Guide to Clinical Preventive Services, 2010-2011: Section 2

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Guide to Clinical Preventive Services, 2010-2011

Section 2. Recommendations for Adults

All recommendation statements in this Guide are abridged. To see the full recommendation statements and recommendations published after March 2010, go to http://www.uspreventiveservicestaskforce.org.

Cancer

Aspirin or Nonsteroidal Anti-inflammatory Drugs for the Primary Prevention of Colorectal Cancer

Summary of Recommendation

The U.S. Preventive Services Task Force (USPSTF) recommends against the routine use of aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent colorectal cancer in individuals at average risk for colorectal cancer.
Grade: D Recommendation.

Clinical Considerations

This recommendation applies to asymptomatic adults at average risk for colorectal cancer, including those with a family history of colorectal cancer, and not to individuals with familial adenomatous polyposis, hereditary nonpolyposis colon cancer syndromes (Lynch I or II), or a history of colorectal cancer or adenomas.
Clinicians should continue to discuss aspirin chemoprophylaxis with patients who are at increased risk for coronary heart disease, but there is good evidence that low-dose aspirin used to prevent coronary heart disease (CHD) events in those at increased risk for CHD does not lead to a reduced incidence of colorectal cancer. Aspirin use by patients at increased risk for coronary heart disease has been shown to reduce all-cause mortality. The evidence and recommendation statements from the USPSTF for aspirin chemoprophylaxis can be found on the AHRQ Web site (http://www.uspreventiveservicestaskforce.org/uspstf/uspsasco.htm).
More than 80% of colorectal cancers arise from adenomatous polyps. However, most adenomatous polyps will not progress to cancer. Age represents a major risk factor for colorectal cancer, with approximately 90% of cases occurring after age 50 years. Thirty to fifty percent of Americans older than age 50 will develop adenomatous polyps. Between 1% and 10% of these polyps will progress to cancer in 5 to 10 years. The risk for a polyp developing into cancer depends on the villous architecture, degree of cytologic dysplasia, size, and total number of polyps.
All persons older than age 50 who are at average risk for colorectal cancer should be screened for colorectal cancer regardless of their aspirin or NSAID use. The USPSTF recommendation on screening for colorectal cancer can be accessed at http://www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm.

This USPSTF recommendation was first published in: Ann Intern Med 2007;146(5):361-64. To read the recommendation, go to: http://www.uspreventiveservicestaskforce.org/uspstf/uspsasco.htm.

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Screening for Bladder Cancer in Adults

Note: The USPSTF was updating its recommendation on this topic during publication of The Guide to Clinical Preventive Services 2010-2011. For the most recent recommendation, please visit the USPSTF Web site at: http://www.USPreventiveServicesTaskForce.org or the USPSTF's Electronic Preventive Services Selector (ePSS) at http://epss.ahrq.gov. You can search the ePSS for recommendations by patient age, sex, and pregnancy status, and you can download the recommendations as well as receive automatic updates to your PDA.

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Genetic Risk Assessment and BRCA Mutation Testing for Breast and Ovarian Cancer Susceptibility

Summary of Recommendations

The U.S. Preventive Services Task Force (USPSTF) recommends against routine referral for genetic counseling or routine breast cancer susceptibility gene (BRCA) testing for women whose family history is not associated with an increased risk for deleterious mutations in breast cancer susceptibility gene 1 (BRCA1) or breast cancer susceptibility gene 2 (BRCA2).
Grade: D Recommendation.

The USPSTF recommends that women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes be referred for genetic counseling and evaluation for BRCA testing.
Grade: B Recommendation.

