for screening adults aged 50-75 (Grade A). The USPSTF recommends using stoolbased or direct visualization strategies but found inadequate data to clearly support one of these methods over others.

Conclusion

Cancer is a major cause of morbidity and mortality in the US. In 2020, almost 10% of the US population had been diagnosed with cancer at some point in their life, and over 600,000 people died from cancer. Fortunately, we are seeing a decline in death rates - in

1990, there were 216 deaths/100,000 population, and by 2018, that number had dropped to 149.1/100,000. Multiple factors contribute to this impressive decline, including improved therapeutics and better methods of monitoring disease. However, prevention and early detection will continue to be essential in reducing cancer morbidity and mortality and following the USPSTF evidence-based recommendations provides an excellent base for family physicians to guide their patients in screening and prevention.

Disclaimer: James J. Stevermer, MD, MSPH, FAAFP is Vice Chair for Clinical Affairs and Professor of Clinical Family and Community Medicine in the Department of Family and Community Medicine at University of Missouri Health in Columbia, MO. Dr. Stevermer is a member of the United States Preventive Services Task Force (USPSTF). This article does not necessarily represent the views and policies of the USPSTF. References found on page 30.

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A Day in the Life of a Family Physician – A Student Series Family physicians have many options when choosing their type of practice or subspecialty to care for patients, teach, or practice management. The MAFP is hosting a free, virtual series of 30-minute sessions for those medical students who are curious about family medicine. All sessions are held live through Zoom as a lunch and learn from 12:00-12:30 pm. Sessions include a brief discussion of the topic followed by time for students to ask questions of the presenters.

Upcoming sessions include: Family Medicine and Obstetrics – April 27, 2022 Misty Todd, MD, Cole Camp Occupational Health Practice and Management – May 25, 2022 Dennis Estep, DO, Joplin

Students can register for free by visiting our website: https://www.mo-afp.org/join/ residents-students/day/

Previous sessions listed below are available to watch at https://www.mo-afp.org/join/residents-students/day/: Fellowships After Residency – January 26, 2022 Brea Lombardo, MD, University of Missouri Columbia Lifestyle Management and Obesity Medicine – February 23, 2022 Kara Mayes, MD, Mercy Clinic Primary Care, St. Louis What I Wish I Knew About Applying for Residency – a 4th Year Medical Student Perspective – March 23, 2022 Kelly Dougherty, MS4, University of Missouri Columbia If you are interested in being a host speaker at one of the 2023 sessions, email the MAFP at office@mo-afp.org, and we will be sure to add you to next year’s lineup.

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Your Voice, Your Message 2022 Advocacy Day Wrap Up

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he Missouri Academy of Family Physicians gathered once again at the Missouri State Capitol to express our support or opposition to our priority legislation (see page 22-23). This year’s gathering included those who met in person in Jefferson City and those who met virtually with their Senators and Representatives. Regardless of how the meeting was conducted, one message was clear; family physicians support team-based care to provide safe care to Missourians.

This annual event began with the addition of two hearings on the MAFP’s Preceptor Workforce Program legislation. HB 2595 and SB 801 were heard in their respective committees, House General Laws Committee, and the Senate Professional Registration Committee. See more details on page 24.

Education is the key to understanding the many nuances of each bill that we engage on through testimony and bill tracking.

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Monday evening focused on educating family physicians, residents, and students on our priority bills. In addition, just like Schoolhouse Rock, How a Bill Becomes a Law, we talked about the pathway for a bill to become a law. As the song says, “I’m just a bill, yes, I’m only a bill,” and we followed through the pathway and ended with “He signed you, Bill, now you’re a law.” The strategies utilized for passage of a bill from the traditional pathway to an amendment to other bills were reviewed and discussed.

Keith Ratcliff, MD, FAAFP, Peter Koopman, MD, and Randy Scheer, MAFP Governmental Consultant, led the discussion on issues such as the preceptor workforce program, scope of practice, limiting assistant physician licenses, patient safety, and practice management.

Tuesday morning kicked off with a quick overview of our priority issues, followed by a quick walk to the building on the hill, the Missouri State Capitol. MAFP scheduled appointments for those attending to meet with their Senators and Representatives. Although not all were available in their offices, some of our elected leaders were pulled from the chamber floor for a quick discussion. Those who did not attend in person contacted their legislators for a conference call, and others used the Speak Out platform to send a quick message on the preceptor workforce program and/or the scope of practice legislation.

The MAFP Board of Directors wrapped up the day with a meeting in the early afternoon. Both in-person and virtual attendees received a pre-planning update for the June strategic planning session, in addition to hearing updates from the Advocacy, Education, and Member Services Commissions. We also announced the delegates for the upcoming National Conference of Constituency Leaders and selected our leaders to participate in the AAFP Family Medicine Advocacy Summit in Washington, DC. And a call to action was made for members to submit a proposed resolution for the 2022 Congress of Delegates. MAFP members interested in submitting a resolution may do so on the MAFP website at https://www.mo-afp.org/about/ congress-of-delegates/ The Family Health Foundation of Missouri also met to discuss upcoming programs such as the summer externship program, transition to practice conference, wine tasting and charcuterie board fund raising event at Annual Fall Conference, Tar Wars, and this year’s National Conference for Family Medicine Residents and Students.

