Preventive services: The good, the bad, and the unproven

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Practice Alert

Preventive services: The good, the bad, and the unproven

J Fam Pract. 2009 July;58(7):374-376

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References

1. US Preventive Services Task Force. Screening for colorectal cancer. October 2008. Available at: www.ahrq.gov/clinic/uspstf/uspscolo.htm. Accessed June 3, 2009.

2. American Cancer Society guidelines for early detection of cancer. Last revised May 21, 2009. Available at: http://www.cancer.org/docroot/PED/content/PED_2_3X_ACS_Cancer_Detection_Guidelines_36.asp?sitearea=PED. Accessed June 3, 2009.

3. US Preventive Services Task Force. Aspirin for the prevention of cardiovascular disease: recommendation statement. March 2009. Available at: http://www.ahrq.gov/clinic/uspstf09/aspirincvd/aspcvdrs.htm. Accessed June 3, 2009.

4. National Cholesterol Education Program. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Final Report. Circulation. 2002;106:3143-3421.Available at: http://circ.ahajournals.org/cgi/content/full/106/25/3143. Accessed June 3, 2009.

5. Campos-Outcalt D. USPSTF scales back approach to lipid screening for women. J Fam Pract. 2008;57:740-742.

6. American Diabetes Association. Standards of medical care in diabetes—2008. Diabetes Care. 2008;31(suppl 1):S12-S54.

FAST TRACK

The USPSTF recommends against screening for prostate cancer in men ≥75 years. In younger men, the evidence is insufficient to make a recommendation.

Screening for hypercholesterolemia. The Task Force’s recommendations for dyslipidemia screening differ markedly from those of the American Heart Association and the Final Report of the National Cholesterol Education Program (NCEP) Expert Panel, which recommend routine screening for all adults starting at age 20 with no age cutoff.⁴ The USPSTF recommends deferring screening until patients are older, except for those at increased risk of coronary heart disease. This controversy was described in a 2008 Practice Alert.⁵

Screening for diabetes. The only asymptomatic patients the Task Force recommends screening for diabetes are those with a sustained blood pressure of more than 135/80 mm Hg, treated or untreated. The American Diabetes Association (ADA) would cast a wider net, recommending that you consider screening for prediabetes or diabetes in those ≥45 years of age, particularly in those with a body mass index of ≥25 kg/m², and in overweight patients <45 years of age who have another risk factor for diabetes.⁶

Screening for colorectal cancer. The Task Force recommends screening adults starting at age 50 until age 75, using fecal occult blood testing, sigmoidoscopy, or colonoscopy. The ACS also recommends these screening modalities, but adds CT colonography and fecal DNA testing to the list of acceptable methods. The USPSTF found insufficient evidence to evaluate the benefits and harms of these newer tests and expressed concern over the high rate of incidental findings and the unknown long-term effects of radiation from CT colonography.

Screening adolescents. The Task Force is in favor of screening teenagers for major depressive disorder (MDD), as long as systems are in place to provide accurate diagnosis, therapy, and follow-up. High-intensity behavioral counseling for sexually active teens and adults at risk is also endorsed for the prevention of sexually transmitted infections. In both areas, however, the Task Force recognizes that adequately addressing these issues will require more than brief office- or clinic-based interventions.

Caring for pregnant women and newborns. According to the USPSTF, pregnant women should be screened for asymptomatic bacteriuria, advised to take a daily folic acid supplement, counseled about tobacco use, and encouraged to breastfeed. Newborns should be screened for congenital hypothyroidism, phenylketonuria, and hearing loss. These most recent A and B recommendations from the USPSTF are summarized in TABLE 3.

TABLE 3
The USPSTF recommends FOR

CARDIOVASCULAR DISEASE PREVENTION
Using aspirin for men 45 to 79 years of age when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage (A). Using aspirin for women 55 to 79 years of age when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage (A). Screening men ≥35 years of age for lipid disorders (A). Screening men 20 to 35 years of age for lipid disorders if they are at increased risk for coronary heart disease (CHD) (B). Screening women ≥45 of age for lipid disorders if they are at increased risk for CHD (A). Screening women 20 to 45 years of age for lipid disorders if they are at increased risk for CHD (B). Asking all adults about tobacco use and providing tobacco cessation interventions for those who use tobacco products (A). Screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) >135/80 mm Hg (B).
CANCER SCREENING
Screening adults for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy beginning at age 50 and continuing until 75 years of age (A).
PREGNANCY
Screening for asymptomatic bacteriuria with urine culture for pregnant women at 12 to 16 weeks’ gestation or at the first prenatal visit, if later (A). Advising all women planning on, or capable of, pregnancy to take a daily supplement containing 0.4 to 0.8 mg (400-800 mcg) of folic acid (A). Asking all pregnant women about tobacco use and providing augmented, pregnancy-tailored counseling for those who smoke (A). Intervening during pregnancy and after birth to promote and support breastfeeding (B).
NEWBORNS
Screening for congenital hypothyroidism (A). Screening for phenylketonuria (A). Screening for hearing loss (B).
ADOLESCENTS
Screening adolescents 12 to 18 years of age for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up (B). Providing high-intensity behavioral counseling to prevent sexually transmitted infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs (B).

Not proven

When evidence is not available, some organizations are willing to issue guidelines based on expert opinion or consensus. Not so the USPSTF. When the Task Force members find current evidence is not sufficient to make a judgment, they put the intervention into Category I, for Insufficient. The new I recommendations range from aspirin to prevent MI and stroke in those ≥80 years to screening children for MDD and performing whole body skin examinations to detect early manifestations of skin cancer. The new I recommendations are listed in TABLE 4.

Preventive services: The good, the bad, and the unproven

References

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