Clinical Considerations

These recommendations apply to women who have not received a diagnosis of breast or ovarian cancer. They do not apply to women with a family history of breast or ovarian cancer that includes a relative with a known deleterious mutation in BRCA1 or BRCA2 genes; these women should be referred for genetic counseling. These recommendations do not apply to men.
Although there currently are no standardized referral criteria, women with an increased-risk family history should be considered for genetic counseling to further evaluate their potential risks.
Certain specific family history patterns are associated with an increased risk for deleterious mutations in the BRCA1 or BRCA2 gene. Both maternal and paternal family histories are important. For non-Ashkenazi Jewish women, these patterns include 2 first-degree relatives with breast cancer, 1 of whom received the diagnosis at age 50 years or younger; a combination of 3 or more first- or second-degree relatives with breast cancer regardless of age at diagnosis; a combination of both breast and ovarian cancer among first- and second-degree relatives; a first-degree relative with bilateral breast cancer; a combination of 2 or more first- or second-degree relatives with ovarian cancer regardless of age at diagnosis; a first- or second-degree relative with both breast and ovarian cancer at any age; and a history of breast cancer in a male relative.
For women of Ashkenazi Jewish heritage, an increased-risk family history includes any first-degree relative (or 2 second-degree relatives on the same side of the family) with breast or ovarian cancer.
About 2 percent of adult women in the general population have an increased-risk family history as defined here. Women with none of these family history patterns have a low probability of having a deleterious mutation in BRCA1 or BRCA2 genes.
Computational tools are available to predict the risk for clinically important BRCA mutations (that is, BRCA mutations associated with the presence of breast cancer, ovarian cancer, or both), but these tools have not been verified in the general population. There is no empirical evidence concerning the level of risk for a BRCA mutation that merits referral for genetic counseling.
Not all women with a potentially deleterious BRCA mutation will develop breast or ovarian cancer. In a woman who has a clinically important BRCA mutation, the probability of developing breast or ovarian cancer by age 70 years is estimated to be 35 percent to 84 percent for breast cancer and 10 percent to 50 percent for ovarian cancer.
Appropriate genetic counseling helps women make informed decisions, can improve their knowledge and perception of absolute risk for breast and ovarian cancer, and can often reduce anxiety. Genetic counseling includes elements of counseling; risk assessment; pedigree analysis; and, in some cases, recommendations for testing for BRCA mutations in affected family members, the presenting patient, or both. It is best delivered by a suitably trained health care provider.
A BRCA test is typically ordered by a physician. When done in concert with genetic counseling, the test assures the linkage of testing with appropriate management decisions. Genetic testing may lead to potential adverse ethical, legal, and social consequences, such as insurance and employment discrimination; these issues should be discussed in the context of genetic counseling and evaluation for testing.
Among women with BRCA1 or BRCA2 mutations, prophylactic mastectomy or oophorectomy decreases the incidence of breast and ovarian cancer; there is inadequate evidence for mortality benefits. Chemoprevention with selective estrogen receptor modulators may decrease incidence of estrogen receptor-positive breast cancer; however, it is also associated with adverse effects, such as pulmonary embolism, deep venous thrombosis, and endometrial cancer. Most breast cancer associated with BRCA1 mutations is estrogen receptor-negative and thus is not prevented by tamoxifen. Intensive screening with mammography has poor sensitivity, and there is no evidence of benefit of intensive screening for women with BRCA1 or BRCA2 gene mutations. Magnetic resonance imaging (MRI) may detect more cases of cancer, but the effect on mortality is not clear.
Women with an increased-risk family history are at risk not only for deleterious BRCA1 or BRCA2 mutations but potentially for other unknown mutations as well. Women with an increased-risk family history who have negative results on tests for BRCA1 and BRCA2 mutations may also benefit from surgical prophylaxis.

This USPSTF recommendation was first published in Ann Intern Med 2005;143:355-361. To read the recommendation, go to: http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrgen.htm.

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Chemoprevention of Breast Cancer

Note: The USPSTF was updating its recommendation on this topic during publication of The Guide to Clinical Preventive Services 2010-2011. For the most recent recommendation, please visit the USPSTF Web site at: http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrpv.htm or the USPSTF's Electronic Preventive Services Selector (ePSS) at http://epss.ahrq.gov. You can search the ePSS for recommendations by patient age, sex, and pregnancy status, and you can download the recommendations as well as receive automatic updates to your PDA.

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Screening for Breast Cancer (2009)

Summary of 2009 Recommendation

The U.S. Preventive Services Task Force (USPSTF) recommends biennial screening mammography for women aged 50 to 74 years.
Grade: B Recommendation.

The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.
Grade: C Recommendation.

The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.
Grade: I Statement.

The USPSTF recommends against teaching breast self-examination (BSE).
Grade: D Recommendation.

The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.
Grade: I Statement.

The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer.
Grade: I Statement.

Clinical Considerations

This recommendation statement applies to women 40 years or older who are not at increased risk for breast cancer by virtue of a known underlying genetic mutation or a history of chest radiation.
Increasing age is the most important risk factor for breast cancer for most women. Women without known deleterious genetic mutations (such as BRCA1 or BRCA2) may still have other demographic, physical, or historical risk factors for breast cancer, but none conveys a clinically important absolute increased risk for cancer.
In recent decades, the early detection of breast cancer has been accomplished by physical examination by a clinician (CBE), by a woman herself (BSE), or by mammography. Standardization of mammography practices enacted by the Mammography Quality Standards Act have led to improved mammography quality. Clinicians should refer patients to Mammography Quality Standards Act-certified facilities, a list of which is available at http://www.fda.gov/cdrh/mammography/certified.html.
In trials that demonstrated the effectiveness of mammography in decreasing breast cancer mortality, screening was performed every 12 to 33 months. The evidence reviewed by the USPSTF indicates that a large proportion of the benefit of screening mammography is maintained by biennial screening, and changing from annual to biennial screening is likely to reduce the harms of mammography screening by nearly half. At the same time, benefit may be reduced when extending the interval beyond 24 months; therefore the USPSTF recommends biennial screening.
Effective treatments, including radiation, chemotherapy (including hormonal treatment), and surgery, are available for invasive carcinoma. Although the standard treatments women receive for ductal carcinoma in situ (DCIS) include surgical approaches as well as radiation and hormonal therapy, considerable debate exists about the optimal treatment strategy for this condition.