The MAFP Political Action Committee discussed the solicitation of donations from members and is preparing to identify our legislator champions to support their 2022 campaigns.

If you didn’t make it to this year’s Advocacy Day, members can always engage in legislative initiatives by: • Contact your legislator on an issue that is important to you • Present testimony at a hearing, either in person or written • Respond to a Speak Out request • Donate to the MAFP PAC • Mark your calendars for next year’s Advocacy Day, tentatively scheduled for February 13-14, 2023 MO-AFP.ORG 21

MAFP Priority Issues and Messages MAFP SUPPORTS PRECEPTOR TAX CREDIT PROGRAM

SUPPORT HB 2595 (Shields) and SB 801 (Hegeman) • Preceptors are a critical component in the learning process for medical and physician assistant students. They provide invaluable experience for students to develop clinical skills and competencies, gain practical experience working with patients, and understand the diversity within the patient population and treatment settings.

• Evidence shows that early and consistent primary care preceptor mentorships for medical students increases the likelihood of students choosing family medicine as a career.

• MAFP supports this self-imposed license fee increase to fund this preceptor tax credit because of the significant need to incentivize preceptors to provide this critical learning opportunity, particularly in rural and healthcare shortage areas.

• Primary care physicians and physician assistants will be able to take advantage of this tax credit program which will be eligible for up to 200 preceptor rotations a year.

• Most preceptors at public schools of medicine are not paid for providing this service.

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• This tax credit could improve exposure of medical students and physician assistants to rural medicine.

MAFP SUPPORTS A PHYSICIAN TO LEAD THE HEALTH CARE TEAM

OPPOSE HB 1482 (Stephens), HB 1578 (Schroer), HB 1602 (Chipman), HB 2383 (Lewis), HB 2434 (Grier), SB 917 (Burlison) • MAFP believes the physician-led team approach delivers the best and most cost-effective care to Missourians and that APRNs, PAs, and APs are dedicated, skilled members of the health care team.

• Alternatives to an expanded scope of practice for APRNs, PAs, and APs are loan repayment/forgiveness/scholarships for primary care physicians; less administrative burden, such as prior authorizations; increased reimbursement for primary care services; and expanded primary care residency slots.

• While APRNs, PAs, and APs have an important role on the health care team, they have not completed training that affords them the same experience and skill as those who have completed a medical education. A Doctorate in Nursing Practice completes

approximately 5,350 hours (of which 500-1,500 are clinical) compared to 20,000 hours (of which 9,000 – 10,000 are clinical) for a physician.

PROTECT OUR PATIENTS • MAFP supports immunizations to protect Missouri’s infants, children, adolescents, adults, and seniors.

Immunizations are among the most cost-effective and successful public health interventions.

• The MAFP supports local health agencies to develop public health policies and plans that could mitigate the impact of the epidemic on their communities. We support evidence-based decisions to ensure the safety and health of communities in ordinary times and in a state of emergency.

• SUPPORT HB 1468 (Pike), OPPOSE HB 2463 (Houx), HB 2467 (Merideth) – Education can change behavior, and educating our youth about the effects of tobacco and vapor products as a drug can curb the use of these dangerous products. MAFP supports increasing the age to purchase tobacco and vapor products from 18 to 21 and adding vapor products to the definition of “smoking.”

• SUPPORT HB 1701 (Roberts) and HB 2243 (Evans) – Prohibits the use of hand-held wireless communication devices and texting while driving.

• SUPPORT HB 1487 (Porter) – Creates the offense of distracted driving with the issuance of a warning notice.

PATIENTS DESERVE ACCESS TO QUALITY HEALTH CARE • The MAFP believes that all Missourians should have access to essential health care services, regardless of social, economic, or political status, race, religion, gender, or sexual orientation. We support measures that increase Medicaid coverage to Missourians who lack affordable health care.

• SUPPORT HB 2077 (Tate) that would require health benefit plans to provide coverage for medically necessary laboratory tests and ultrasounds related to an enrollee’s pregnancy.

• SUPPORT HB 2242 (Phifer) which extends the current coverage of pregnant women receiving MO HealthNet pregnancy-related and postpartum benefits and Show-Me Healthy Babies Program benefits (HB 2374, Bosley) from 60 days to one year following the last day of their pregnancy. Positions and opinions are based on information available at the time of print. MAFP | 722 West High Street | Jefferson City, MO 65101 | (573) 635-0830 | mo-afp.org

SAFEGUARD THE PHYSICIAN AND PATIENT RELATIONSHIP

• OPPOSE HB 1555 (Gregory), HB 2096 (Seitz) – Physical therapists should work with a referring physician to ensure proper diagnosis and treatment of the patient.

• OPPOSE HB 2165 (Buchheit-Courtway), SB 829 (Brown) – A physician and patient relationship is not established through a questionnaire. This is a useful tool in assessing an existing patient and for minor issues. It is important to interview the patient, take a medical history, and perform a physical exam.

