The Guide to Clinical Preventive Services 2005

The Guide to Clinical Preventive Services

2005Recommendations of the U.S. Preventive Services Task Force

What the U.S. Preventive Services TaskForce Grades MeanThe U.S. Preventive Services Task Force (USPSTF)grades its recommendations based on the strength ofevidence and magnitude of net benefit (benefits minusharms).

A. The USPSTF strongly recommends that cliniciansprovide [the service] to eligible patients. The USPSTFfound good evidence that [the service] improves importanthealth outcomes and concludes that benefits substantiallyoutweigh harms.

B. The USPSTF recommends that clinicians provide [theservice] to eligible patients. The USPSTF found at leastfair evidence that [the service] improves important healthoutcomes and concludes that benefits outweigh harms.

C. The USPSTF makes no recommendation for or againstroutine provision of [the service]. The USPSTF foundat least fair evidence that [the service] can improve healthoutcomes but concludes that the balance of benefits andharms is too close to justify a general recommendation.

D. The USPSTF recommends against routinely providing[the service] to asymptomatic patients. The USPSTFfound at least fair evidence that [the service] is ineffectiveor that harms outweigh benefits.

I. The USPSTF concludes that the evidence isinsufficient to recommend for or against routinelyproviding [the service]. Evidence that [the service] iseffective is lacking, of poor quality, or conflicting, and thebalance of benefits and harms cannot be determined.

See page 164 for more information on how the USPSTFarrives at the grades for its recommendations.

The Guide to Clinical Preventive Services

2005

Recommendations of the U.S. Preventive Services Task Force

The recommendation statements in this Guide areabridged. To view the full recommendation statements orrecommendation statements published after 2004, go towww.preventiveservices.ahrq.gov.

The U.S Preventive Services Task Force’s (USPSTF) PDAprogram, the Interactive Preventive Services Selector, isupdated frequently with new USPSTFrecommendations. The tool is available on the Web fordownload to PDA devices. Users can searchrecommendations by patient age, sex, and pregnancystatus. To download, go to http://pda.ahrq.gov.

Recommendations made by the USPSTF areindependent of the U.S. Government. They should notbe construed as an official position of AHRQ or the U.S. Department of Health and Human Services.

ForewordThe Agency for Healthcare Research and Quality

(AHRQ) is pleased to present The Guide to ClinicalPreventive Services 2005, which will give you theinformation you need to provide evidence-basedclinical preventive services to your patients.

Research has clearly demonstrated that providinghigh quality, evidence-based preventive care is anelement integral to helping people live healthier lives.We also know from research that the best way toensure that preventive services are deliveredappropriately is to make evidence-based informationreadily available at the point of care.

To that end, The Guide puts the “gold standard” ofpreventive care at your fingertips so you can provideeffective preventive services, based on the latestscientific evidence, to your patients every day. Withinits pages are recommendations on 45 clinicalpreventive services made by the U.S. PreventiveServices Task Force from 2001 to 2004.

The Task Force, sponsored by AHRQ, is anindependent panel of experts in primary care andprevention that systematically reviews the evidence ofeffectiveness and develops recommendations forclinical preventive services. Its mission is to evaluatethe benefits of individual services based on age, sex,and risk factors for disease; make recommendationsabout which preventive services should be incorporated

iii

routinely into primary medical care and for whichpopulations; and identify a research agenda for clinicalpreventive care.

In very basic terms, the Task Force has reviewed allthe available scientific evidence to create a road mapfor effective, appropriate clinical preventive services.The unbiased recommendations made by the TaskForce have helped policymakers, clinicians, andinsurers distinguish necessary from unnecessary servicesand have explained those services that are harmful orabout which there is uncertainty. And we know thatThe Guide will help you in your practice.

I urge you to use the evidence andrecommendations contained in The Guide to directyour screening and diagnostic discussions. Usingevidence to guide clinical decisions is key to fulfillingthe "first do no harm" ethos by which the health caresystem must operate.