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Clinical Breast Examination

Potential Preventable Burden. The evidence for CBE, although indirect, suggests that CBE may detect a substantial proportion of cases of cancer if it is the only screening test available. In parts of the world where mammography is infeasible or unavailable (such as India), CBE is being investigated in this way.

Potential Harms. The potential harms of CBE are thought to be small but include false-positive test results, which lead to anxiety and breast cancer worry, as well as repeated visits and unwarranted imaging and biopsies.

Costs. The principal cost of CBE is the opportunity cost incurred by clinicians in the patient encounter.

Current Practice. Surveys suggest that the CBE technique used in the United States currently lacks a standard approach and reporting standards. Clinicians who are committed to spending the time on CBE would benefit their patients by considering the evidence in favor of a structured, standardized examination.

Digital Mammography

Potential Preventable Burden. Digital mammography detects some cases of cancer not identified by film mammography; film mammography detects some cases of cancer not identified by digital mammography. Overall detection is similar for many women. For women who are younger than 50 years or have dense breast tissue, overall detection is somewhat higher with digital mammography. It is not clear whether this additional detection would lead to reduced mortality from breast cancer.

Potential Harms. The possibility of false-positive test results is similar for film and digital mammography. It is uncertain whether overdiagnosis occurs more with digital mammography than with film mammography.

Costs. Digital mammography is more expensive than film mammography.

Current Practice. Some clinical practices are now switching their mammography equipment from film to digital. This may curtail the availability of film mammography in some areas.

Magnetic Resonance Imaging

Potential Preventable Burden. Studies of the use of contrast-enhanced MRI for breast cancer screening have been conducted only in very high-risk populations. In these studies, MRI detected more cases of cancer than did mammography. It is unknown whether detecting these additional cases of cancer would lead to reduced breast cancer mortality.

Potential Harms. Contrast-enhanced MRI requires the injection of contrast material. Studies of MRI screening have shown that MRI yields many more false-positive results than does mammography. Magnetic resonance imaging has the potential to be associated with a greater degree of overdiagnosis than mammography.

Costs. Magnetic resonance imaging is much more expensive than either film or digital mammography.

Current Practice. Magnetic resonance imaging is not currently used for screening women at average risk for breast cancer.

Screening Mammography in Women 75 Years or Older

Potential Preventable Burden. No women 75 years or older have been included in the multiple randomized clinical trials of breast cancer screening. Breast cancer is a leading cause of death in older women, which might suggest that the benefits of screening could be important at this age. However, 3 facts suggest that benefits from screening would probably be smaller for this age group than for women aged 60 to 69 years and probably decrease with increasing age: 1) the benefits of screening occur only several years after the actual screening test, whereas the percentage of women who survive long enough to benefit decreases with age; 2) a higher percentage of the type of breast cancer detected in this age group is the more easily treated estrogen receptor-positive type; and 3) women of this age are at much greater risk for dying of other conditions that would not be affected by breast cancer screening.

Potential Harms. Screening detects not only cancer that could lead to a woman's death but also cancer that will not shorten a woman's life. Women cannot benefit from—but can be harmed by—the discovery and treatment of this second type of cancer, which includes both cancer that might some day become clinically apparent and cancer that never will. Detection of cancer that would never have become clinically apparent is called overdiagnosis, and it is usually followed by overtreatment. Because of a shortened life span among women 75 years or older, the probability of overdiagnosis and unnecessary earlier treatment increases dramatically after about age 70 or 75 years. Overdiagnosis and unnecessary earlier treatment are important potential harms from screening women in this age group.

Current Practice. Studies show that many women 75 years or older are currently being screened.

This USPSTF recommendation was first published in: Ann Intern Med 2009; 151:716-726.
To read the recommendation, go to: http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm.

Screening for Breast Cancer (2002)

Note: The Department of Health and Human Services, in implementing the Affordable Care Act, uses the 2002 recommendation on Breast Cancer Screening, below. The USPSTF provides this information to assist primary care clinicians as they discuss insurance and coverage issues with their patients.

Summary of Recommendation

The U.S. Preventive Services Task Force (USPSTF) recommends screening mammography, with or without clinical breast examination (CBE), every 1-2 years for women aged 40 and older.
Grade: B Recommendation.

The USPSTF concludes that the evidence is insufficient to recommend for or against routine CBE alone to screen for breast cancer.
Grade: I Statement.

The USPSTF concludes that the evidence is insufficient to recommend for or against teaching or performing routine breast self-examination (BSE).
Grade: I Statement.

