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Interviewer: When you've been out and about, you may have seen it driving or in a parking lot in South Salt Lake, Ogden, Provo, Kearns, Glendale, or maybe some place else in the Salt Lake Valley. And you've always wondered, "What is the Wellness Bus and who can take advantage of this free resource?"

Nancy Ortiz is the mobile health program operations manager, which includes overseeing the University of Utah Wellness Bus. Nancy, let's just start off with what is the Wellness Bus?

Nancy: So the Wellness Bus is a mobile prevention and education clinic that is focused on really making communities healthier. So it's a 39-foot Winnebago that has been outfitted to travel around to different communities and provide free screening services for not only diabetes but other chronic disease.

So when you come to the bus, you can get . . . Everything is no cost. It's free. You can get a simple glucose test, and if your sugar is high, we can also do what's called an A1C test. Additionally, we can test your cholesterol, a whole lipid panel. We test your height, weight, your BMI. We test your waist circumference. And then, additionally, we have a registered dietician that offers free nutritional counseling or coaching on the bus.

Again, all services are free. And we go to the same locations because we want people to come back. We want to help people manage their diabetes or their pre-diabetes, or prevent pre-diabetes or diabetes, or help them with their high blood pressure. So we encourage people to come back and that's why we go to the same locations every week.

Interviewer: And the individuals that come and visit the Wellness Bus, what is the impetus? What inspired them to actually go into this bus, into this situation that they might not be familiar with? What got them there?

Nancy: That's a great question because as we found out, just because you build it or park it there doesn't mean they come inside, right? A lot of people just go walk by out of curiosity, like, "What is that?" But people, they do want to know, and we hope more people want to know. As we say, what are your numbers? What is your glucose? What is your blood pressure? What is your cholesterol? What do those numbers look like? Sometimes they can be a burden.

We don't diagnose on the bus because we don't have medical providers. We work with community health workers. So we say we identify. So the person that does finally make that decision to come into the bus, we do the screenings. And of course, they hope that their health looks pretty good. But in the event that it doesn't look . . . the numbers aren't ideal, we can help them find a provider if they don't have one.

And studies have shown that lots of times, people will not seek care because of the cost. They don't want to burden their family. Money is already tight. So we have services available where we can help people get either free or low-cost medical care. So we are there trying to help the person find affordable resources.

Interviewer: That would be a scary thing, finding out that you have a health condition, and definitely a reason why you just walk on by as opposed to finding out.

Nancy: Exactly.

Interviewer: So it's great that you're connecting people with community to resources that can help in their situation. Tell me about somebody. Walk me through somebody comes in, they find out, "I've got a high fasting glucose. I might have diabetes." You connect them with some resources. What's the journey like after that point?

Nancy: Right. Again, they've gotten this bad news, but we are there to encourage and say, "Through education and lifestyle changes," which is why we have a registered dietician on the bus, "you can really manage it."

We're here to educate you on ways to reduce your sugar levels or you're high cholesterol levels. And we highly encourage you to see a medical provider because it could be that you they need to be on other medication or insulin.

And once you've met with the provider, we encourage you to come back to the bus. We are here, again, for support. And a lot of times, Scot, it's just the social support.

We have an individual. He had diabetes when he came onboard. He comes to the bus pretty much every week. And his glucose levels are improving because I think that social interaction. He knows the people on the bus, like, "Hey, Alex. Hi, Maria. Hi, Veka." That really helps people, I think, pay attention more to their health and make them feel like somebody cares.

We try to make people feel comfortable. We try to break down on the bus as many barriers as possible.

People can come on the bus and remain anonymous if they want. We ask them general information, name, address, a little bit of medical history, but you don't have to fill it out. If people don't want to give their information, and some don't for fear that it's going to come back to them in some bad ways, it's like, "You don't have to give your real name. You don't have to give your address." We don't want that to be a barrier.