Carolyn M. Clancy, M.D.DirectorAgency for Healthcare Research and Quality

iv

Foreword

PrefaceSince its inception 20 years ago, the U.S.

Preventive Services Task Force (USPSTF) hasremained true to its original mission: 1) to evaluatethe benefits of primary and secondary preventiveservices in apparently healthy persons based on age,sex, and risk factors for disease, and 2) to makerecommendations about which preventive servicesshould be incorporated into primary care practice.While the intended audience for theserecommendations continues to be primary careclinicians, the reach of the Task Force has expandedover time: recommendations of the USPSTF arenow considered by many to be the “gold standard”for preventive services, informing recommendationsdeveloped by professional societies, coverage policiesof many health plans and insurers, health carequality measures, and national health objectives.

USPSTF methods have evolved to incorporatenot only the quality of evidence supporting a specificpreventive service, but also the magnitude of netbenefit in providing the service. Eachrecommendation is based on a rigorous review of theevidence involving a series of steps:

• Creation of an analytic framework and a set ofkey questions that determines the scope of theliterature review.

v

• Systematic review of the relevant literature toanswer the key questions.

• Quality rating of bodies of literature supportingeach key question.

• Estimation of benefits and harms.

• Determination of the balance of benefits andharms of the service.

The recommendation is then linked to a lettergrade that reflects the magnitude of net benefit(balance of benefits and harms) and the strength ofthe evidence supporting the provision of a specificpreventive service. The recommendation is gradedfrom “A” (strongly recommended) to “D”(recommended against). The Task Force gives an“I” recommendation when the evidence isinsufficient to determine net benefit.

The USPSTF realizes that clinical decisionsabout patients involve more complex considerationsthan the evidence alone; clinicians should alwaysunderstand the evidence but individualize decision-making to the specific patient and situation. TheClinical Considerations section of each USPSTFRecommendation Statement helps cliniciansimplement the recommendations by offeringpractical information so they can tailor theserecommendations to individual patients. TheUSPSTF suggests that clinicians:

vi

Preface

• Discuss services with “A” and “B”recommendations with eligible patients, andoffer them as a priority.

• Discourage the use of services with “D”recommendations unless there are unusualadditional considerations.

• Give lower priority to services with “C”recommendations; they need not be providedunless there are individual considerations in favorof providing the service.

• For services with “I” recommendations, carefullyread the Clinical Considerations section forguidance, and help patients understand theuncertainty surrounding these services.

The Guide to Clinical Preventive Services 2005 is acompilation of abridged USPSTF recommendationsreleased from 2001 to 2004 and can be used as anevidence-based tool at the point of patient care.Some recommendations have been updated fromthose made by the USPSTF in 1996, while othersaddress preventive services not previously consideredby the USPSTF. The complete USPSTFrecommendation statements are available along withtheir supporting scientific evidence atwww.preventiveservices.ahrq.gov. In addition, theUSPSTF searchable PDA program, the Interactive

vii

Preface

Preventive Services Selector, is updated regularly withall current “A,” “B,” and “D” USPSTFrecommendations. The program is available athttp://pda.ahrq.gov.

I hope you find The Guide to Clinical PreventiveServices 2005 to be a useful tool as you care forpatients.