• OPPOSE SB 965 – (Roberts) – Dentists administering vaccines further fragments the patient and physician relationship by adding another provider of care. Dentists focus on oral health and treatment and do not have a patient’s full medical history.

• OPPOSE HB 2107 (Gregory) – Athletic trainers’ access to patients without a diagnosis further fragments the physician and patient relationship. Insurance coverage for these services will further stretch Medicaid funding and cover services and treatment without a diagnosis.

• SUPPORT HB1741 (Dogan) and HB 2230 (Ingle), OPPOSE HB 2452 (Cook) – The pharmacist and physician work collaboratively so their combined expertise is used to optimize the therapeutic effect of pharmaceutical agents in patient care. When vaccines are administered elsewhere, the information should be transmitted back to the patient’s primary care physician and their state registry to assure continuity of the patient’s medical record. The physician’s knowledge of the patient history could minimize a potential adverse reaction to the vaccine.

• OPPOSE HB 2166 (Porter), SB 991 (Hough) - Patient access to care issue in rural areas if clinic staff are not allowed to offer in-clinic x-rays.

MAFP CONTINUES TO SUPPORT EFFECTIVE OPIOID PRESCRIBING

• OPPOSE HB 2394 (Ingle) and HB 2240 (Appelbaum) – MAFP opposes codifying the CDC guidelines into regulations because it undermines the physician and patient shared decision making. It would also disrupt the care of patients who are currently receiving long-term chronic pain treatment. Missouri’s current treatment infrastructure does not have the capacity to absorb a large number of patients newly cut off from opioid treatment.

PRACTICE MANAGEMENT

• SUPPORT HB 1715 (Riley), SB 975 (Burlison) – This bill modifies the rules for determining the admissibility of evidence of collateral source payments in civil actions.

• SUPPORT HB 2201 (Sander) – MAFP supports protection of health care providers against liability in COVID-19 related actions, including setting the statute of limitations to one year after the alleged harm.

• SUPPORT SB 947 (White) which modifies prior authorization for a particular health care service if, in the most recent six-month period, not less than 90% of the prior authorization requests submitted by that provider for that particular health care service, the health care provider would not be required to obtain prior authorization.

OTHER IMPORTANT LEGISLATION

• OPPOSE Expansion of Assistant Physician - OPPOSE HB 2296 (Derges), SUPPORT SB 938 (White) - Medical school trains students to become residents, not physicians. Residency provides graduated responsibility, oversight, and progressive duties to many different patients (chronic and complex conditions), pathologies, practice settings, and undifferentiated signs and symptoms which require critical thinking and differential diagnosis.

• NEUTRAL HB 2004 (Shaul), SB 1002 (Bernskoetter) – With the expansion of telehealth and workforce shortage, we support the need to join the Interstate Medical Licensure Compact based on the Missouri Board for Registration of the Healing Arts oversight and board certification should not be required for physician participation. The MAFP will continue to monitor these bills to ensure appropriate language is utilized.

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2022 National Residency Match Day

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he 2022 National Residency Match Program (NRMP) had the most family medicine positions available in history. NRMP reported that 4,935 family medicine positions were offered which is 91 more than last year.

A total of 4,470 medical students and graduates matched to family medicine residency programs this year. U.S. MD and DO seniors and graduates accounted for 3,232 of those matches.

Results indicated growth in the number of osteopathic medical students (DO) entering family medicine. 1,496 DO seniors matched to family medicine residency programs, which was up 53 matches from last year – a record high.

The number of U.S. MD students matching into family medicine did not increase despite more positions available this year. Only 8.4% of matched U.S. MD seniors matched in family medicine.

The Missouri Academy of Family Physicians is excited to support medical students entering Missouri family medicine residency programs and would like to extend a warm welcome to those coming from out-ofstate schools. Congratulations to all!

Data from nrmp.org and aafp.org.

John Kaschke, MD, a Southern Illinois University School of Medicine Student, matched with the University of Missouri Kansas City’s Family Medicine Residency Program.

Support for Preceptor Workforce Program Bill

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hird time’s a charm…right? We hope so as we are working our ways through the capitol halls and in the hearing rooms supporting MAFP’s preceptor workforce program bill. The measure was introduced in the House (HB 2595-Shields) and Senate (SB 801-Hegeman).

The Preceptor Workforce Program would create a self-funded tax credit for physicians and physician assistants to precept students in a rural area. To be eligible for the tax credit, the physician or physician assistant cannot receive payment from the medical school for precepting. And, for a cumulative 120 hours of precepting, they would be eligible for up to three $1,000 tax credits in one year – which are not applicable to past income due and cannot be carried over to the next tax year. Funding for this tax credit would come from a $7 per license fee increase for physicians and a $3 per license fee increase for physician assistants.

Thanks to strategic efforts by our governmental consultants, Brian and Randy and a little bit of luck, the House and Senate bills were heard on the same day in conjunction with Advocacy Day on February 28.