We have Spanish speakers on board, so we have that language, but we have an interpretation service that we use that we have access to 240 languages and dialects. We can get someone that speaks their language within a minute on the phone. So we don't want that to be a barrier.

We travel to communities that have high rates of diabetes and chronic disease, trying to make it easier for people to come to the bus. So just trying to break down those barriers of . . .

You asked me previously why someone would or wouldn't come on to the bus. We're just trying to get as close to them as we can and say, "Just please come on board. Let's just have a conversation. Let's look at your blood. It's just a finger prick. We're not doing blood draws out of the arm. It's just a simple prick on the finger."

So it's just about letting you know where you are, again, on the spectrum of good health versus ill health, and that's what we want people to know. We are not there to shame anybody. So, again, we want people to feel comfortable that we're not here to judge you on your weight or how you eat.

Interviewer: It's no reflection of a personal shortcoming at all.

Nancy: It's not. It part, lots of times, it's about education.

Interviewer: What would you say to somebody that might see the Wellness Bus parked some place and they're thinking about coming in but they're not sure?

Nancy: Don't even give it a second thought. Just open the door and come on in. Our staff is so friendly. They're going to make you feel like you're just sitting in your living room while you're getting your finger poked.

I mean, please, don't hesitate to come in. Just find out what your health looks like. Just get a baseline. And if it needs improvement, we can help you make those improvements. And if the numbers look good, that's even better. You can walk out of there feeling, "Hey, I'm even healthier than I thought I was," or, "There are little improvements that I need to make," or, "Wow, I do need to see a doctor or a provider at this point."

But again, we are there to help you on this journey not just today and say, "Oh, this is what your numbers look like," but, "Hey, come back. We are here every week whatever location we're at. We will help you on this journey to better health." So please, hop on board.

So you just had your Pap smear or your mammogram and it wasn't that bad was it? Or your colonoscopy. Okay, it really was that bad, but you didn't remember it. Are you wondering when you can stop doing these tests?

I asked a woman I know, who is in the health and fitness business, when she thought she could stop doing her cancer screening, you know, Paps, mammos, colonoscopy. She said, "Never," with a smile. She never wanted to stop her cancer screening, "It isn't all that bad, and it makes me feel safe," she said. I replied that cancer screening decisions about when and how often is a cost, risk, benefit analysis, and there are some data to inform that decision. She said, "You go with your brain, I go with my heart."

Well, let's go with the brain for a little while, okay? Let's start with Pap smears. The recommendations about Pap smears have been changing as we know more about what mostly causes cervical cancer -- the HPV virus -- and how fast it grows, usually not too fast. Cervical cancer does not increase with age for a lot of reasons. Sexual activity and the number of partners doesn't increase with age. Well, usually. And the cervix in postmenopausal women may not be as receptive to the virus. So there are good reasons to say that when you get to 65, if you've had normal Pap smears for the past 10 years, that means you actually have been having Pap smears in the past 10 years, and you haven't had an abnormal Pap in 20 years, you can stop testing. There's some pretty solid numbers to back this up, and the U.S. Preventive Services Task Force makes that recommendation.

Okay. How about colonoscopy? Well, colon cancer does not decrease with age. But if you don't have any family history of colon cancer and if your previous colonoscopies, that assumes that you've had some, have not shown any polyps or precancerous lesions, you can stop at 75. That's the recommendation of the U.S. Preventive Services Task Force and the American College of Physicians.

Lastly, mammography. Breast cancer does not decrease with age. It increases with age. The aggressiveness of breast cancer is less in older women than it is in younger women. But women still will get treated, which can be aggressive in and of itself. The U.S. Preventive Services Task Force said there's not enough evidence to recommend for or against mammograms at age 75 and older. But about a quarter of deaths from breast cancer each year are attributed to a diagnosis made in women after the age of 74. Women as they get older are less likely to get mammograms. About three-quarters of women 50 to 74 have had a mammogram in the past two years, but only 40% of women over 85. Of course, many women over 85 are in poor health, and mammography is just not on the list of things to do. And clinicians are less likely to recommend mammography if a woman is in poor health. The American Cancer Society suggests women should continue mammograms as long as their overall health is good and they have a life expectancy of at least 10 more years.