Clinical Considerations

The precise age at which the benefits from screening mammography justify the potential harms is a subjective judgment and should take into account patient preferences. Clinicians should inform women about the potential benefits (reduced chance of dying from breast cancer), potential harms (e.g., false-positive results, unnecessary biopsies), and limitations of the test that apply to women their age. Clinicians should tell women that the balance of benefits and potential harms of mammography improves with increasing age for women between the ages of 40 and 70.
Women who are at increased risk for breast cancer (e.g., those with a family history of breast cancer in a mother or sister, a previous breast biopsy revealing atypical hyperplasia, or first childbirth after age 30) are more likely to benefit from regular mammography than women at lower risk. The recommendation for women to begin routine screening in their 40s is strengthened by a family history of breast cancer having been diagnosed before menopause.
The USPSTF did not examine whether women should be screened for genetic mutations (e.g., BRCA1 and BRCA2) that increase the risk for developing breast cancer, or whether women with genetic mutations might benefit from earlier or more frequent screening for breast cancer.
In the trials that demonstrated the effectiveness of mammography in lowering breast cancer mortality, screening was performed every 12-33 months. For women aged 50 and older, there is little evidence to suggest that annual mammography is more effective than mammography done every other year. For women aged 40-49, available trials also have not reported a clear advantage of annual mammography over biennial mammography. Nevertheless, some experts recommend annual mammography based on the lower sensitivity of the test and on evidence that tumors grow more rapidly in this age group.
The precise age at which to discontinue screening mammography is uncertain. Only 2 randomized controlled trials enrolled women older than 69 and no trials enrolled women older than 74. Older women face a higher probability of developing and dying from breast cancer but also have a greater chance of dying from other causes. Women with comorbid conditions that limit their life expectancy are unlikely to benefit from screening.
Clinicians should refer patients to mammography screening centers with proper accreditation and quality assurance standards to ensure accurate imaging and radiographic interpretation. Clinicians should adopt office systems to ensure timely and adequate follow-up of abnormal results. A listing of accredited facilities is available at http://www.fda.gov/cdrh/mammography/certified.html.
Clinicians who advise women to perform BSE or who perform routine CBE to screen for breast cancer should understand that there is currently insufficient evidence to determine whether these practices affect breast cancer mortality, and that they are likely to increase the incidence of clinical assessments and biopsies.

This USPSTF recommendation was first published in: Ann Intern Med 2002; 137 (Part 1):344-346.
To read the recommendation, go to: http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca2002.htm.

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Screening for Cervical Cancer

Note: An update to this recommendation is in progress. Please visit our Web site at http://www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm or the USPSTF's Electronic Preventive Services Selector (ePSS) at http://epss.ahrq.gov for the most current recommendation.

Summary of Recommendations

The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening for cervical cancer in women who have been sexually active and have a cervix.
Grade: A Recommendation.

The USPSTF recommends against routinely screening women older than age 65 for cervical cancer if they have had adequate recent screening with normal Pap smears and are not otherwise at high risk for cervical cancer (go to Clinical Considerations).
Grade: D Recommendation.

The USPSTF recommends against routine Pap smear screening in women who have had a total hysterectomy for benign disease.
Grade: D Recommendation.

The USPSTF concludes that the evidence is insufficient to recommend for or against the routine use of new technologies to screen for cervical cancer.
Grade: I Statement.

The USPSTF concludes that the evidence is insufficient to recommend for or against the routine use of human papillomavirus (HPV) testing as a primary screening test for cervical cancer.
Grade: I Statement.