The champions of this bill came out in full force with several supporters presenting testimony at the House General Laws Committee hearing and the Senate Professional Registration Committee: • John Paulson, DO, PhD, FAAFP, MAFP Board Chair • John Burroughs, MD, MAFP President • Chris Paynter, DO, Missouri Society of the American College of Osteopathic Family Physicians • Genevieve Del Rosario, Assistant Professor, PA Program, Saint Louis University • Jordan Wells, PA Student, Saint Louis University • Kelly Dougherty, Medical Student, University of Missouri Columbia No opposing testimony was presented on this bill. John Paulson, DO, shared that this “Is a recruitment effort because there is no better way to get students into rural Missouri than to have strong preceptors who are going to teach them and educate them to provide quality learning experiences.” John Burroughs, MD, a preceptor, spoke about his experience as a preceptor and wants to have students experience 24

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family medicine outside of the academic setting. Kelly Dougherty, a 4th-year medical student at the University of Missouri Columbia, is in the rural-track pipeline program at the university. As a future rural family physician, she shared a lesson she learned from one of her preceptors that she is “human and not better than any of her patients and that she should always treat them like the people they are.” This is the impact of a preceptor!

Their compelling testimony was heard, and each committee voted out the bills. There is a long way to go, but with the bill working through both chambers simultaneously, it is increasing the possibility of the bill’s passage. This in-person testimony was in addition to many letters of support that were sent to the committee emphasizing the importance of this program to the recruitment of preceptors in rural areas.

Assistant Physician License Limitations

Also, at the Senate Professional Registration Committee hearing, SB 938 (White) was heard to limit the length of time an assistant physician can hold a license. The purpose of this limitation is to allow them sufficient time to match to a residency and to remove the “career path” for a medical student to practice medicine without a residency. The MAFP has a long-standing position opposing the assistant physician mid-level provider, and we support this measure to ensure fully-trained physicians provide care to patients. John Paulson, DO, reviewed the match process with the committee and multiple opportunities that a medical student goes through to match into residency. There are many reasons a medical student doesn’t match including insufficient residency spots, but also the professionalism and academic status of the medical students. Again, there was no opposition testimony presented at this hearing.

Updates to these bills are included in the weekly legislative update reports e-mailed to MAFP members.

2021 Congress of Delegates – Part 2 The AAFP Congress of Delegates (COD) was quite unique for 2021 and presented challenges for the delegation. Because of the ongoing COVID pandemic, your COD speakers in conjunction with the AAFP Board of Directors, made the decision to divide the functions of the Congress into two separate meetings. The first meeting allowed for the election of officers, and the second addressed the resolutions that were to be considered.

This year the MAFP delegation was comprised of Dr. Kate Lichtenberg and Dr. Keith Ratcliff serving as Delegates, and Dr. Peter Koopmann and Dr. Sarah Cole serving as Alternate Delegates. Our MAFP president, Dr. John Paulson, participated with the delegation as well. We chose to meet in person with appropriate precautions to consider the candidates in real-time as the AAFP was providing their virtual presentations. The choice to meet in person served our delegation well. It was much easier to achieve consensus with all relevant voices available in the same room for spirited and lively deliberation, and controversial issues were dealt with directly.

As published in the last issue of the Missouri Family Physician magazine, the first meeting was planned as a virtual event and scheduled for September 27th and 28th. The Congress was charged with completing the election of officers and new Board members at this initial meeting so the AAFP could continue the normal cycle of succession. During this first phase of the 2021 COD, Dr. Ada Stewart of Columbia, South Carolina advanced to Board Chair and Dr. Sterling Ransone of Deltaville, Virginia advanced to President of the AAFP. The Congress elected Dr. Tochi Iroku-Malize of Hempstead, New York as our President-Elect, Dr. Russell Kohl of Stilwell, Kansas as Speaker, and Dr. Daron Gersch of Long Prairie, Minnesota as Vice Speaker. Three new board members were elected, including Dr. Karen Smith of Raeford, North Carolina, Dr. Sarah Nosel of New York City, and Dr. Teresa Lovins of Columbus, Indiana. The Congress also confirmed the appointments of Dr. Samuel Mathis of Galveston, Texas as the New Physician Board Member in addition to Dr. Amanda Stisher from the University of Alabama as the Resident Board Member. Ms. Amy Hoffman from the Penn State College of Medicine was confirmed as Student Member of the Board.

The second portion of the 2021 COD was actually held in 2022.

Planning had been ongoing for an in-person Congress in February.

Still, pandemic circumstances in Kansas City led to the decision by the Speakers to pivot to a virtual platform, including reference committee deliberations. Your MAFP delegation starts the work of the Congress several months prior to the event as resolutions are submitted by the various constituencies, assigned to reference committees, and available for written testimony to be submitted.

We task all MAFP board members by a survey to provide input on the submitted resolutions to consider whether the resolution topic is important to our members and whether we should support the resolution. Our awesome staff of Kathy and Bill produce an analysis that our delegation uses when providing live testimony at reference committee hearings.

