A. Health Maintenance: Across the Ages What Not to Do
Conditions for which the USPSTF recommends against routine screening in asymptomatic adults:
Aspirin to prevent myocardial infarction in men aged <45 years
Asymptomatic bacteriuria in men and nonpregnant women
Bacterial vaginosis in asymptomatic pregnant women at low risk for preterm delivery
BRCA-related cancers in women not at increased risk
Cancers: cervix (if hysterectomy), ovary, pancreas, prostate, testicular
Carotid artery stenosis
Chronic obstructive pulmonary disease
Gonorrhea in low-risk men and women
Heart disease in low-risk patients using ECG, electron-beam computed tomography (EBCT)
Routine aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) for primary prevention of colorectal cancer for average risk
Vitamin supplements with β-carotene to prevent cancer and cardiovascular disease (CVD)
B. Health Maintenance: Across the Ages—Insufficient Evidence
Conditions for which the USPSTF found insufficient evidence to promote routine screening in asymptomatic adults at low risk:
Abuse of elderly and vulnerable adults
Cancers: bladder, oral, skin
Chlamydia in men
Clinical breast examination beyond screening mammography, women aged ≥40 years
Diabetes mellitus if blood pressure (BP) <135/80 mmHg
Gestational diabetes mellitus
Peripheral artery disease with the ankle-brachial index
Vitamin supplementation with A, C, E, multivitamins to prevent cancer and heart disease
Vitamin D and calcium supplementation to prevent fractures: men, premenopausal women
C. Health Maintenance: Across the Ages—Aspirin
The role of aspirin in health maintenance and promotion varies according to whether it is used for primary or secondary/tertiary prevention. For the latter, it is generally beneficial (Table 15-3). For primary prevention it is not that simple (Tables 15-4, 15-5, and 15-6). The USPSTF recommends against the routine use of aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent colorectal cancer in persons at average risk for colorectal cancer (grade D recommendation).
Table 15–3.Indications for aspirin (ASA) therapy summary of available guidelines & recent evidence in selected disease states and Concomitant Therapies ||Download (.pdf) Table 15–3.Indications for aspirin (ASA) therapy summary of available guidelines & recent evidence in selected disease states and Concomitant Therapies
|Topic ||Available Guidelines and Recent Evidence |
Diabetes secondary prevention
ADA Diabetes Guidelines 2010
Men > 50 (women > 60) years of age and one of the following: family history of CVD, smoking, hypertension, dyslipidemia, albuminuria
Br Med J. 2009 meta-analysis
No difference in risk of major CV events, CV mortality, or all-cause mortality between ASA and placebo → role of ASA in this population questioned
Decreased risk of MI in men, but not in women (significant study heterogeneity)
Heart failure secondary prevention
ACC/AHA Update to Heart Failure Guidelines 2009
No recommendation at this time, due to controversial evidence
Aspirin may negate the positive effect of angiotensin-converting enzyme (ACE) inhibitor therapy
Dual therapy (ASA + warfarin) secondary prevention
ACCP Antithrombotic and Thrombolytic Therapy Guidelines 2008
Patients with mechanical heart valves
And a history of coronary artery disease, peripheral arterial disease, or other risk factors for atherosclerotic disease (1B)
Who have additional risk factors for thromboembolism: atrial fibrillation, hypercoagulable state, or low ejection fraction (1B)
Consider if bioprosthetic heart valves and additional risk factors for thromboembolism (2C)
Particularly in patients with a history of atherosclerotic disease.
Following clopidogrel discontinuation in patients on triple therapy.
No dual therapy if at high risk for bleeding history of GI bleed or age > 80 (2C)
Dual antiplatelet therapy (ASA + clopidogrel) secondary and tertiary prevention
ACCP Antithrombotic and Thrombolytic Therapy Guidelines 2008: primary prevention
Recommend against routine use of aspirin and clopidogrel (1A)
ACCP Antithrombotic and Thrombolytic Therapy Guidelines 2008: secondary prevention
NSTE ACS: clopidogrel × 12 months (1A)
Symptomatic coronary artery disease (2B)
PCI with bare-metal stent: clopidogrel × 12 months (1A)
PCI with drug-eluting stent: clopidogrel × 12 months (1B)
Indefinitely if low risk of bleeding and combination tolerable (2C)
Triple therapy (ASA + clopidogrel + warfarin) tertiary prevention
ACCP Antithrombotic and Thrombolytic Therapy Guidelines 2008
PCI with bare-metal stent and strong indication for warfarin: clopidogrel × 4 weeks (2C)
PCI with drug-eluting stent and strong indication for warfarin: clopidogrel × 12 months (2C)
Consider warfarin INR goal of 2.0–2.5
Grades of Recommendation
|1A ||1B ||1C ||2A ||2B ||2C |
|Definition ||Strong recommendation, high-quality evidence ||Strong recommendation, moderate-quality evidence ||Strong recommendation, low- or very-low-quality evidence ||Weak recommendation, high-quality evidence ||Weak recommendation, moderate-quality evidence ||Weak recommendation, Low- or very-low-quality evidence |
Table 15–4.Evidence for use of aspirin for primary prevention of cardiovascular events and associated increased risk of adverse events in men versus women. ||Download (.pdf) Table 15–4.Evidence for use of aspirin for primary prevention of cardiovascular events and associated increased risk of adverse events in men versus women.