Clinical Considerations

The goal of cytologic screening is to sample the transformation zone, the area where physiologic transformation from columnar endocervical epithelium to squamous (ectocervical) epithelium takes place and where dysplasia and cancer arise. A meta-analysis of randomized trials supports the combined use of an extended tip spatula to sample the ectocervix and a cytobrush to sample the endocervix.
The optimal age to begin screening is unknown. Data on natural history of HPV infection and the incidence of high-grade lesions and cervical cancer suggest that screening can safely be delayed until 3 years after onset of sexual activity or until age 21, whichever comes first. Although there is little value in screening women who have never been sexually active, many U.S. organizations recommend routine screening by age 18 or 21 for all women, based on the generally high prevalence of sexual activity by that age in the U.S. and concerns that clinicians may not always obtain accurate sexual histories.
Discontinuation of cervical cancer screening in older women is appropriate, provided women have had adequate recent screening with normal Pap results. The optimal age to discontinue screening is not clear, but risk of cervical cancer and yield of screening decline steadily through middle age. The USPSTF found evidence that yield of screening was low in previously screened women after age 65. New American Cancer Society (ACS) recommendations suggest stopping cervical cancer screening at age 70. Screening is recommended in older women who have not been previously screened, when information about previous screening is unavailable, or when screening is unlikely to have occurred in the past (e.g., among women from countries without screening programs). Evidence is limited to define "adequate recent screening." The ACS guidelines recommend that older women who have had three or more documented, consecutive, technically satisfactory normal/negative cervical cytology tests, and who have had no abnormal/positive cytology tests within the last 10 years, can safely stop screening.
The USPSTF found no direct evidence that annual screening achieves better outcomes than screening every 3 years. Modeling studies suggest little added benefit of more frequent screening for most women. The majority of cervical cancers in the United States occur in women who have never been screened or who have not been screened within the past 5 years; additional cases occur in women who do not receive appropriate follow-up after an abnormal Pap smear. Because sensitivity of a single Pap test for high-grade lesions may only be 60-80%, however, most organizations in the United States recommend that annual Pap smears be performed until a specified number (usually two or three) are cytologically normal before lengthening the screening interval. The ACS guidelines suggest waiting until age 30 before lengthening the screening interval; the American College of Obstetricians and Gynecologists (ACOG) identifies additional risk factors that might justify annual screening, including a history of cervical neoplasia, infection with HPV or other sexually transmitted diseases (STDs), or high-risk sexual behavior, but data are limited to determine the benefits of these strategies.
Discontinuation of cytological screening after total hysterectomy for benign disease (e.g., no evidence of cervical neoplasia or cancer) is appropriate given the low yield of screening and the potential harms from false-positive results in this population. Clinicians should confirm that a total hysterectomy was performed (through surgical records or inspecting for absence of a cervix); screening may be appropriate when the indications for hysterectomy are uncertain. ACS and ACOG recommend continuing cytologic screening after hysterectomy for women with a history of invasive cervical cancer or DES exposure due to increased risk for vaginal neoplasms, but data on the yield of such screening are sparse.
A majority of cases of invasive cervical cancer occur in women who are not adequately screened. Clinicians, hospitals, and health plans should develop systems to identify and screen the subgroup of women who have had no screening or who have had inadequate past screening.
Newer Food and Drug Administration (FDA)-approved technologies, such as the liquid-based cytology (e.g., ThinPrep®), may have improved sensitivity over conventional Pap smear screening, but at a considerably higher cost and possibly with lower specificity. Even if sensitivity is improved, modeling studies suggest these methods are not likely to be cost-effective unless used with screening intervals of 3 years or longer. Liquid-based cytology permits testing of specimens for HPV, which may be useful in guiding management of women whose Pap smear reveals atypical squamous cells. HPV DNA testing for primary cervical cancer screening has not been approved by the FDA and its role in screening remains uncertain.

This USPSTF recommendation was first published by: Agency for Healthcare Research and Quality, Rockville, MD. January 2003. To read the recommendation, go to: http://www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm.

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Screening for Colorectal Cancer

Summary of Recommendations

The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods may vary.
Grade: A Recommendation.

The USPSTF recommends against routine screening for colorectal cancer in adults 76 to 85 years of age. There may be considerations that support colorectal cancer screening in an individual patient.
Grade: C Recommendation.

The USPSTF recommends against screening for colorectal cancer in adults older than age 85 years.
Grade: D Recommendation.

The USPSTF concludes that the evidence is insufficient to assess the benefits and harms of computed tomographic colonography and fecal DNA testing as screening modalities of colorectal cancer.
Grade: I Statement.

Clinical Considerations

These recommendations apply to adults 50 years of age and older, excluding those with specific inherited syndromes (the Lynch syndrome of familial adenomatous polyposis) and those with inflammatory bowel disease. The recommendations do apply to those with first-degree relatives who have had colorectal adenomas or cancer, although for those with first-degree relatives who developed cancer at a younger age or those with multiple affected first-degree relatives, an earlier start to screening may be reasonable. Data suggest that colorectal cancer has a higher mortality rate in African Americans. The reasons for this differential are not well known, and the recommendations are intended to apply to all ethnic and racial groups.

When the screening test results in the diagnosis of clinically significant colorectal adenomas or cancer, the patient will be followed by a surveillance regimen and recommendations for screening are no longer applicable. The USPSTF did not address evidence for the effectiveness of any particular surveillance regimen after diagnosis and/or removal of adenomatous polyps.
The relative sensitivity and specificity of the different colorectal screening tests with adequate data to assess cancer detection—colonoscopy, flexible sigmoidoscopy, and fecal tests—can be depicted as follows:
- Sensitivity: Hemoccult II < fecal immunochemical tests ≤ Hemoccult SENSA ≈ flexible sigmoidoscopy < colonoscopy
- Specificity: Hemoccult SENSA < fecal immunochemical tests ≈ Hemoccult II < flexible sigmoidoscopy = colonoscopy

For the operator-dependent tests—flexible sigmoidoscopy, CT colonography, and colonoscopy—better operator training and more experience have a high likelihood of improving sensitivity. Approaches related to certification, such as quality standards and possibly minimum volume requirements, could be used to achieve the goal of improving operator performance and therefore test sensitivity. Assurance of performance of high-quality endoscopy should be part of all screening programs.
Because several screening strategies have similar efficacy, efforts to reduce colon cancer deaths should focus on implementation of strategies that maximize the number of individuals who get screening of some type. The different options for colorectal cancer screening tests are variably acceptable to patients; eliciting patient preferences is one step in improving adherence. Ideally, shared decision making between clinicians and patients would incorporate information on local test availability and quality as well as patient preference.
Screening for colorectal cancer reduces mortality through detection and treatment of early-stage cancer and detection and removal of adenomatous polyps. The degree to which each of these mechanisms contributes to a reduction in mortality is unknown, although it is likely that the largest reduction in colorectal cancer mortality during the 10 years after initial screening comes from the detection and removal of early-stage cancer. Colonoscopy is a necessary step in any screening program that reduces mortality from colorectal cancer. This reduction in mortality does come at the expense of significant morbidity associated with colonoscopy. Evidence does not currently allow a differential estimate of colonoscopy-related morbidity for different age groups or for examinations done with or without biopsy.