With 2020 being the first AAFP experience at a virtual meeting, the Speakers decided last year to limit each constituency to a maximum of two resolutions, but for the 2021 COD no such limit

Read part 1 in the January-March 2022 issue of Missouri Family Physician online at https://www.mo-afp.org/communications/magazine/.

was prescribed. An all-time record of over 80 resolutions were submitted necessitating the convening of additional reference committees to manage the huge volume of work. A wide scope of topics was submitted. Submitted resolutions can be viewed online at https://www.aafp.org/about/congress-delegates/2021/withreferrals.mem.html.

Our MAFP delegation met virtually on January 16th to review the data collected from the MAFP board survey and to plan both written and oral testimony to the reference committees. On January 22nd and 23rd, the AAFP reference committees met via a virtual platform known as LUMI to consider oral testimony on the resolutions.

Though the platform was not ideal, with some pauses and delays during testimony, the work was accomplished. Missouri had the honor of having two members of our delegation chosen to serve on reference committees this year. Dr. Peter Koopman served on one of two Advocacy Reference Committees and Dr. Kate Lichtenberg served on the Reference Committee on Health of the Public and Science. We applaud them for their additional work this year.

Reference committee reports are produced and recommendations are made to the Congress. The recommendation can take several forms, including adopting the resolution, not adopting the resolution, adopting a substitute resolution, or referral to the AAFP Board for further consideration. Any delegate can extract an item from a reference committee report, and in most years that item would be debated on the floor of the Congress until the body reaches consensus. Unfortunately, in a virtual format that debate is difficult to accomplish, and the Speakers decided this year that extracted items would be considered for in person floor debate during the upcoming 2022 COD. A summary of the Actions of the 2021 Virtual Reference Committee Hearings can be found https:// www.aafp.org/about/congress-delegates/2021/rcreports.mem. html. Expect a very full work agenda for the upcoming 2022 COD this fall.

Your MAFP delegation presented two resolutions for consideration at the COD in 2021. Resolution 312 authored by Dr. Peter Koopman advocating for insurance coverage of ambulatory blood pressure monitoring was adopted, and resolution 303 authored by Dr. Josephine Glaser requesting the AAFP develop a tool kit to help with physicians’ rights of conscience was referred to the Board for further consideration.

As your delegation, we feel it is an honor to serve the MAFP, and we attempt to present the opinions of our membership as best we can. We can only know our members’ opinion if you choose to provide it to us. So please, when you receive a survey from Kathy asking for input, do not be shy.

Respectfully; Keith Ratcliff, MD, FAAFP, Delegate Kate Lichtenberg, MD, MPH, FAAFP, Delegate Peter Koopman, MD, FAAFP, Alternate Delegate Sarah Cole, DO, FAAFP, Alternate Delegate MO-AFP.ORG 25

Virtual CME Addresses the Science of Key Family Medicine Topics

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he Missouri Academy of Family Physicians is hosting topic-driven CME nights this Spring. These CME sessions are scientific, focused on specific areas of practice, and designed for attendees to deliver the best care possible for Missourians. Sessions are held the third Thursday of February, March, April, and May from 6-8 PM. With two one-hour sessions per evening, attendees can earn up to 8.0 AAFP Prescribed Credits.

Presenters and attendees engage via Zoom meetings for the convenience of our members. Presenters deliver information live and attendees can ask questions either through a Chat function or verbally throughout the session.

Based on evaluations received from attendees so far, these sessions have met their expectations with format, topic interest, and quality of speakers. These sessions are not available for enduring CME. As of publication, MAFP has held two of the four sessions. Those interested in any of the remaining sessions can access more information and register at https://www.mo-afp.org/cme-events/ spring-cme/.

First Contact: Headache in Primary Care Session, with P. Christopher H. Gottschalk, MD, FAHS, Headache Medicine, Yale School of Medicine, discussed understanding the science of headaches with a focus on migraines. Dr. Gottschalk provided practical information on diagnosis and management of headaches to allow family physicians to provide better care for their patients.

April 21, 2022 – Cancer

Palliative Care for the Patient with Cancer Kevin Craig, MD, Brittany McCarty, DO and Carl Tunink, MD University of Missouri School of Medicine Cancer and Immunotherapy for the Primary Care Physician Shadi Haddadin, MD, CPE, HMDC - Jefferson City Medical Group

May 19, 2022 – Musculoskeletal

Gout for the Family Physician Abhijeet Danve, MD, MHS, FACP - Yale School of Medicine Relative Energy Deficiency Syndrome (REDS) in Female Athletes Christian Verry, MD - Mercy Family Medicine Residency

Bringing Evidence to the End-of-Life: Clinical Pearls for Palliating Symptoms Based on Evidence-Based Research, by John Burroughs, MD, Crossroads Hospice shared data and decades of experience in caring for patients receiving or considering hospice.