|Prevention Outcome & Increased Risk ||Men ||Women |
|Cardiovascular events ||✓ ||✓ |
|Myocardial infarctions ||✓ || |
|Ischemic stroke || ||✓ |
|Cardiovascular mortality or all-cause mortality || || |
|Hemorrhagic stroke ||✓ || |
|Gastrointestinal bleeding ||✓ ||✓ |
Table 15–5.When to use aspirin for primary prevention of MI (men) and stroke (women) per age and 10-year Framingham risk for event. ||Download (.pdf) Table 15–5.When to use aspirin for primary prevention of MI (men) and stroke (women) per age and 10-year Framingham risk for event.
|Men (years) ||10-year MI risk ||< 45 ||45–59 ||60–69 ||70–79 ||> 80 ||Risk:benefit consideration for patients with GI risk |
|Women (years) ||10-year stroke risk ||<55 ||55–59 ||60–69 ||70–79 ||> 80 |
|Framingham Score ||4–8% || ||✓ || || ||Evidence lacking ||GI risk > benefit |
|3–7% || || || || || || |
|9–11% || ||✓ ||✓ || ||Evidence lacking ||GI risk = benefit |
|8–10% || || || || || || |
|>12% || ||✓ ||✓ ||✓ ||Evidence lacking ||GI risk < benefit |
|>11% || || || || || || |
Table 15–6.When to add proton pump inhibitor therapy to ASA. ||Download (.pdf) Table 15–6.When to add proton pump inhibitor therapy to ASA.
|Aspirin Therapy: Proton pump inhibitor therapy recommended based on gastrointestinal risk factors |
|One of the following ||Two of the following |
|Concomitant other NSAID use ||Age >60 years |
|History of ulcer complication ||Corticosteroid steroid use |
|History of ulcer disease ||Dyspepsia |
|Concomitant antiplatelets ||Gastroesophageal reflux disease symptoms |
|Concomitant anticoagulants || |
|History of gastrointestinal bleeding || |
D. Health Maintenance: Ages 18–39
Table 15-7 summarizes USPSTF grade A and grade B screening and counseling recommendations for average-risk 18–39-year-olds. Below the screening tests in focus are as follows: hypertension, cervical cancer, Chlamydia, lipid disorders, depression, tobacco, and specific screening for those at increased risk.
Table 15–7.Health promotion & preventive screening for adults aged 18–39. ||Download (.pdf) Table 15–7.Health promotion & preventive screening for adults aged 18–39.
|Grade ||Recommended Health Promotion or Screening |
|A ||Asymptomatic bacteriuria: screen—pregnant women |
|A ||Chlamydia: Screen—Women Ages 24 and Younger OR Women Ages 25 and Older at Increased Risk |
|A ||Folic acid: Supplementation—all women planning or capable of pregnancy |
|A ||HIV: Screening—age 15–65 once, more frequently for high-risk people |
|A ||HIV: Screen—pregnant women |
|A ||Hepatitis B virus: Screen—pregnant women |
|A ||High Blood Pressure: Screen—Adults 18 and Over |
|A ||Lipid disorders in adults: Screen—men aged ≥35 years |
|A ||Rh(D) blood typing: Screen—pregnant women, first pregnancy-related visit |
|A ||Syphilis: Screen—pregnant women |
|A ||Syphilis: Screen—men and women at increased risk |
|A ||Tobacco use: Counsel and interventions for adults |
|A ||Tobacco use: Counsel and interventions for pregnant women |
|B ||Alcohol misuse: Screen and behavior counseling interventions in primary care—adults |
|B ||BRCA-related cancer: Risk assessment, genetic counseling, and genetic testing—women at increased risk |
|B ||Breastfeeding: Primary care interventions to promote—all pregnant women and new mothers |
|B ||Chlamydia: Screen—pregnant women aged ≤24 years or pregnant women aged ≥25 years who are at increased risk |
|B ||Depression: Screen—adolescents, aged 12–18 years, in clinical practices with systems of care |
|B ||Depression: Screen—adults aged ≥18 years—when staff-assisted depression care supports are in place |
|B ||Gonorrhea: Screening—pregnant women and women at increased risk |
|B ||Healthy diet: Counsel—adult with hyperlipidemia and other risk factors for CVD |
|B ||Hepatitis C virus infection: Screen—adults at high risk and adults born between 1945 and 1965 |
|B ||Intimate-partner violence: Screen—women of childbearing age |
|B ||Iron-deficiency anemia: Screen—asymptomatic pregnant women |
|B ||Obesity: Screen for and management of—all adults |
|B ||Rh(D) blood typing: Screen—antibody testing unsensitized Rh(D-negative pregnant women |
|B ||Sexually transmitted infections: Behavioral counseling—sexually active adolescents and adults at increased risk |
|B ||Skin cancer: Behavioral counseling—persons aged 10–24 years |
|B ||Type 2 diabetes mellitus: Screen men and women with sustained blood pressure >135/80 mmHg |
Hypertension is the most common condition seen in family medicine. It contributes to many adverse health outcomes, including premature deaths, heart attacks, renal insufficiency, and stroke. Blood pressure measurement identifies individuals at increased risk for cardiovascular disease. Treatment of hypertension decreases the incidence of cardiovascular disease events.