Ned Calonge, M.D., M.P.H.Chair, U.S. Preventive Services Task Force

viii

Preface

ContentsForeword ................................................................iii

Preface .....................................................................v

Section 1. Preventive Services Recommended by the USPSTF

Recommended Preventive Services ...................3

Table of Recommended Preventive Services .......................................................8

Section 2. Recommendations for Adults

Cancer...............................................................15

Bladder Cancer in Adults, Screening...............15Breast Cancer, Chemoprevention....................17Breast Cancer, Screening ................................23Cervical Cancer, Screening..............................26Colorectal Cancer, Screening ..........................32Lung Cancer Screening ...................................36Oral Cancer, Screening ...................................38Ovarian Cancer, Screening..............................39Pancreatic Cancer, Screening...........................41Prostate Cancer, Screening ..............................43Skin Cancer, Counseling to Prevent................46Skin Cancer, Screening....................................48Testicular Cancer, Screening............................50Vitamin Supplementation to Prevent Cancer

and Cardiovascular Disease, Routine .........52

ix

Heart and Vascular Diseases .............................55

Aspirin for the Primary Prevention of Cardiovascular Events ................................55

Coronary Heart Disease, Screening.................60High Blood Pressure, Screening ......................63Lipid Disorders in Adults, Screening...............67

Infectious Diseases ...........................................71

Asymptomatic Bacteriuria, Screening..............71Chlamydial Infection, Screening .....................73Hepatitis B Virus Infection, Screening............77Hepatitis C in Adults, Screening.....................79Syphilis Infection, Screening ...........................81

Injury and Violence ..........................................85

Family and Intimate Partner Violence, Screening ...................................................85

Mental Health Conditions and Substance Abuse ...........................................................89

Alcohol Misuse, Screening and BehavioralCounseling Interventions in Primary Careto Reduce ..................................................89

Dementia, Screening .......................................96Depression, Screening .....................................98

Suicide Risk, Screening .................................102Tobacco Use and Tobacco-Caused Disease,

Counseling to Prevent .............................104

x

Contents

Metabolic, Nutritional, and Endocrine Conditions .................................................109

Diet, Behavioral Counseling in PrimaryCare to Promote a Healthy......................109

Hormone Therapy for the Prevention of Chronic Conditions in Postmenopausal Women....................................................115

Obesity in Adults, Screening.........................118

Physical Activity, Behavioral Counseling in Primary Care to Promote .......................123

Thyroid Disease, Screening ..........................126Type 2 Diabetes Mellitus in Adults,

Screening .................................................128

Musculoskeletal Conditions ...........................133

Low Back Pain in Adults, Primary Care Interventions to Prevent ..........................133

Osteoporosis in Postmenopausal Women, Screening .................................................135

Obstetric and Gynecologic Conditions ..........141Bacterial Vaginosis in Pregnancy, Screening ..141Breastfeeding, Behavioral Interventions to

Promote ..................................................143Gestational Diabetes Mellitus, Screening ......146Rh (D) Incompatibility, Screening ...............148

xi

Contents

Section 3. Recommendations for Children

Dental Caries in Preschool Children, Prevention ...............................................153

Idiopathic Scoliosis in Adolescents, Screening ................................................155

Newborn Hearing Screening ........................157Visual Impairment in Children Younger

Than Age 5 Years, Screening....................159

Appendixes and Index

Appendix A. How the U.S. Preventive Services Task Force Grades Its Recommendations ..164

Appendix B. Members of the U.S. Preventive Services Task Force 2001-2004 ...............166

Appendix C. Acknowledgments ....................169Index of Recommendations (Alphabetical by

Topic) ......................................................173

xii

Contents

Section 1.

Preventive ServicesRecommended by theUSPSTF

All recommendation statements in this Guide areabridged. To see the full recommendation statements and recommendations published after 2004, go towww.preventiveservices.ahrq.gov.

Recommended PreventiveServices

The U.S. Preventive Services Task Force (USPSTF)recommends that clinicians discuss these preventiveservices with eligible patients and offer them as apriority. All these services have received an “A”(strongly recommended) or a “B” (recommended)grade from the Task Force.

For definitions of all grades used by the USPSTF,see the inside front cover. The full listings of allUSPSTF recommendations for adults and children arein Section 2 (P. 13) and Section 3 (P. 151).