In this context, the best measure for the morbidity that results from any screening program for colorectal cancer is the number of colonoscopies required to achieve a reduction in mortality. Although improvements in mortality will generally be associated with increasing morbidity that results from the screening and surveillance program, the goal of a screening program should be to maximize the number of life-years gained while minimizing the harms.

In a report prepared for the USPSTF by 2 groups in the Cancer Intervention and Surveillance Modeling Network (CISNET), investigators conducted microsimulation analyses that applied programs of screening to standard populations of adults in the United States. These analyses permitted a comparison of expected outcomes among testing strategies involving the fecal tests, flexible sigmoidoscopy, or colonoscopy (as noted below). In the models, the predicted total number of colonoscopies included those resulting from surveillance after detection of colorectal neoplasia. The models assumed lifetime monitoring by colonoscopy every 3 to 5 years depending on the number and size of the adenomas detected. It is not the intent of the USPSTF to endorse this particular approach to surveillance, but standardizing the approach to surveillance is necessary to compare screening strategies in the models.

For all screening modalities, starting screening at age 50 resulted in a balance between life-years gained and colonoscopy risks that was more favorable than commencing screening earlier. Despite the increasing incidence of colorectal adenomas with age, for individuals previously screened the gain in life-years associated with extending screening from age 75 years to 85 years was small in comparison to the risks of screening people in this decade. For adults who have not previously been screened, decisions about first-time screening in this age group should be made in the context of the individual's health status and competing risks, given that the benefit of screening is not seen in trials until at least 7 years later. For persons older than 85 years, competing causes of mortality preclude a mortality benefit that outweighs the harms.

This USPSTF recommendation was first published in: Ann Intern Med 2008;149(9):627-638.
To read the recommendation, go to: http://www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm.

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Lung Cancer Screening

Summary of Recommendation

The U.S. Preventive Services Task Force USPSTF) concludes that the evidence is insufficient to recommend for or against screening asymptomatic persons for lung cancer with either low dose computerized tomography (LDCT), chest x-ray (CXR), sputum cytology, or a combination of these tests.
Grade: I Statement.

Clinical Considerations

The benefit of screening for lung cancer has not been established in any group, including asymptomatic high-risk populations such as older smokers. The balance of harms and benefits becomes increasingly unfavorable for persons at lower risk, such as nonsmokers.
The sensitivity of LDCT for detecting lung cancer is 4 times greater than the sensitivity of CXR. However, LDCT is also associated with a greater number of false-positive results, more radiation exposure, and increased costs compared with CXR.
Because of the high rate of false-positive results, many patients will undergo invasive diagnostic procedures as a result of lung cancer screening. Although the morbidity and mortality rates from these procedures in asymptomatic individuals are not available, mortality rates due to complications from surgical interventions in symptomatic patients reportedly range from 1.3% to 11.6%; morbidity rates range from 8.8% to 44%, with higher rates associated with larger resections.
Other potential harms of screening are potential anxiety and concern as a result of false-positive tests, as well as possible false reassurance because of false-negative results. However, these harms have not been adequately studied.

This USPSTF recommendation was first published in: Ann Intern Med 2004;140:738-739.
To read the recommendation, go to: http://www.uspreventiveservicestaskforce.org/uspstf/uspslung.htm.

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Screening for Oral Cancer

Note: An update to this recommendation is in progress. Please visit our Web site at http://www.uspreventiveservicestaskforce.org/uspstf/uspsoral.htm or the USPSTF's Electronic Preventive Services Selector (ePSS) at http://epss.ahrq.gov for the most current recommendation.

Summary of Recommendation

The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routinely screening adults for oral cancer.
Grade: I Statement.

Clinical Considerations

Direct inspection and palpation of the oral cavity is the most commonly recommended method of screening for oral cancer, although there are little data on the sensitivity and specificity of this method. Screening techniques other than inspection and palpation are being evaluated but are still experimental.
Tobacco use in all forms is the biggest risk factor for oral cancer. Alcohol abuse combined with tobacco use increases risk.
Clinicians should be alert to the possibility of oral cancer when treating patients who use tobacco or alcohol.
Patients should be encouraged to not use tobacco and to limit alcohol use in order to decrease their risk for oral cancer as well as heart disease, stroke, lung cancer, and cirrhosis.

This USPSTF recommendation was first published by: Agency for Healthcare Research and Quality, Rockville, MD. February 2004. To read the recommendation, go to: http://www.uspreventiveservicestaskforce.org/uspstf/uspsoral.htm.