Hypertension is defined as elevated blood pressure, either systolic blood pressure (SBP) or diastolic blood pressure (DBP), on at least two separate occasions separated by one to several weeks. In persons
18–60 years of age—elevation is either a SBP of ≥140 mmHg or a DBP of ≥90 mmHg.
≥60 years of age—elevation is either a SBP of ≥150 mmHg or a DBP of ≥90 mmHg.
≥18 years of age with chronic kidney disease—defined as an estimated or measured glomerular filtration rate of <60 mL/min per 1.73 m2 in individuals aged <70 years–elevation is either a SBP of ≥140 mmHg or a DBP of ≥90 mmHg.
Of any age with albuminuria (>30 mg of albumin/g of creatinine)—elevation is either a SBP of ≥140 mmHg or a DBP of ≥90 mmHg.
The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC8) recommends screening every 2 years in persons with blood pressure of <120/80 mmHg and every year with systolic blood pressure of 120–139 mmHg or diastolic blood pressure of 80–90 mmHg. The American Heart Association (AHA) has issued similar recommendations beginning at age 20.
Hypertension should be treated. Treatment is addressed in Chapter 35.
Cervical cancer screening is discussed in detail in Chapter 27.
The USPSTF recommends screening for Chlamydia infection in all sexually active women aged ≤24 years, or women aged ≥25 years at increased risk. The optimal screening interval for nonpregnant women is unknown. The CDC recommends at least annual screening for women at increased risk. Chlamydia trachomatis infection is the most common sexually transmitted bacterial infection in the United States. In women, genital infection may result in urethritis, cervicitis, pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and chronic pelvic pain. Infection during pregnancy is related to adverse pregnancy outcomes, including miscarriage, premature rupture of membranes, preterm labor, low birth weight, and infant mortality. The benefits of screening and subsequent treatment in high-risk pregnant and nonpregnant individuals are substantial.
The USPSTF identified no evidence of the benefits of screening women who are not at increased risk for Chlamydia infection. In this low-risk population it is moderately certain that the benefits outweigh the risks of screening to only a small degree. Nucleic acid amplification tests (NAATs) for Chlamydia have high specificity and sensitivity as screening tests and may be used with either urine or vaginal swabs.
Screening of pregnant women for Chlamydia infection is recommended for all women at the first prenatal visit. For those who remain at increased risk or acquire a new risk factor, such as a new sexual partner, screening should be repeated during the third trimester.
Men aged >35 years should be screened for lipid disorders. This age may be reduced to 20 if there is an increased risk for coronary heart disease. Screening for women does not need to start until age 45.
The optimal interval for screening is uncertain. Reasonable options include every 5 years, with shorter intervals for those with risk factors (eg, diabetes mellitus) or lipid levels close to those warranting therapy.
High levels of total cholesterol (TC) and low-density lipoprotein-cholesterol (LDL-C) and low levels of high- density lipoprotein–cholesterol (HDL-C) are independent risk factors for coronary heart disease. The risk is highest in those with a combination of risk factors. Therefore, a careful review of the complete risk factor profile is necessary to assess the benefit of screening and subsequent lowering of high cholesterol levels with medications. (Please see Chapter 37 for a full discussion of lipid disorders.)
Depression is common and a leading cause of disability in both adolescents and adults. Screening for depression improves the accurate identification of depressed patients in primary care settings. The USPSTF concluded that the net benefit of screening adults for depression is higher (moderate) when staff-assisted depression care supports are in place to ensure accurate diagnosis, effective treatment, and follow-up. In the absence of such care supports, the net benefit may be small. Numerous formal screening tools are available, but there is insufficient evidence to recommend one tool over another. All positive screens should trigger a full diagnostic interview.
6. Tobacco use counseling
Cessation of tobacco use may be the single most important lifestyle intervention for the maintenance and improvement of health. All adults should be assessed for tobacco use and tobacco cessation interventions provided for those who use tobacco products. Tobacco use, cigarette smoking in particular, is the leading cause of preventable death in the United States, resulting in >400,000 deaths annually from cardiovascular disease, respiratory disease, and cancer. Smoking during pregnancy results in the deaths of approximately 1000 infants annually and is associated with an increased risk for premature birth and intrauterine growth retardation. Environmental tobacco smoke may contribute to death in ≤38,000 people annually.
Cessation of tobacco use is associated with a corresponding reduction in the risk of heart disease, stroke, and lung disease. Tobacco cessation at any point during pregnancy yields substantial health benefits for the expectant mother and fetus.