Well, how long am I going to live? I went online and Googled, "How long will I live?" There are lots of calculators because insurance companies and pension plans really want to know. Well, I tried a life expectancy calculator that was developed by the University of Pennsylvania and has been mentioned in the mainstream media. It asks sex not gender, age, height, weight, alcohol, smoking, diabetes, marriage status, whether I exercised, ate my veggies. I didn't fudge my weight or height. This calculator said I was going to live till 93 and I had a 75% chance of living to 85.

Another life expectancy calculator from confused.com asked me just a few questions, not my height or weight,or smoking, or alcohol, or diabetes. It did ask my relationship status, and options included happy relationship and married, but these were mutually exclusive. You could only pick one. Well, this one had my life expectancy of 97. And the calculator from Northwest Mutual, a well-respected life insurance company, cranked me out at 98.

Well, I really don't want to hang around the planet all that long. But I really hope that my savings will take me up there, and I'm going to have to have mammograms for a while yet.

Thanks for joining us for the "Seven Domains of Women's Health" on The Scope.

Interviewer: It used to be 50. Now it's 45 and there's a good reason for that. Huntsman Cancer Institute and University of Utah Health says more lives can be saved if men and women who are at average risk of colorectal cancer get screened at 45 instead of 50 years old. Dr. Priyanka Kanth is from Huntsman Cancer Institute. Why the change? What happened?

Dr. Kanth: Over the years since mid-'90s to early 2000, we have noticed an increased risk, increase incidence, and mortality. Actually both. So increased cases and people dying from colorectal cancer. And that was the main reason people started looking into it, researchers started looking into it and came up with this studies, modeling studies. And that's why this recommendation was changed.

Interviewer: Yeah. And the reason that's so important is because unlike other disease that perhaps might show symptoms, and then you would go get treatment. That's not how colorectal cancer presents. It really is screening is the best way to save lives.

Dr. Kanth: Absolutely. You're very right about it. So most of the early onset cancers or any colorectal cancer, early stages do not produce symptoms. Polyp usually starts with a polyp, which is a little bump in the colon and it changes into colon cancer. These polyps do not produce symptoms and they grow slowly, and you will never know you have one. So that's the biggest problem with colorectal cancer. And by the time you have symptoms, it's fairly late. So screening is the best strategy to prevent this cancer.

Interviewer: And this new research has just really shown that people between 45 and 49 because catching it early is the best defense that a lot of good can be done by having it at 45.

Dr. Kanth: Absolutely. Absolutely. There are certain research which has shown that there was a drastic increase even between age 49 and 50. So one study showed that there was an increase of almost 46% between age 49 and 50. So if we decrease it from 50 to 45, we are really hoping to capture that colon cancer patient. And this would be very, very beneficial between that age group.

The other thing I would like to say that this is also an incentive, an added benefit to increase screening from age 50 to 55, 50 to 54. But traditionally, it has been on the lower side if you do it from 50 to 75. There's slightly decreased screening rates in screening uptake between age 50 to 55. So this will help patients who are thinking about it at age 50, but did not get it till age 55. Now they're like, "Oh, you have to get it done at 45, let's get it one at by age 48." Something like that. So this will be very helpful at that point.

Interviewer: Is there a perception that colorectal cancer is an older person's disease?

Dr. Kanth: Yes. I think a lot of us, a lot of our patients in general public we think cancer is an old person's disease, especially colorectal cancer. That's not the case anymore. This is still true. Most colorectal cancer will still be diagnosed when you're older, but there has been a rise in patients who are younger than age 50. Some of it is because of genetic causes, but the rise has been in the average risk. So this perception should be changed. We should consider 45 as new 50 to start screening now.