Alcohol Misuse, Screening and BehavioralCounseling Interventions in Primary Care toReduce. Use screening and behavioral counseling toreduce alcohol misuse by adults, including pregnantwomen. “B” Recommendation. (P. 89)

Aspirin for the Primary Prevention ofCardiovascular Events. Discuss aspirinchemoprevention with adults who are at increased riskfor coronary heart disease. Address the potentialbenefits and harms of aspirin therapy. “A”Recommendation. (P. 55)

Bacteriuria, Screening for Asymptomatic. Screen allpregnant women, using urine culture, at 12-16 weeks’gestation. “A” Recommendation. (P. 71)

3

Recommended Preventive Services

Breast Cancer, Chemoprevention. Discuss withwomen at high risk for breast cancer and at low riskfor adverse effects of chemoprevention. Inform patientsof the potential benefits and harms. “B”Recommendation. (P. 17)

Breast Cancer, Screening. Screening mammography,with or without clinical breast examination, every 1-2years for women 40 years of age and older. “B” Recommendation. (P. 23)

Breastfeeding, Behavioral Interventions to Promote.Recommend structured breastfeeding education andbehavioral counseling programs. “B” Recommendation.(P. 143)

Cervical Cancer, Screening. Screen women who havebeen sexually active and have a cervix. “A” Recommendation. (P. 26)

Chlamydial Infection, Screening. Routinely screen allsexually active women 25 years of age and younger,and other asymptomatic women at increased risk forinfection. “A” Recommendation. Routinely screen allasymptomatic pregnant women 25 years of age andyounger and others at increased risk. “B” Recommendation. (P. 73)

Colorectal Cancer, Screening. Screen men andwomen 50 years of age or older. “A” Recommendation.(P. 32)

Dental Caries in Preschool Children, Prevention.Primary care clinicians should prescribe oral fluoridesupplementation at currently recommended doses to

4


preschool children older than 6 months of age whoseprimary water source is deficient in fluoride. “B” Recommendation. (P. 153)

Depression, Screening. Screen adults in clinicalpractices that have systems in place to assure accuratediagnosis, effective treatment, and follow-up. “B” Recommendation. (P. 98)

Diabetes Mellitus in Adults, Screening for Type 2.Screen adults with hypertension or hyperlipidemia. “B” Recommendation. (P. 128)

Diet, Behavioral Counseling in Primary Care toPromote a Healthy. Intensive behavioral dietarycounseling for adult patients with hyperlipidemia andother known risk factors for cardiovascular and diet-related chronic disease. Intensive counseling can bedelivered by primary care clinicians or by referral toother specialists, such as nutritionists or dietitians. “B”Recommendation. (P. 109)

Hepatitis B Virus Infection, Screening. Screenpregnant women at their first prenatal visit. “A” Recommendation. (P. 77)

High Blood Pressure, Screening. Screen adults 18years of age and older. “A” Recommendation. (P. 63)

Lipid Disorders in Adults, Screening. Routinelyscreen men 35 years of age and older and women 45years of age and older. Treat abnormal lipids in peopleat increased risk for coronary heart disease. “A”Recommendation. Routinely screen younger adults

5


(men 20 to 35 years of age and women 20 to 45 yearsof age) if they have other risk factors for coronary heartdisease. “B” Recommendation. Include measurement oftotal cholesterol and high density lipoproteincholestereol. “B” Recommendation. (P. 67)

Obesity in Adults, Screening. Screen all adultpatients. Offer intensive counseling and behavioralinterventions to promote sustained weight loss forobese adults. “B” Recommendation. (P. 118)

Osteoporosis in Postmenopausal Women,Screening. Routinely screen women 65 years of ageand older. Begin at age 60 for women at increased riskfor osteoporotic fractures. “B” Recommendation. (P. 135)

Rh (D) Incompatibility, Screening. Perform Rh (D)blood typing and antibody testing for all pregnantwomen during their first visit for pregnancy-relatedcare. “A” Recommendation. Repeated Rh (D) antibodytesting for all unsensitized Rh (D)-negative women at24-28 weeks’ gestation, unless the biological father isknown to be Rh (D)-negative. “B” Recommendation.(P. 148)