Smoking cessation interventions, including brief (<10 minutes) behavioral counseling sessions and pharmacotherapy delivered in primary care settings, are effective in increasing the proportion of smokers who successfully quit and remain abstinent for 1 year. Even minimal counseling interventions (<3 minutes) are associated with improved smoking cessation rates. One of several screening strategies aimed at engaging patients in smoking cessation discussions is the “5A” behavioral counseling framework:
Ask about tobacco use.
Advise to quit through clear personalized messages.
Assess willingness to quit.
Assist to quit.
Arrange follow-up and support.
7. Screening and counseling specifically for persons aged 18–39 years at increased risk
HIV—screen once for all persons aged 15–65 years, more for those at increased risk (A).
Syphilis—screen for men and women at increased risk (A).
BRCA mutation testing for breast and ovarian cancer (B).
Gonorrhea—screen women who are pregnant or at increased risk (B).
Healthy diet—screen adults with hyperlipidemia and other risk factors for coronary heart disease (CHD) (B).
Intimate-partner violence—screen women of childbearing age (B).
Sexually transmitted infections—provide behavioral counseling for sexually active adolescents and adults at increased risk (B).
Skin cancer—provide behavioral counseling for children, adolescents, and young adults aged 18–24 years (B).
Type 2 diabetes mellitus—screen men and women with sustained blood pressure of ≥135/80 mmHg (B).
Lipid disorders in adults—screen women aged 20–44 and men aged 20-34 years at increased risk for CHD (B).
E. Health Maintenance: Ages 40–49 with Emphasis on Breast Cancer and Lipid Screening
Tables 15-8, 15-9, and 15-10 summarize USPSTF recommendations for average-risk 40–49-year-olds.
Table 15–8.Health promotion & preventive screening for adults aged 40–49. ||Download (.pdf) Table 15–8.Health promotion & preventive screening for adults aged 40–49.
|Intervention ||Target Group,a Screening Intervalb ||Grade ||Recommendation |
|Aspirin to prevent CVDc || ||A ||Aspirin daily when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage |
blood pressure (BP)
|Every 1–2 years depending on BP ||A ||Screen every 2 years in persons with BP <120/80 mmHg and every year in persons with BP 120-130/80-90 mmHg |
Men > 35, Q5y
Women > 45 if risk for CHD, every 5 years
|A ||For women, the risk factors include diabetes, previous personal history of CHD or non-coronary atherosclerosis, a family history of cardiovascular disease before 50 in males and 60 in females, tobacco, hypertension, obesity (BMI >30) |
|Pap smear ||Every 1–3 years ||A ||Screen for cervical cancer in women who have been sexually active and have a cervix |
|HIV ||If high risk ||A ||Risks include men having sex with men, unprotected sex with multiple partners, injection drug use, sex worker, history of sex with partners who are HIV+, bisexual, or injection drug users, history of STI, transfusion between 1978 and 1985 |
|Syphilis ||If high risk ||A ||Risks include men who have sex with men and engage in high risk sexual behavior, commercial sex workers, persons who exchange sex for drugs, and those in adult correctional facilities |
|Chlamydia ||If high risk ||A ||Risks factors include a history of Chlamydia or other STI, new or multiple sexual partners, inconsistent condom use, and exchanging sex for money or drugs |
| ||A ||Ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products |
|Against routine screening in normal-risk women aged 40–49 years ||C ||Offer mammography to an individual patient if she is at higher risk of breast cancer (http://www.cancer.gov/bcrisktool/), then screen biennially |
|Diabetes Mellitus Type 2 ||All with sustained blood pressure >135/80 mmHg ||B ||Screen asymptomatic adults with sustained blood pressure greater than 135/80 mmHg. |
| ||B ||Clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults |
|Alcohol misuse || ||B ||Screen for risky or hazardous drinking and provide behavioral counseling interventions to reduce alcohol misuse by adults |
|Depression ||If there are systems in place to ensure accurate diagnosis, effective treatment, and follow-up ||B ||Screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow up |
|STI ||If high risk ||B ||Screen adults with STI in past year or multiple current sexual partners |
Table 15–9.Insufficient evidence for clinical breast examinations and breast self-examinations. ||Download (.pdf) Table 15–9.Insufficient evidence for clinical breast examinations and breast self-examinations.
|Intervention ||Target Group ||Grade ||Recommendation |
|Clinical breast exam ||Women ||I ||Could not determine benefits of CBE alone or the incremental benefit of adding CBE to mammography |
|Breast self-exam ||Women ||D ||Against teaching breast self-examination (BSE) |
Table 15–10.USPSTF (2009) breast cancer screening recommendations in women using film mammography. ||Download (.pdf) Table 15–10.USPSTF (2009) breast cancer screening recommendations in women using film mammography.
|Population ||Ages 40–49 Years ||Ages 50–74 Years ||Ages ≥75 Years |
|Recommendation ||Do not screen routinely. Individualize decision to begin biennial screening according to the patient’s context, risk and values. ||Screen every 2 years ||No recommendation |
| ||Grade: C ||Grade: B ||Grade: I (insufficient evidence) |
|Risk assessment ||Recommendation applies to women aged ≥40 years not at increased risk by virtue of a known genetic mutation or history of chest radiation. Increasing age is the most important risk factor for most women. || |
|Screening tests ||Standardization of film mammography has led to improved quality. Refer patients to facilities certified under the Mammography Quality Standards Act (MQSA). || |
|Timing of screening ||Evidence indicates that biennial screening is optimal. This preserves most of the benefit of annual screening and cuts the risk nearly in half. A longer interval may reduce the benefit. || |
|Benefit/riskbalance || |
There is convincing evidence that screening with film mammography reduces breast cancer mortality, with a greater absolute reduction for women aged 50–74 years than for younger women.