(COMPLETED) February 17, 2022 – Neurology

First Contact – Headache in Primary Care P. Christopher H. Gottschalk, MD, FAHS - Headache Medicine, Yale School of Medicine New Developments in Dementia Treatment Joel I. Shenker, MD, PhD - University of Missouri School of Medicine

(COMPLETED) March 17, 2022 – Geriatrics

Bringing Evidence to the End-of-Life: Clinical Pearls for Palliating Symptoms Based on Evidence-Based Research John Burroughs, MD - Crossroads Hospice Reversal of Cognitive Decline: The Science, The Tools, and the Transformation Kenneth Sharlin, MD, MPH, IFMCP - Sharlin Health and Neurology LLC 26

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Reversal of Cognitive Decline: the Science, the Tools, and the Transformation by Kenneth Sharlin, MD, MPH, IFMCP, Sharlin Health and Neurology LLC, explained the neuroscience that causes cognitive decline and provided a multifaceted approach including lifestyle management and pharmacotherapies.

MEMBERS IN THE NEWS

Koopman Selected as AAFP Representative on AFMAC Peter Koopman, MD, FAAFP, was recently selected as the American Academy of Family Physician’s representative on the Academic Family Medicine Advocacy Council (AFMAC) which is a council of family medicine organizations whose aim to address government advocacy issues related to medical education. The term will be for two years.

Congratulations Dr. Koopman!

Nelson Appointed to AAFP Commission on Diversity, Equity and Inclusiveness Colbert Nelson, DO, MPH, was appointed to serve on the newly formed American Academy of Family Physicians (AAFP) Commission Diversity, Equity, and Inclusiveness in Family Medicine (CDEIFM). His term of service began March 23, 2022, and ends December 14, 2023.

This commission will apply diversity, equity, inclusiveness and antiracism lenses to inform and guide the Academy’s recommendations, policies and work addressing disparities in care, health and the workforce.

Congratulations Dr. Nelson!

Stevermer Honored with MU Hickman Teaching Award James Stevermer, MD, FAAFP, won the highest honor in medical education bestowed by the University of Missouri — the Jane Hickman Photo: Michael Hosokawa, EdD and James Stevermer, MD Teaching Award — during the School of Medicine’s annual Education Day. Stevermer is medical director of Callaway Physicians, a residency training site in Fulton, Missouri. He serves as the medical director of the Mid-Missouri Area Health Education Center, which oversees rural training for University of Missouri medical students. He is also vice chair for clinical affairs and professor of clinical family and community medicine at the MU School of Medicine.

“Dr. Stevermer’s academic accomplishments and values resulted in his membership in the U.S. Preventive Service Task Force, a task force of some of the best minds in medicine who determine, study and recommend the current and future practice of medicine,” said senior associate dean of education and faculty development Michael Hosokawa, EdD, the chairman of the Hickman Award committee.

Stevermer also has had a strong influence in the Rural Track program and has been a significant residency faculty member for family medicine residents at the Callaway Family Medicine Clinic in Fulton, Missouri. He was applauded for demonstrating the essence of the Jane Hickman Teaching Award through his commitment to patients, students, residents, fellow physicians and other members of the health care team.

Congratulations Dr. Stevermer!

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MEMBERS IN THE NEWS

Plank Earns CAE Credential The American Society of Association Executives (ASAE) has announced that Bill Plank, Assistant Executive Director of the Missouri Academy of Family Physicians (MAFP) has earned the Certified Association Executive (CAE®) designation.

The CAE is the highest professional credential in the association industry. To be designated as a Certified Association Executive, an applicant must hold a bachelor’s degree, meet stringent organization management work experience guidelines, complete a minimum of 100 hours of specialized professional development, pass a stringent examination in association management, and pledge to uphold a code of ethics. To maintain the certification, individuals must undertake ongoing professional development and activities in association and nonprofit management.

More than 4,000 association professionals currently hold the CAE credential. The CAE Program is accredited by the National Commission for Certifying Agencies (NCCA).

Bill joined the MAFP in February 2020 as the Assistant Executive Director. He is a graduate of William Woods University earning his undergraduate degree in Business Management with an emphasis in Human Resources.

CoxHealth FMR to Expand Partnership with Jordan Valley Community Health Center CoxHealth Family Medicine Residency and Jordan Valley Community Health Center recently announced they are expanding their partnership to add two resident physicians at Jordan Valley this summer. They will now have a total of four resident physicians and two faculty physicians serving patients.

According to CoxHealth Family Medicine Residency, they have plans to add two resident physicians per year for at least the next three years, reaching a total of six.

“This transition provides better access to care for our community and impactful opportunities for our resident physicians,” said Dr. Shelby Hahn, program director of CoxHealth Family Medicine Residency. “Through the expansion of our partnership with Jordan Valley Community Health Center, our staff and resident physicians are able to serve both north and south Springfield with access and service to all who need it.”

Pabst Appointed to AAFP Commission Kathy Pabst, MBA, CAE, has been appointed to serve as a member of the American Academy of Family Physicians’ Federal and State Policy Commission for a three-year term beginning in December, 2021.

The Federal and State Policy Commission is one of seven commissions that direct AAFP policies and programs. This commission informs and guides the Academy’s federal advocacy program and its support for constituent chapters in their advocacy efforts before state governments.

Kathy has led the Missouri Academy of Family Physicians since 2014 as their executive director. She is responsible for the advocacy, education, and member services provided to the membership. Her educational background includes a bachelor of science degree in management and a master’s degree in business administration. She earned her Certified Association Executive credential from the American Society of Association Executives.