6


Syphilis Infection, Screening. Screen persons atincreased risk and all pregnant women. “A”Recommendation. (P. 81)

Tobacco Use and Tobacco-Caused Disease,Counseling to Prevent. Screen all adults and providetobacco cessation interventions for those who usetobacco products. Screen all pregnant women andprovide augmented pregnancy-tailored counseling tothose who smoke. “A” Recommendation. (P. 104)

Visual Impairment in Children Younger Than Age 5Years, Screening. Screen to detect amblyopia,strabismus, and defects in visual acuity. “B”Recommendation. (P. 159)

7


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Section 2.

Recommendationsfor Adults


Clinical Considerations

n Bladder cancer is 2 to 3 times more common inmen than in women and is unusual before age 50.Bladder cancer is heterogeneous; it is a spectrum ofconditions, most of which are not life-threatening.

n Screening tests—such as microscopic urinalysis,urine dipstick, urine cytology, or such new tests asbladder tumor antigen (BTA) or nuclear matrixprotein (NMP22) immunoassay—can detectbladder cancers that are clinically unapparent.However, because of the low prevalence of bladdercancer, the positive predictive value of these tests islow.

n Smoking increases the risk for bladder cancer; about50% of all cases of bladder cancer occur in currentor former smokers. Smokers should be counseled onquitting smoking.

Cancer

Screening for Bladder Cancer in Adults

15

Summary of Recommendation

The U.S. Preventive Services Task Force(USPSTF) recommends against routine screeningfor bladder cancer in adults. Rating: DRecommendation.

n People in occupations that involve exposure tochemicals used in the dye or rubber industries mayalso have increased risk for bladder cancer. TheUSPSTF did not review the evidence for targetedscreening for those with occupational exposure.

This USPSTF recommendation was first published by:Agency for Healthcare Research and Quality, Rockville,MD. June 2004. www.preventiveservices.ahrq.gov.

16

Screening for Bladder Cancer in Adults


n Clinicians should consider both the risk for breastcancer and the risk for adverse effects whenidentifying women who may be candidates forchemoprevention.

Risk for breast cancer. Older age; a family history ofbreast cancer in a mother, sister, or daughter; and ahistory of atypical hyperplasia on a breast biopsy arethe strongest risk factors for breast cancer. Table 1indicates how the estimated benefits of tamoxifenvary depending on age and family history. Otherfactors that contribute to risk include race, early ageat menarche, pregnancy history (nulliparity or older

Chemoprevention of Breast Cancer

17

Summary of Recommendations

The U.S. Preventive Services Task Force(USPSTF) recommends against routine use oftamoxifen or raloxifene for the primary preventionof breast cancer in women at low or average riskfor breast cancer. (See Clinical Considerations for adiscussion of risk.) Rating: D Recommendation.

The USPSTF recommends that cliniciansdiscuss chemoprevention with women at high riskfor breast cancer and at low risk for adverse effectsof chemoprevention. (See Clinical Considerationsfor a discussion of risk.) Clinicians should informpatients of the potential benefits and harms ofchemoprevention. Rating: B Recommendation.

age at first birth), and number of breast biopsies.The risk for developing breast cancer within thenext 5 years can be estimated using risk factorinformation by completing the National CancerInstitute Breast Cancer Risk Tool (the “Gailmodel,” available at http://cancer.gov/bcrisktool/ or800-4-CANCER). Clinicians can use thisinformation to help individual patients consideringtamoxifen therapy estimate the potential benefit.However, the validity, feasibility, and impact ofusing the Gail model to identify appropriatecandidates for chemoprevention have not beentested in a primary care setting. The Gail modeldoes not incorporate estradiol levels or estrogen use,factors that some studies suggest may influence theeffectiveness of tamoxifen.