Harms (risks) of screening include psychological risks, additional medical visits, imaging, and biopsies in women without cancer, inconvenience due to false-positive screening results, risks of unnecessary treatment, and radiation exposure. Risks seem moderate for each age group.
False-positive results are a greater concern for younger women; treatment of cancer that would not become clinically apparent during a woman’s life (overdiagnosis) is an increasing problem as women age.
|Nothing specific recommended (grade I) || ||Among women aged ≥75 years, evidence of benefit is lacking. |
Please see Tables 15-9 and 15-10 and Chapter 27 for discussion of screening for breast cancer.
All women aged ≥45 years should be screened for lipid disorders. Women aged 20–44 years should be screened if they are at increased risk for coronary heart disease (CHD). Increased risk, for this recommendation, is defined by the presence of any of the following risk factors: diabetes, previous personal history of CHD or noncoronary atherosclerosis (eg, abdominal aorta aneurysm, peripheral artery disease, carotid artery stenosis), a family history of cardiovascular disease before age 50 years in male relatives or age 60 years in female relatives, tobacco use, hypertension, obesity (BMI >30). (Further discussion of dyslipidemia is found in section on health maintenance for ages 18–39 years (above) and in Chapter XX.)
F. Health Maintenance: Ages 50–59
Table 15-11 summarizes USPSTF recommendations for average-risk 50–59-year-olds, with major changes in recommendations for prostate and lung cancer screening.
Table 15–11.Health promotion & preventive screening for adults aged 50–59. ||Download (.pdf) Table 15–11.Health promotion & preventive screening for adults aged 50–59.
|USPSTF Grade ||Recommended Health Promotion or Screening |
|Aa ||Aspirin to prevent CVD in men: Ages 45–79 years to reduce risk of MI when potential benefit outweighs potential harm of an increase in GI hemorrhage |
|Aa ||Aspirin to prevent CVD in women: Ages 55–79 years to reduce risk of ischemic strokes when potential benefit outweighs potential harm of an increase in GI hemorrhage |
|Aa ||Cervical cancer: Screen sexually active women aged ≤21 years Q3y as long as normal |
|Aa ||Chlamydia: Screen women aged ≤24 years or women aged ≥25 years who at increased risk |
|A ||Colorectal cancer: Screen adults aged 50–75 years |
|A ||HIV: Screen adults and adolescents aged 15-65 years once, more frequently for those with high-risk behaviors |
|A ||High blood pressure: Screen adults aged ≥18 years |
|A ||Lipid disorders in adults: Screen men aged ≥35 years |
|A ||Lipid disorders in adults: Screen women ≥45, increased risk for CHD |
|A ||Syphilis: Screen men and women at increased risk |
|Aa ||Tobacco use: Counseling and interventions for adults |
|B ||Alcohol misuse: Screening and behavioral counseling |
|B ||BRCA mutation testing for breast and ovarian cancer: Women, increased risk |
|B ||Breast cancer: Preventive medication discussion—women, increased risk |
|Ba ||Breast cancer: Screening with mammography for women 50–74 years |
|Ba ||Depression: Screen adults aged ≥18 years when staff-assisted depression care supports are in place |
|B ||Gonorrhea: Screen pregnant women and women at increased risk |
|B ||Healthy diet: Counsel adults with hyperlipidemia and other risk factors for CVD |
|B ||Lung cancer: Annual screening for lung cancer with low-dose computed tomography in adults ages 55–80 years who have a 30-pack/yr smoking history and currently smoke or have quit within the past 15 years; screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to undergo curative lung surgery |
|B ||Obesity: Screening and intensive counseling for obese men and women |
|B ||Sexually transmitted infections: Behavioral counseling for sexually active adolescents and adults at increased risk |
|B ||Type 2 diabetes mellitus: Screen men and women if sustained BP ≥135/80 mmHg |
|Da ||Prostate cancer screening |
1. Colorectal cancer screening
This should occur from age 50 to 75 years using a variety of tests, as follows:
Sensitivity—Hemoccult II < fecal immunochemical tests < Hemoccult SENSA ≈ flexible sigmoidoscopy < colonoscopy
Specificity—Hemoccult SENSA < fecal immunochemical tests ≈ Hemoccult II < flexible sigmoidoscopy = colonoscopy
Screening with fecal occult blood testing, sigmoidoscopy, or colonoscopy reduces mortality, assuming 100% adherence to any of these regimens: (1) annual high-sensitivity fecal occult blood testing, (2) sigmoidoscopy every 5 years combined with high-sensitivity fecal occult blood testing every 3 years, or (3) screening colonoscopy at intervals of 10 years. Evidence is insufficient regarding screening with fecal DNA or CT colonography.