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UMKC Student Presented Community Service Champion Award The University of Missouri-Kansas City School of Medicine held its 1st Annual Community Service Awards Ceremony in September to honor UMKC medical students for volunteering in the Kansas City community. Rachel Wright, MS5, was presented the Community Service Champion Award for volunteering over 100 hours in COVID-19 vaccination clinics during 2020 and 2021.

Congratulations to Rachel and her classmates who accomplished this honorable achievement, and thank you for your dedication to serving your communities!

Bruce R. Williams, DO, FACOFP, Elected 2022–23 ACOFP President The American College of Osteopathic Physicians (ACOFP) Board of Governors recently announced Bruce Williams, DO, FACOFP, as the new president for the 2022-23 term. Williams was invested during the ACOFP Congress of Delegates on March 16, 2022 in Dallas, Texas.

Williams is on the faculty for Kansas City University College of Osteopathic Medicine and serves as the university’s associate dean of clinical education. He has practiced osteopathic family medicine for more than 30 years in Eastern Jackson County, Missouri.

“I look forward to advancing osteopathic medicine, “Williams noted. “Our osteopathic philosophy and our techniques are central to who we are, and we need to promote the benefits they provide— not only to our patients, but also to our osteopathic family physician colleagues.”

Congratulations, Dr. Williams!

Richardson Claims First Runner-up in Dr. USA Pageant

Sequita Richardson, MD, FAAFP, was named first runner-up in the Dr. USA pageant, held virtually on September 17, 2021. The competition recognizes the professional achievements of American women who have a Ph.D. degree or higher.

Dr. Richardson is a tireless supporter of education, especially for underrepresented students.

She is a Doctor of Medicine, family practice physician, and partner with Encompass Medical Group. She has spent her career volunteering with organizations like Heart to Heart International as part of breast cancer awareness forums, served as a mentor with the St. Teresa’s Academy, and provided physicals for Convoy of Hope and the YMCA. Dr. Richardson currently holds the title of Dr. Missouri USA 2021 and uses the special designation and platform to promote self-care and wellness. She has reclaimed the Dr. Missouri USA title for another year by winning first runner-up. “I’m excited to continue my work as Dr. Missouri and refine and revamp my virtual series promoting self-care on social media platforms,” she said.

Congratulations to Dr. Richardson!

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References Current Breast Imaging Management: An Introductory Primer — pages 9-10 1.

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American College of Radiology Appropriateness Criteria. https:// www.acr.org/Clinical-Resources/ACR-Appropriateness-Criteria.

Accessed 2/13/22.

Monticciolo D, Newell M, Moy L, et al. Breast Cancer Screening in Women at Higher-Than-Average Risk: Recommendations From the ACR. J Coll Radiol. 2018 March; 15(3): 408-414.

Brentnall A, Cuzick J, Buist D, et al. Long-term Accuracy of Breast Cancer Risk Assessment Combining Classic Risk Factors and Breast Density. JAMA Oncol. 2018 Sept; 4(9): 1-10.

Seely J, Alhassan T. Screening for breast cancer in 2018- what should we be doing today? Curr Oncol. 2018 Jun; 25(Suppl 1): S115-S124.

Vinnicombe S. Breast density: why all the fuss? Clin Radiol. 2018 Apr; 73(4): 334-357.

Nolan I, Kuhner C, Dy G. Demographic and Temporal Trends in Transgender Identities and Gender Confirming Surgery. Transl Androl Urol. 2019 June; 8(3): 184-190.

Brown A, Lourenco A, Niell B, et al. ACR Appropriateness Criteria Transgender Breast Cancer Screening. J Coll Radiol. 2021 Nov; 18(11): S502-S515.

Howlader N, Noone AM, Krapcho M, Miller D, Bishop K, Kosary CL, Yu M, Ruhl J, Tatalovich Z, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). Lifetime Risk (Percent) of Being Diagnosed with Cancer by Site and Race/Ethnicity; Males, 18 SEER Areas, 20122014SEER Cancer Statistics Review, 1975-2014, National Cancer Institute. Bethesda, MD, https://seer.cancer.gov/csr/1975_2014/, based on November 2016 SEER data submission, posted to the SEER web site, April 2017.

Human Papillomavirus: Lung and Oropharyngeal Cancers — pages 11-12 1.