Risk for adverse effects. Women are at lower risk foradverse effects from chemoprevention if they areyounger; have no predisposition to thromboembolicevents such as stroke, pulmonary embolism, or deepvenous thrombosis; or do not have a uterus.

n In general, the balance of benefits and harms ofchemoprevention is more favorable for:

1. Women in their 40s who are at increased risk forbreast cancer and have no predisposition tothromboembolic events.

2. Women in their 50s who are at increased risk forbreast cancer, have no predisposition tothromboembolic events, and do not have auterus.

18


n For example, a woman who is 45 years of age andhas a mother, sister, or daughter with breast cancerwould have approximately a 1.6 percent risk fordeveloping breast cancer over the next 5 years(Table 1). On average, treating such women withtamoxifen for 5 years would prevent about threetimes as many invasive cancers (8 per 1,000) as thenumber of serious thromboembolic complicationscaused (1 stroke and 1 to 2 pulmonary emboli per1,000). Among women 55 years of age, benefitsexceed harms only for those who are not at risk forendometrial cancer; and the margin of benefit issmall unless risk for breast cancer is substantiallyincreased (for example, 4% over 5 years).

n Women younger than 40 years of age have a lowerrisk for breast cancer, and thus will not experienceas large an absolute benefit from breast cancerchemoprevention as older women. Women 60 yearsof age and older, who have the highest risk forbreast cancer also have the highest risk forcomplications from chemoprevention, with a lessfavorable balance of benefits and harms.TheUSPSTF found more evidence for the benefits oftamoxifen than for the benefits of raloxifene.Currently, only tamoxifen is approved by the U.S.Food and Drug Administration (FDA) for thespecific indication of breast cancerchemoprevention. Although there are biologicalreasons to suspect that raloxifene should havesimilar benefits, trial data currently are limited to

19



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one study in which the primary outcome wasfracture prevention. Additional trials to furtherevaluate this drug’s efficacy for breast cancerchemoprevention are underway, including a trialcomparing efficacy and safety of raloxifene andtamoxifen. Raloxifene is approved by the FDA forpreventing and treating osteoporosis.

Reference1. Gail MH, Costantino JH, Bryant J, et al. Weighing the

risks and benefits of tamoxifen treatment for preventingbreast cancer. J Natl Cancer Inst. 1999;91:1829-1846.

This USPSTF recommendation was first published in:Ann Intern Med. 2002; 137(1):56-58.

22



n The precise age at which the benefits fromscreening mammography justify the potential harmsis a subjective judgment and should take intoaccount patient preferences. Clinicians shouldinform women about the potential benefits(reduced chance of dying from breast cancer),potential harms (eg, false-positive results,unnecessary biopsies), and limitations of the testthat apply to women their age. Clinicians shouldtell women that the balance of benefits andpotential harms of mammography improves withincreasing age for women between the ages of 40and 70.

Screening for Breast Cancer

23


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.Rating: B Recommendation.

The USPSTF concludes that the evidence isinsufficient to recommend for or against routineCBE alone to screen for breast cancer. Rating: I Recommendation.

The USPSTF concludes that the evidence isinsufficient to recommend for or against teachingor performing routine breast self-examination(BSE). Rating: I Recommendation.

n Women who are at increased risk for breast cancer(eg, those with a family history of breast cancer in amother or sister, a previous breast biopsy revealingatypical hyperplasia, or first childbirth after age 30)are more likely to benefit from regularmammography than women at lower risk. Therecommendation for women to begin routinescreening in their 40s is strengthened by a familyhistory of breast cancer having been diagnosedbefore menopause.

n The USPSTF did not examine whether womenshould be screened for genetic mutations (eg,BRCA1 and BRCA2) that increase the risk fordeveloping breast cancer, or whether women withgenetic mutations might benefit from earlier ormore frequent screening for breast cancer.