For a more complete discussion of colorectal cancer screening, see Chapter XX.
Screen every 2 years if blood pressure is <120/80 mmHg and every year with systolic blood pressure of 120–139 mmHg or diastolic blood pressure of 80–90 mmHg.
Benefits must outweigh risks. See earlier discussion of acetylsalicylic acid (ASA) and Tables 15-3, 15-4, 15-5, and 15-6. Aspirin should not be initiated to prevent stroke in women aged <55 years of age. Aspirin should not be used to prevent colorectal cancer in persons at average risk for colorectal cancer.
4. Prostate cancer screening (USPSTF recommendation D)
As discussed earlier, an effective screening test should detect disease early, and early treatment should improve morbidity and mortality. There is no conclusive evidence that treatment of prostate cancers detected by screening improves outcomes. Recognition of the fact that most men with prostate cancer do not die and the limitations of currently available prostate screening tests has led to fluidity regarding the best prostate screening practices. As new data become available, the guidelines from major organizations seem to be increasingly similar with some nuances.
The USPSTF recommends against prostate cancer screening (recommendation D), based on their conclusion of the current evidence that there is very small potential benefit and significant potential risk from screening. The American Academy of Family Physicians (AAFP) supports the USPSTF guidelines.
The American Cancer Society (ACS) recommends that men make an informed decision with their physicians as to whether they should be tested for prostate cancer. Starting at age 50 years, men should discuss the pros and cons of testing with a physician. If they are African American or have a father or brother who had prostate cancer before age 65, men should discuss testing with a physician starting at age 45. If men decide to be tested, they should opt for the prostate-specific antigen (PSA) blood test with or without a rectal exam. How often they are tested will depend on their PSA level.
The American Urologic Association (AUA) guidelines are as follows:
PSA screening in men under age 40 years is not recommended.
Routine screening in men aged 40–54 years at average risk is not recommended.
For men aged 55–69 years, the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1000 men screened over a decade against the known potential risks associated with screening and treatment. For this reason, shared decision making is recommended for men aged 55–69 years who are considering PSA screening, and proceeding according to patients’ values and preferences.
To reduce the harms of screening, a routine screening interval of ≥2 years may be preferred over annual screening in those men who have participated in shared decision making and decided on screening. As compared to annual screening, it is expected that 2-year screening intervals will preserve most of the benefits and reduce the risk of overdiagnosis and false positives.
Routine PSA screening is not recommended in men over age 70 or any man with a <10–15-year life expectancy.
The reasons for these changes away from the prior recommendations to screen are based on new, large, long-running studies. Also, epidemiologic data factor in as well. Prostate cancer is the most common nondermatologic cancer in US males. If they live to be 90 years old, one out of six US males will be diagnosed with prostate cancer. Risk factors for development of prostate cancer include advanced age, family history, and race. Nearly 70% of prostate cancer diagnoses occur in men aged ≥65 years. The risk of developing prostate cancer is nearly 2.5 times greater in men with a family history of prostate cancer in a first-degree relative. Rates of prostate cancer occurrence are lower in Asian and Hispanic males than in non-Hispanic Caucasian males. African-American men are at twice the risk of white men. While US men have an approximately 16% lifetime risk of being diagnosed with prostate cancer, they have only ~3% risk of dying from it.
Digital rectal examination (DRE) and prostate-specific antigen (PSA) testing are the most commonly used prostate cancer screening tools. Physician-performed DRE is limited in that it allows only a portion of the prostate gland to be palpated and has poor interrater reliability. Sensitivity of DRE is low (53–59%), and positive predictive value (PPV) is only 18–28%. The PPV of PSA for prostate cancer screening is similarly low, at ~30%. Proposed prostate cancer screening methods include using PSA cutoff of 4 ng/mL, measuring PSA velocity, and percent free PSA. No currently available data demonstrates a mortality benefit with any of these. Whether DRE adds value to PSA screening is debatable, if not doubtful. DRE should not be used as a standalone test to screen for prostate cancer.
Both DRE and PSA screening can lead to detection of clinically insignificant prostate cancers, exposing patients to undue psychological distress and potentially harmful procedures and treatments, such as biopsy and radical prostatectomy. Unfortunately, DRE and PSA screening can also miss aggressive prostate cancers.
The USPSTF assigns a B recommendation to annual screening for lung cancer with low-dose computed tomography in adults aged 55–80 years who have a 30-pack/yr smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to undergo curative lung surgery. This has been a controversial recommendation because of concerns about radiation exposure (high false positive findings on initial screen leading to more CT scanning; the 25-year recommendation is based on studies of 3 years of screening), cost-benefit concerns, and the unsure role of screening in people who continue to smoke (eg, whether a negative screen will impede the desire to quit, whether a false-positive screen will result in increased quit rates). The AAFP has not endorsed this recommendation. Like all USPSTF recommendations, it will be reevaluated as new data emerge.