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Screening for Ovarian Cancer

Note: An update to this recommendation is in progress. Please visit our Web site at http://www.uspreventiveservicestaskforce.org/uspstf/uspsovar.htm or the USPSTF's Electronic Preventive Services Selector (ePSS) at http://epss.ahrq.gov for the most current recommendation.

Summary of Recommendation

The U.S. Preventive Services Task Force (USPSTF) recommends against routine screening for ovarian cancer.
Grade: D Recommendation.

Clinical Considerations

There is no existing evidence that any screening test, including CA-125, ultrasound, or pelvic examination, reduces mortality from ovarian cancer. Furthermore, existing evidence that screening can detect early-stage ovarian cancer is insufficient to indicate that this earlier diagnosis will reduce mortality.
Because there is a low incidence of ovarian cancer in the general population (age-adjusted incidence of 17 per 100,000 women), screening for ovarian cancer is likely to have a relatively low yield. The great majority of women with a positive screening test will not have ovarian cancer (i.e., they will have a false-positive result). In women at average risk, the positive predictive value of an abnormal screening test is, at best, approximately 2% (i.e., 98% of women with positive test results will not have ovarian cancer).
The positive predictive value of an initially positive screening test would be more favorable for women at higher risk. For example, the lifetime probability of ovarian cancer increases from about 1.6% in a 35-year-old woman without a family history of ovarian cancer to about 5% if she has 1 relative and 7% if she has 2 relatives with ovarian cancer. If ongoing clinical trials show that screening has a beneficial effect on mortality rates, then women at higher risk are likely to experience the greatest benefit.

This USPSTF recommendation was first published in: Ann Fam Med 2004;2:260-262.
To read the recommendation, go to: http://www.uspreventiveservicestaskforce.org/uspstf/uspsovar.htm.

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Screening for Pancreatic Cancer

Summary of Recommendation

The U.S. Preventive Services Task Force (USPSTF) recommends against routine screening for pancreatic cancer in asymptomatic adults using abdominal palpation, ultrasonography, or serologic markers.
Grade: D Recommendation.

Clinical Considerations

Due to the poor prognosis of those diagnosed with pancreatic cancer, there is an interest in primary prevention. The evidence for diet-based prevention of pancreatic cancer is limited and conflicting. Some experts recommend lifestyle changes that may help to prevent pancreatic cancer, such as stopping the use of tobacco products, moderating alcohol intake, and eating a balanced diet with sufficient fruit and vegetables.
Persons with hereditary pancreatitis may have a higher lifetime risk for developing pancreatic cancer. However, the USPSTF did not review the effectiveness of screening these patients.

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Screening for Prostate Cancer

Summary of Recommendations

The U.S. Preventive Services Task Force (USPSTF) concludes that the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years.
Grade: I Statement.

The USPSTF recommends against screening for prostate cancer in men age 75 years or older.
Grade: D Recommendation.

Clinical Considerations

This recommendation applies to men in the general U.S. population.
Older men, African-American men, and men with a family history of prostate cancer are at increased risk for diagnosis of and death from prostate cancer. Unfortunately, the previously described gaps in the evidence regarding potential benefits of screening also apply to these men.
The PSA test is more sensitive than the digital rectal examination for detecting prostate cancer. The conventional PSA screening cut-point of 4.0 μg/L detects many cases of prostate cancer; however, some early cases will be missed by this cut-point. Using a lower cut-point to define an abnormal PSA level detects more cases of cancer.
The proportion of cancer cases detected by lower cutpoints that would ever become clinically apparent is unknown; lower cut-points would label many more men as potentially having cancer. For example, lowering the PSA cut-point to 2.5 μg/L would more than double the number of U.S. men between 40 and 69 years of age with abnormal results.

Variations of PSA screening, including the use of age-adjusted PSA cut-points, free PSA, PSA density, PSA velocity, PSA slope, and PSA doubling time, have been proposed to improve detection of "clinically important" prostate cancer cases. However, no evidence suggests that any of these testing strategies improves health outcomes.
Given the uncertainties and controversy surrounding prostate cancer screening in men younger than age 75 years, a clinician should not order the PSA test without first discussing with the patient the potential but uncertain benefits and the known harms of prostate cancer screening and treatment. Men should be informed of the gaps in the evidence and should be assisted in considering their personal preferences before deciding whether to be tested.
Because of the uncertainty about the benefits of treating prostate cancer detected by screening men younger than age 75 years, there is no consensus regarding optimal treatment. Current management strategies for localized prostate cancer include watchful waiting (observation with palliative treatment for symptoms only), active surveillance (periodic biochemical monitoring with conversion to curative treatment for signs of disease progression), radical prostatectomy, external-beam radiation therapy, and brachytherapy (or radioactive seed implantation therapy).
If treatment for prostate cancer detected by screening improves health outcomes, the population most likely to benefit from screening will be men age 50 to 74 years. Even if prostate cancer screening is determined to be effective, the length of time required to experience a mortality benefit is greater than 10 years. Because a 75-year-old man has an average life expectancy of about 10 years, very few men age 75 years or older would experience a mortality benefit. Similarly, men younger than age 75 years who have chronic medical problems and a life expectancy of fewer than 10 years are also unlikely to benefit from screening and treatment.
The yield of screening in terms of cancer cases detected declines rapidly with repeated annual testing. If screening were to reduce deaths, PSA screening as infrequently as every 4 years could yield as much of a benefit as annual screening.
Shared decision-making resources specific to prostate cancer screening for clinicians and patients are available from the Centers of Disease Control and Prevention (http://www.cdc.gov/cancer/prostate/publications/).