Interviewer: And really that number, age 45 is the most important number. It's not do I have a family history? It's not do I have symptoms? It's not am I a man or a woman and think I'm less likely to get it. Really as soon as anyone hits that age of average risk of 45, that's the trigger you should go get it checked.

Dr. Kanth: Absolutely. Very correct. So 50 was . . . the same recommendation was for anyone, any gender, male, female. Any person who hits 50, you should get a colonoscopy. Now that has changed to 45. So it doesn't matter if you have symptoms, you should get it checked, especially if you don't have family history. If you have family history, that's a different story. If you don't have family history or average risk, please go get checked at age 45.

Interviewer: How is this going to impact those that do have an increased risk? Not an average risk, an increased risk? Does that also drop their age that they should go in down or do we know?

Dr. Kanth: So, at this point, if you have a family history, we usually start screening early. Most of the time we start screening at age 40. Or if somebody had colon cancer, I'd say whatever age, 10 years before they had colon cancer. So that may not change so much. It's possible we can look at the data and that may change again, but at this point, this recommendation is only for average risk. So family history is a different cohort of patients. That is still a very good point for primary care physician for all of us to ask that history from patients, "Do you have a family history of colon cancer?" Because your risk might be very different from the average risk.

Interviewer: So have that conversation if you're above average risk with your physician, your provider is whether or not you should get it earlier.

Dr. Kanth: Absolutely. Yes.

Interviewer: All right. And for the recommendation, is a colonoscopy okay? The home stool test, is that impacted by this age going down to 45?

Dr. Kanth: The best screening is the one that gets done. So that's another message which has to be delivered by providers. Colonoscopy is not the only screening test. Colonoscopy is gold standard because you can see the polyps you can remove it before it turn into cancer. But there are other very, very good stool tests which can detect colon cancer easily. They are non-invasive, you stay at home, you don't have any logistics around it. And those are good tests to be done. So that's a big message which everyone should know that colonoscopy is not the only way to detect cancer. There are other very good stool tests, which everyone should consider. If you're declining colonoscopy for any reason, do go for a stool test.

Interviewer: So if it's a stool test or if it's the colonoscopy, it doesn't matter. Average risk needs to be 45 now.

Dr. Kanth: Absolutely.

Interviewer: All right. And also, I understand with the new recommendation that Medicare, Medicaid, and also your commercial insurance will cover either one of those screenings starting at 45.

Dr. Kanth: That is correct. And that's what we believe after the new recommendation which has been endorsed by pretty much all the societies that all these should be now covered under preventive care just that how we had it at age 50. Even now, some insurances are already covering at age 45, but that was more sporadic. So now we expect this to be 100% covered.

Dr. Tom Miller: Screening for prostate cancer.

Dr. Blake Hamilton: Oh my.

Dr. Tom Miller: Why the oh my?

Dr. Blake Hamilton: This is a very controversial subject.

Dr. Tom Miller: This is Dr. Tom Miller. We are going to be talking about prostate cancer screening next on The Scope.

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Dr. Tom Miller: Hi, I'm here with Dr. Blake Hamilton. He's the medical director for the urology clinic, and he's also associate director for the division of urology. Let's talk about it. Is prostate cancer screening with P.S.A. testing something that's time has come and gone?

Dr. Blake Hamilton: No, I don't think so. It's a shifting environment to be sure, but I think it still has relevance.

Dr. Tom Miller: You know, the national guidelines, or a couple of the guidelines out there now say that you really don't need to screen men for prostate cancer using the blood test, the P.S.A., prostate specific antigen test. That's based on a couple of large studies, I believe. The outcomes of those studies, one in Europe, one in the United States, didn't back up the idea that using this test could save lives best that the studies showed.

Dr. Blake Hamilton: We have to go back and understand the history of P.S.A. P.S.A. is a protein that's produced by the prostate. It has a role. It has a function. We learned many years ago, three decades ago, that it goes up in prostate cancer, and when you treat prostate cancer it goes down. It became used as a marker for recurrence of treated prostate cancer. It continues to be very reliable. It's one of the best blood markers that we have for cancer.