G. Health Maintenance: Ages 60–74
Table 15-12 summarizes USPSTF recommendations for average-risk 60–74-year-olds.
Table 15–12.Health promotion and preventive screening for adults aged 60–74. ||Download (.pdf) Table 15–12.Health promotion and preventive screening for adults aged 60–74.
|Group ||Recommendations |
Pap smear: At least every 3 years (A)
Mammogram: Every 1–2 years (B)
Colorectal cancer: Screeninga (A)
Osteoporosis screening: All women aged ≥65 years and high-risk women starting at age 60: screen using DEXA or bone densitometry testing (B)
Weight and BMI: Screen for obesity using BMI (body mass index) (B)
Blood pressure: Annually for all adults (A)
Tobacco: Counsel about quitting (A)
Alcohol: Counsel to reduce alcohol misuse (B)
Aspirin chemoprevention: Postmenopausal women and all with increased coronary heart disease risk (A)
Cholesterol: Test every 5 years (A)
Abdominal aortic aneurysm (AAA): Ultrasound once in men who have ever smoked (B,C)
Colorectal cancer: Screeninga (A)
Weight and BMI: Screen for obesity using BMI (body mass index) (B)
Blood pressure: Annually for all adults(A)
Tobacco: Counsel about quitting (A)
Alcohol: Counsel to reduce alcohol misuse (B)
Screening tests in focus: Abdominal aortic aneurysm (AAA) and osteoporosis.
1. Screening for abdominal aortic aneurysm (AAA), men only:
One-time screening for AAA by ultrasonography in men aged 65–75 who have ever smoked (B).
No recommendation for or against screening for AAA in men aged 65–75 years who have never smoked (C).
Against routine screening for AAA in women (D), due to false-positive rate and lower prevalence of AAA.
2. Screening for osteoporosis in postmenopausal women:
All women aged ≥65 years should be screened routinely for osteoporosis (B).
Women at increased risk1 for osteoporotic fractures should begin screening at age 60 (B).
No recommendation for or against routine osteoporosis screening in postmenopausal women aged <60 or in women aged 60–64 years who are not at increased risk for osteoporotic fractures (C).
Screening should occur every 3 years even if treatment is initiated.
Osteoporosis Risk Assessment Tools
JV Can Med Assoc J. 2000;162(9):1289–1294.
H. Health Maintenance: Age ≥75
Perhaps the most important aspect of health maintenance in people aged ≥75 years is lifestyle. HM recommendations for this age group are summarized in Table 15-13 and discussed below.
Table 15–13.Health promotion & preventive screening for adults aged ≥75 years. ||Download (.pdf) Table 15–13.Health promotion & preventive screening for adults aged ≥75 years.
|Condition ||USPSTF Recommendations (Grade) ||Alternate Recommendations from Other Organizations |
|Tobacco abuse ||Recommended (A) || |
|Alcohol misuse ||Recommended (A) || |
|Nutrition screening and counseling ||Recommended (B)—for patients with risk factors for cardiovascular disease || |
|Hypertension ||Recommended (A) || |
|Hyperlipidemia ||Recommended (A) || |
|Aspirin for prevention of cardiovascular disease ||Recommended (A)—in men aged ≤79 years || |
|Aspirin for prevention of ischemic stroke ||Recommended (A)—in women aged ≤79 years || |
|Diabetes ||Recommended (B) for BP ≥135/80 mmHg || |
|Obesity ||Recommended (B) || |
|Depression ||Recommended (B)—if supportive care available || |
|Falls ||Recommended (B)—use of exercise, physical therapy, vitamin D supplementation if high risk, community-dwelling ||AGS: All older adults should be screened for falls within the last year |
|Colon cancer ||Not recommended routinely (C),—consider in select patients aged 75–85 years; recommendation against (D) ages >85 ||ACG: Indefinite screening after age 50 |
|Prostate cancer ||Recommendation against (D)—PSA ||AUAa, ACS: DRE and PSA annually for men aged ≥50 years with life expectancy ≥10 years |
|Breast cancer ||Neither for nor against (I) ||AGS: mammogram every 3 years for adults aged ≥75 years if life expectancy ≥4 yearsa |
|Cervical cancer ||Recommendation Aaainst (I) || |
|Hearing Impairment ||Neither for nor against (I) || |
|Vision impairment ||Neither for nor against (I) || |
|Dementia ||Neither for nor against (I) ||Dementia |
In patients aged ≥75 years, health maintenance decisions become more complex. The focus remains both primary and secondary prevention; however, there are relatively few studies evaluating the utility and impact of HM interventions in this population. Therefore, it becomes increasingly important to work with geriatric patients to make informed, individualized HM decisions. Among patients aged ≥75 years, there exist wide variations in the number and severity of comorbid conditions, functional status, life expectancy, and patients’ overall goals of care and preferences. Each of these factors must be considered when discussing HM interventions in older patients. Consideration of both benefits and risks of any HM intervention is also essential.