n In the trials that demonstrated the effectiveness ofmammography in lowering breast cancer mortality,screening was performed every 12-33 months. Forwomen aged 50 and older, there is little evidence tosuggest that annual mammography is more effectivethan mammography done every other year. Forwomen aged 40-49, available trials also have notreported a clear advantage of annual mammographyover biennial mammography. Nevertheless, someexperts recommend annual mammography basedon the lower sensitivity of the test and on evidencethat tumors grow more rapidly in this age group.

n The precise age at which to discontinue screeningmammography is uncertain. Only 2 randomized

24


controlled trials enrolled women older than 69 andno trials enrolled women older than 74. Olderwomen face a higher probability of developing anddying from breast cancer but also have a greaterchance of dying from other causes. Women withcomorbid conditions that limit their life expectancyare unlikely to benefit from screening.

n Clinicians should refer patients to mammographyscreening centers with proper accreditation andquality assurance standards to ensure accurateimaging and radiographic interpretation. Cliniciansshould adopt office systems to ensure timely andadequate follow-up of abnormal results. A listing ofaccredited facilities is available athttp://www.fda.gov/cdrh/mammography/certified.html.

n Clinicians who advise women to perform BSE orwho perform routine CBE to screen for breastcancer should understand that there is currentlyinsufficient evidence to determine whether thesepractices affect breast cancer mortality, and thatthey are likely to increase the incidence of clinicalassessments and biopsies.

This USPSTF recommendation was first published in:Ann Intern Med. 2002; 137 (Part 1):344-346.

25


Screening for Cervical Cancer

26


The U.S. Preventive Services Task Force(USPSTF) strongly recommends screening forcervical cancer in women who have been sexuallyactive and have a cervix. Rating: ARecommendation.

The USPSTF recommends against routinelyscreening women older than age 65 for cervicalcancer if they have had adequate recent screeningwith normal Pap smears and are not otherwise athigh risk for cervical cancer (go to ClinicalConsiderations). Rating: D Recommendation.

The USPSTF recommends against routine Papsmear screening in women who have had a totalhysterectomy for benign disease. Rating: DRecommendation.

The USPSTF concludes that the evidence isinsufficient to recommend for or against theroutine use of new technologies to screen forcervical cancer. Rating: I Recommendation.

The USPSTF concludes that the evidence isinsufficient to recommend for or against theroutine use of human papillomavirus (HPV)testing as a primary screening test for cervicalcancer. Rating: I Recommendation.


n The goal of cytologic screening is to sample thetransformation zone, the area where physiologictransformation from columnar endocervicalepithelium to squamous (ectocervical) epitheliumtakes place and where dysplasia and cancer arise. Ameta-analysis of randomized trials supports thecombined use of an extended tip spatula to samplethe ectocervix and a cytobrush to sample theendocervix.1

n The optimal age to begin screening is unknown.Data on natural history of HPV infection and theincidence of high-grade lesions and cervical cancersuggest that screening can safely be delayed until 3years after onset of sexual activity or until age 21,whichever comes first.2 Although there is little valuein screening women who have never been sexuallyactive, many U.S. organizations recommend routinescreening by age 18 or 21 for all women, based onthe generally high prevalence of sexual activity bythat age in the U.S. and concerns that cliniciansmay not always obtain accurate sexual histories.

n Discontinuation of cervical cancer screening in olderwomen is appropriate, provided women have hadadequate recent screening with normal Pap results.The optimal age to discontinue screening is not clear,but risk of cervical cancer and yield of screeningdecline steadily through middle age. The USPSTFfound evidence that yield of screening was low inpreviously screened women after age 65. New