Dr. Tom Miller: No question. I think we all know that we find more prostate cancer using this test. The question is does it save lives in the long run.

Dr. Blake Hamilton: The two studies that you refer to, depending on how you interpret them, show that there was not enough difference between the group that was screened and the group that was not screened. There are several problems with those studies. One is that they may not be mature enough. They had an average follow up of eight, nine, ten years, and the arms are separating. If we get to 15 years I think we'll see a difference. I think we'll see a clear separation between those two arms. The other problem is there are some methodological problems in how the patients were accrued. It's complicated. I think the real issue is that some people with prostate cancer will suffer immensely and die, and many will not. What we really need to do is do a better job of trying to predict who needs treatment and who doesn't. I think that what's happened over the last couple of decades is when men are diagnosed with prostate cancer based on P.S.A. screening they automatically have gotten treatment. So, in a sense as a community we've over-treated men with prostate cancer.

Dr. Tom Miller: I think part of the concern is also the potential complications of the surgery or the other treatments available for prostate cancer. I mean it's not a benign procedure, and there are outcomes that are difficult for the patient. I think that is coloring the judgment of some of the task force groups that are looking at screening guidelines currently.

Dr. Blake Hamilton: The problem is you still have some 250,000 men who will be diagnosed with prostate cancer this year in the United States. There will be some 35,000 of those who will die from prostate cancer. To say that prostate cancer screening with P.S.A. has come and gone would be throwing the baby out with the bathwater. What we need to do is keep the screening but make better decisions about when to biopsy and when to treat prostate cancer. Already we're seeing a significant decline in the number of men who are being treated, and that's appropriate. But, we've got to keep looking for the ones that are going to be lethal cancers, because they're real.

Dr. Tom Miller: Let's talk practicalities. Are you saying that we should continue to follow the past guidelines which say begin screening in men at the age of 50, and then continue screening every year with P.S.A. testing?

Dr. Blake Hamilton: There are now many alternatives to that.

Dr. Tom Miller: Right.

Dr. Blake Hamilton: One alternative, which comes from the U.S. preventive services task force, is to not screen at all. The American Urological Association has modified their guidelines to suggest that we screen maybe not every year but every two years in men between the ages of 55 and 70 where we think that we'll find the highest yield in the patients for whom it will really matter. Screening in 80 year olds, not important. Screening in the younger generation, not enough data to show evidence that it helps or makes a difference.

Dr. Tom Miller: Younger generation meaning 50 years old and above?

Dr. Blake Hamilton: Less than 55.

Dr. Tom Miller: Less than 55.

Dr. Blake Hamilton: Although there are many researchers who would argue that between 45 and 55 should be included. The guidelines as we have them now would be that those men in that 15 year window, and screening not as intensely as we have in the past, but not to give it up.

Dr. Tom Miller: Let's say that your P.S.A. is elevated. What should the patient do? Should they go then to a urologist who specializes in prostate cancer? A lot of this, as you say, is going to depend on the expertise of the specialist taking care of this type of problem.

Dr. Blake Hamilton: I think most urologists have the ability to evaluate an elevated P.S.A. and make a decision on a biopsy. There continue to be a variety of opinions out there. If you have a single elevation in the P.S.A. I think it's reasonable to wait some time and repeat it and think about what that means.

Dr. Tom Miller: So, screening is something that you believe we should continue. You think it's a good idea.

Dr. Blake Hamilton: Yes, I think we should continue screening but do it judiciously and appropriately, and then think carefully without automatic treatment of those who are diagnosed with prostate cancer.

Dr. Tom Miller: A final thought. What about that time honored rectal exam? Do we still have to do that on patients? It's the brunt of so many jokes.

Dr. Blake Hamilton: Yes, it is. Unfortunately, there are some bad prostate cancers that have low P.S.A.s and are only found on physical examination, so we're going to continue doing that exam, Tom.