Guidelines regarding cancer screening in patients aged ≥75 years especially require individualized, patient-specific discussions and decisions. The United States Preventive Task Force (USPSTF) suggests that the benefits of colon cancer screening in adults aged 75–85 years do not outweigh the risks, and explicitly recommends against it in patients aged >85 years. The American College for Gastroenterology (ACG) recommends colon cancer screening beginning at age 50 and does not suggest when to discontinue screening.
For breast cancer screening, USPSTF recommends neither for nor against mammography in women aged ≥75 years. The American Geriatric Society (AGS) recommends screening mammography every 3 years after age 75 with no upper age limit for women with an estimated life expectancy of ≥4 years. The American Cancer Society (ACS) and USPSTF agree that older women with previously negative Pap results do not benefit from ongoing screening for cervical cancer after the age of 75.
Prostate cancer screening remains a controversial topic, with USPSTF advising against the use of prostate-specific antigen (PSA) for prostate cancer. A detailed discussion of prostate cancer and prostate cancer screening is included elsewhere in this chapter.
The American Geriatric Society recommends screening all older adults for a history of falls within the last year, and USPSTF recommends the use of exercise, physical therapy, and vitamin D supplementation in community-dwelling older adults at increased risk for falls. USPSTF recommends neither for nor against screening for vision impairment, hearing impairment or dementia in asymptomatic patients aged ≥75 years.
I. Health Maintenance: Adult Immunizations
Tables 15-14 and 15-15 summarize the vaccination recommendations for adults.
Table 15–14.Immunizations for adults aged ≥18 years: general recommendations. ||Download (.pdf) Table 15–14.Immunizations for adults aged ≥18 years: general recommendations.
|Age (yrs) ||Tdap/Td Q10y ||HPV 0, 2, 6 mo ||Varicella 0, ≥4 wk Livea ||Zoster 1 Dose Livea ||MMR 1-2 Doses Livea ||Influenza 1 Dose/yr Nasal=Livea ||Pneumococcal 1 Dose ||HAV 0, 6-12 mo ||HBV 0, 1, 6 mo ||Meningococcal 1-2 Doses (5 yr Apart) |
|Tdap × 1, then Td ||Age ≥26 ||Patients without immunity || ||Patients without immunity ||Nasal or IM || || || || |
|Give ||√ ||√ ||√ || ||√ ||√ || || || || |
|Tdap × 1, then Td || ||Patients without immunity || ||Patients without immunity ||Nasal or IM || || || || |
|Give ||√ || ||√ || ||√ ||√ || || || || |
|Tdap × 1, then Td || ||Patients without immunity || ||Patients without immunity ||Nasal or IM || || || || |
|Give ||√ || ||√ || ||√ ||√ || || || || |
| ||<65 Tdap × 1 then Td Q10y ≥65 Td only || ||Patients without immunity || ||Born before 1957 and without immunity ||≥65 priority IM only ||≥65: if received dose ≥65 and 5 y passed, give 2nd dose || || || |
|Give ||√ || ||√ ||√ ||√ ||√ ||√ || || || |
|Td ||+ ||Patients without immunity || || ||IM || || || || |
|Give ||√ || ||√ ||√ || ||√ || || || || |
Table 15–15.Immunizations for adults aged ≥18 years: compelling and special indications. ||Download (.pdf) Table 15–15.Immunizations for adults aged ≥18 years: compelling and special indications.
|Condition ||Tdap/Td Every 10 years ||HPV 0, 2, 6 months ||Varicella 0, ≥4 week Livea ||Zoster 1 Dose Livea ||MMR 1-2 Doses Livea ||Influenza 1 dose/year Nasal=Livea ||Pneumococcal 1 Dose ||HAV 0, 6-12 months ||HBV 0, 1, 6 months ||Meningococcal 1-2 Doses (5 years Apart) |
|Asthma || || || || || || ||√ || || || |
|Cigarette smoking || || || || || || ||√ || || || |
|Pregnancy ||Tdap postpartum 2 years from last Td || ||Do not give; could cause harm ||Do not give; could cause harm ||Only postpartum; could cause harm before ||√ || || || || |
|Health care workers ||Tdap × 1, 2 years from last Td || || || ||2 doses (if not immune) ||√ || ||If work with HAV ||√ || |
|Contact with children ||Infants <12 mo Tdap × 1, 2 years from last Td || || || || ||Children <5 years || || || || |
|International travel to certain countries || || || || ||2 doses (if not immune) || || ||√ ||√ ||√ 2 doses if residing in endemic countries |
|Students in post–secondary school || || || || ||2 doses (if not immune) || || || || ||Students living in dormitories |
|Immuno-suppressed || || || || || ||√ ||2 doses (5 years apart) || || || |
|Nursing home residents || || || || || ||√ ||√ || || || |
|Certain chronic disease statesb || || || || || ||√ ||√ || || || |
|Renal disorders || || || || || || ||2 doses (5 years apart) || || || |
|Asplenia || || || || || || ||2 doses (5 years apart) || || ||√ |
|Chronic liver disease || || || || || || || ||√ || || |
|MSM || || || || || || || ||√ ||√ || |
|Illegal drug use || || || || || || || ||√ ||√ || |
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