This USPSTF recommendation was first published in: Ann Intern Med 2008;149:185-191.
To read the recommendation, go to: http://www.uspreventiveservicestaskforce.org/uspstf/uspsprca.htm.

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Counseling to Prevent Skin Cancer

Note: The USPSTF was updating its recommendation on this topic during publication of The Guide to Clinical Preventive Services 2010- 2011. For the most recent recommendation, please visit the USPSTF Web site at http://www.uspreventiveservicestaskforce.org/uspstf/uspsskco.htm or the USPSTF's Electronic Preventive Services Selector (ePSS) at http://epss.ahrq.gov. You can search the ePSS for recommendations by patient age, sex, and pregnancy status, and you can download the recommendations as well as receive automatic updates to your PDA.

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Screening for Skin Cancer

Summary of Recommendation

The U.S. Preventive Services Task Force (USPSTF) concludes that the current evidence is insufficient to assess the balance of benefits and harms of using whole-body skin examination by a primary care clinician or patient skin self-examination for the early detection of cutaneous melanoma, basal cell cancer, or squamous cell skin cancer in the adult general population.
Grade: I Statement.

Clinical Considerations

This recommendation applies to the adult general population without a history of premalignant or malignant lesions. The USPSTF did not examine the outcomes related to surveillance of patients at extremely high risk, such as those with familial syndromes (for example, the familial atypical mole and melanoma syndrome).
Clinicians should remain alert for skin lesions with malignant features noted in the context of physical examinations performed for other purposes. Asymmetry, border irregularity, color variability, diameter greater than 6 mm (ABCD criteria), or rapidly changing lesions are features associated with an increased risk for cancer. Biopsy of suspicious lesions is warranted.
Clinicians should be aware that fair-skinned men and women older than 65 years, patients with atypical moles, and those with more than 50 moles constitute known groups at substantially increased risk for melanoma. Other risk factors for skin cancer include family history and a considerable past history of sun exposure and sunburns. Benefits from screening are uncertain, even in high-risk patients.

This USPSTF recommendation was first published in: Ann Intern Med 2009;150:188-193.
To read the recommendation, go to: http://www.uspreventiveservicestaskforce.org/uspstf/uspsskca.htm.

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Screening for Testicular Cancer

Note: An update to this recommendation is in progress. Please visit the USPSTF Web site at http://www.uspreventiveservicestaskforce.org/uspstf/uspstest.htm or the USPSTF's Electronic Preventive Services Selector (ePSS) at http://epss.ahrq.gov for the most recent recommendation.

Summary of Recommendation

The U.S. Preventive Services Task Force (USPSTF) recommends against routine screening for testicular cancer in asymptomatic adolescent and adult males.
Grade: D Recommendation.

Clinical Considerations

The low incidence of testicular cancer and favorable outcomes in the absence of screening make it unlikely that clinical testicular examinations would provide important health benefits. Clinical examination by a physician and self-examination are the potential screening options for testicular cancer. However, little evidence is available to assess the accuracy, yield, or benefits of screening for testicular cancer.
Although currently most testicular cancers are discovered by patients themselves or their partners, either unintentionally or by self-examination, there is no evidence that teaching young men how to examine themselves for testicular cancer would improve health outcomes, even among men at high risk, including men with a history of undescended testes or testicular atrophy.
Clinicians should be aware of testicular cancer as a possible diagnosis when young men present to them with suggestive signs and symptoms. There is some evidence that patients who present initially with symptoms of testicular cancer are frequently diagnosed as having epididymitis, testicular trauma, hydrocele, or other benign disorders. Efforts to promote prompt assessment and better evaluation of testicular problems may be more effective than widespread screening as a means of promoting early detection.

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Routine Vitamin Supplementation to Prevent Cancer and Cardiovascular Disease

Note: The USPSTF was updating its recommendation on this topic during publication of The Guide to Clinical Preventive Services 2010-2011. For the most recent recommendation, please visit the USPSTF Web site at http://www.uspreventiveservicestaskforce.org/uspstf/uspsvita.htm or the USPSTF's Electronic Preventive Services Selector (ePSS) at http://epss.ahrq.gov. You can search the ePSS for recommendations by patient age, sex, and pregnancy status, and you can download the recommendations as well as receive automatic updates to your PDA.

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