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What are the five threats to a woman's health? You might be surprised at what you learn. Today I'll tell you about the five for life, the five most important screenings and tests every woman needs to get and when you should get them.

For a lot of women, their priority is to take care of everyone else; your family, your work, your community, but you neglect taking care of yourself. That's why today I'm going to make it easier by telling you about the five for life. The five most important screenings you need. You should know how you stand on each one of these. Your cholesterol, your pap smear, your mammogram, your colonoscopy and you skin, testing and assessing all these for health is very important and you might be surprised at some of the things you hear.
Screening #1: Cholesterol

Women have always thought that heart disease was a man's disease. But after the age of 70, more women die from heart disease than men. Heart disease is the number one killer of women. And heart disease can be prevented if you control your cholesterol. So you should know what your cholesterol is, it should be tested by the time you're in your 40s and then every five years after that. Preventing high cholesterol or treating high cholesterol can save your heart. So even if you eat right and exercise and do all the things that you know you should do, most of what your cholesterol is doing and why it's doing it comes from your genes. You can do everything right and still have a high cholesterol.
Screening #2: Pap smear

It turns out that pap smears are very cheap, and although women don't like them, very easy to do and no one ever died from a pap smear. Even though you might think you might. Pap smears are, they are to detect cervical cancer. Cervical cancer isn't very common, only about 1 in 100, to 1 in 200 will get it. But it's treatable in its precancerous state and the screening test, a pap smear, picks up cancer before its cancer. So easy test and it's cheap, every woman should get one. Every woman should get one by the time you're 21, and then every couple years, but after you've had 3 normal pap smears you only need to get them every 3 years. Prevent it before it becomes cancer.
Screening #3: Mammogram

Women think that breast cancer is automatically a death sentence and that's not true. Breast cancer, if detected before it's advanced, is very curable and women who have their breast cancers detected by mammography only, no lumps yet, will have a 97% chance of surviving. So if you're going to detect it early you have to get your mammogram. There are controversies about when and how often but suffice it to say that at 50 you should have had a mammogram and then every year to two after that. High risk women, women who have a mom or a sister who've had breast cancer or who've had breast cancer before, should have their mammograms earlier and more often.
Screening #4: Colonoscopy

The Katie Couric test. Did you know that 1 out of 16 women are going to get colon cancer. Now that's actually more common than most people think it would be and colon cancer, like cervical cancer, has a precancerous stage that can be treated before it becomes cancer. So by 50, you should have the colonoscopy. Now it's another test that you don't want to do and it's a private test and it's yucky. However, it's not that bad, they give you some really fun juice to make you not be worried about it and it's much easier than your friends and family have told you.
Screening #5: Skin

Well, you look at your arms and you look at your face, but there are places on your skin that you can't see. And particularly in Utah, where people have been exposed to bright sunlight in the summer, we have more skin cancers as we age. So there are some skin cancers which are very deadly, those dark melanoma skin cancers which should be picked up early. So skin cancer is not a death sentence, in fact, skin cancers are the most common cancers in men and in women, and picked up early they can be removed with minimal surgery, but you have to pick them up, so somebody has to look at your skin and has to look at your skin all over. And that doesn't mean your honey. So your dermatologist should look at your skin.

The most important thing a woman can do about the five for life is, do them. Get a friend, do it together, grab your daughter, grab your mother, spend a day, do them and then go out to lunch, or go out to lunch, oh no, the colonoscopy, you have to get the lunch after the colonoscopy, not before. So get a friend and just make a day of it. Get all five done and then you're done, for at least maybe three years. Once every three years you should take care of yourself, and to do that, you can do the five for life in one half day through University of Utah Health Care, or talk to your doctor about what's appropriate screening for you when you go in for anyone of a number of issues. Say when should I be screened for these five things? The five for life. Your cholesterol, your pap smear, your mammogram, your colonoscopy and your skin screen. The five for life can save your life.

updated: February 7, 2020
originally published: September 25, 2013