Karnosky J, Dietmaier W, Knuettel H, Freigang V, Koch M, Koll F, Zeman F, Schulz C HPV and lung cancer: A systematic review and meta-analysis. Cancer Reports 2021;4:e1350 https://doi. org/10.1002/cnr2.1350 2. de Martel C, Plummer M, Vignat J, Franceschi S. Worldwide burden of cancer attributable to HPV by site, country and HPPv type. Int J Cancer 2017;141:664-70 https://doi.org/10.1002/ijc.30716 3. Fernandes JV, TAAdM F, JCV DA, RNO C MGF DC, Andrade VS, JMG DA. Link between chronic inflammation and human papillomavirusinduced carcinogenesis. Oncol Lett. 2015;9(3):1015-26 https:// doi.org/10.3892/ol.2015.2884 4. Kakavandi E, Shahbahrami R, Goudazi H, Eslami G, Faghihloo E, Anoikis resistance and oncoviruses. J Cell Biochem. 2017 https:// doi.org/10.1002/jcb.26363 5. Zhai K, Ding J, Shi HZ. HPV and lung cancer risk: A meta-analysis J Clin Virology 63(2015) 84-90 6. Wang J, Fang C, Wang M, Yu MC, Bai KJ, Lu PC, et al. HPV as a marker to predict overall survival in lung adenocarcinoma. In J Cancer 2014: 134:65-71 7. Bray et al. GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018:2018:1-31 8. Hashibe M, et al. Interaction between tobacco and alcohol use and the risk of head and neck cancer: pooled analysis in the international head and neck cancer epidemiology consortium.

Cancer Epidemiol Biomarkers Prev Am Assoc Cancer Res Cosponsored by Am Soc Prev Oncol 2009;18:541-50 9. Kobayashi K, et al. A Review of HPV-related head and neck cancer.

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pharyngeal cancers. J Fam Pract. Jul/Aug 2020;69(6):301-303.

11. Wu et al. HPV positive status is favorable prognostic factor in nonnasopharyngeal head and neck squamous cell carcinoma patients: A retrospective study from the surveillance, epidemiology, and end results database. Oncol. Sept. 2021;11:1-13 https://doi. org/10.3389/fonc.2021.688615 12. Franco, M., Mazzucca, S., Padek, M. et al. Going beyond the individual: how state-level characteristics relate to HPV vaccine rates in the United States. BMC Public Health 19, 246 (2019). https://doi.org/10.1186/s12889-019-6566-y 13. Markowitz L, Dunne E, Saraiya M, Chesson H, Curtis C, Gee J, Bocchini J Jr, Unger E. Human Papillomavirus Vaccination Recommedantions for the Advisiry Committee on Immunization Practices (ACIP). Morb Mortal Wkly Rep. 2014;63(RR05):1-30 14. Centers for Disease Control and Prevention. Human Papillomavirus (HPV) Vaccine. https://www.cancer.gov/about-cancer/causesprevention/risk/infectious-agents/hpv-vaccine-fact-sheet#q8.

Updated May 16, 2018.

Colorectal Cancer Screening: Updated Recommendations from the USPSTF — pages 13-14 1.

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Stoffel EM, Murphy CC. “Epidemiology and Mechanisms of the Increasing Incidence of Colon and Rectal Cancers in Young Adults.” Gastroenterology. 2020;158(2):341-353.

Luong A, Fahmy, M, Wu, B. “Colorectal Cancer Incidence and Demographic Trends in Patients Less Than 50 Years Old In A Large Integrated Healthcare System.” Am J Gastroenterol.

2019;114:S123.

Macrae FA. “Colorectal Cancer: Epidemiology, Risk Factors, and Protective Factors.” In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on February 7, 2022.)

Botteri E, Borroni E, Sloan EK, et al. “Smoking and Colorectal Cancer Risk, Overall and by Molecular Subtypes: A MetaAnalysis.” Am J Gastroenterol. 2020;115(12):1940-1949.

Li H, Boakye D, Chen X, Hoffmeister M, Brenner H. “Association of Body Mass Index With Risk of Early-Onset Colorectal Cancer: Systematic Review and Meta-Analysis.” Am J Gastroenterol.

2021;116(11):2173-2183.

Ali Khan U, Fallah M, Tian Y, et al. “Personal History of Diabetes as Important as Family History of Colorectal Cancer for Risk of Colorectal Cancer: A Nationwide Cohort Study.” Am J Gastroenterol. 2020;115(7):1103-1109.

Grady WM, Markowitz SD. “The molecular pathogenesis of colorectal cancer and its potential application to colorectal cancer screening.” Dig Dis Sci. 2015;60(3):762-772.

Lee MS, Menter DG, Kopetz S. “Right Versus Left Colon Cancer Biology: Integrating the Consensus Molecular Subtypes.” J Natl Compr Canc Netw. 2017;15(3):411-419.

Shaukat A, Kahi C, Burke, C, et al. “ACG Clinical Guideline: Colorectal Cancer Screening 2021.” Am J Gastroenterol. 2021;116:458–479.

Zhang J, Cheng Z, Ma Y, et al. “Effectiveness of screening modalities in colorectal cancer: a network meta-analysis.” Clinical Colorectal Cancer. 2017;16(4), 252-263.

Diebel A, Deng L, Cheng CY, et al. “Evaluating key characteristics of ideal colorectal cancer screening modalities: the microsimulation approach.” Gastrointestinal Endoscopy. 2021;94(2), 379-390.

Final Recommendation Statement. “Colorectal Cancer: Screening.”

U.S. Preventive Services Task Force. May 18, 2021. https://www. uspreventiveservicestaskforce.org/uspstf/recommendation/ colorectal-cancer-screening. (Accessed February 14, 2022).

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