27


American Cancer Society (ACS) recommendationssuggest stopping cervical cancer screening at age 70.Screening is recommended in older women whohave not been previously screened, wheninformation about previous screening is unavailable,or when screening is unlikely to have occurred inthe past (eg, among women from countries withoutscreening programs). Evidence is limited to define“adequate recent screening.” The ACS guidelinesrecommend that older women who have had threeor more documented, consecutive, technicallysatisfactory normal/negative cervical cytology tests,and who have had no abnormal/positive cytologytests within the last 10 years, can safely stopscreening.2

n The USPSTF found no direct evidence that annualscreening achieves better outcomes than screeningevery 3 years. Modeling studies suggest little addedbenefit of more frequent screening for most women.The majority of cervical cancers in the UnitedStates occur in women who have never beenscreened or who have not been screened within thepast 5 years; additional cases occur in women whodo not receive appropriate follow-up after anabnormal Pap smear.3,4 Because sensitivity of asingle Pap test for high-grade lesions may only be60-80%, however, most organizations in the UnitedStates recommend that annual Pap smears beperformed until a specified number (usually two orthree) are cytologically normal before lengtheningthe screening interval.5 The ACS guidelines suggest

28


waiting until age 30 before lengthening thescreening interval2; the American College ofObstetricians and Gynecologists (ACOG) identifiesadditional risk factors that might justify annualscreening, including a history of cervical neoplasia,infection with HPV or other sexually transmitteddiseases (STDs), or high-risk sexual behavior,7 butdata are limited to determine the benefits of thesestrategies.7

n Discontinuation of cytological screening after totalhysterectomy for benign disease (eg, no evidence ofcervical neoplasia or cancer) is appropriate given thelow yield of screening and the potential harms fromfalse-positive results in this population.7,8 Cliniciansshould confirm that a total hysterectomy wasperformed (through surgical records or inspectingfor absence of a cervix); screening may beappropriate when the indications for hysterectomyare uncertain. ACS and ACOG recommendcontinuing cytologic screening after hysterectomyfor women with a history of invasive cervical canceror DES exposure due to increased risk for vaginalneoplasms, but data on the yield of such screeningare sparse.

n A majority of cases of invasive cervical cancer occurin women who are not adequately screened.3,4

Clinicians, hospitals, and health plans shoulddevelop systems to identify and screen the subgroupof women who have had no screening or who havehad inadequate past screening.

29


n Newer Food and Drug Administration (FDA)-approved technologies, such as the liquid-basedcytology (eg, ThinPrep®), may have improvedsensitivity over conventional Pap smear screening,but at a considerably higher cost and possibly withlower specificity. Even if sensitivity is improved,modeling studies suggest these methods are notlikely to be cost-effective unless used with screeningintervals of 3 years or longer. Liquid-based cytologypermits testing of specimens for HPV, which maybe useful in guiding management of women whosePap smear reveals atypical squamous cells. HPVDNA testing for primary cervical cancer screeninghas not been approved by the FDA and its role inscreening remains uncertain.

References1. Martin-Hirsch P, Lilford R, Jarvis G, Kitchener HC.

Efficacy of cervical-smear collection devices: a systematicreview and meta-analysis [published erratum appears inLancet. 2000 Jan 29;355(9201):414]. Lancet.1999;354(9192):1763-1770.

2. Smith RA, Cokkinides V, von Eschenbach AC, et al.American Cancer Society Guideline for the EarlyDetection of Cervical Neoplasia and Cancer. CA CancerJ Clin. 2002;52(1):8-22.

3. Hildesheim A, Hadjimichael O, Schwartz PE, et al. Riskfactors for rapid-onset cervical cancer. Am J ObstetGynecol. 1999;180(3 Pt 1):571-577.

30


4. Janerich DT, Hadjimichael O, Schwartz PE, et al. Thescreening histories of women with invasive cervicalcancer, Connecticut. Am J Public Health.1995;85(6):791-794.

5. Hartman KE, Hall SA, Nanda K, Boggess JF, ZolnounD. Screening for Cervical Cancer. Systematic EvidenceReview. No. 25. (Prepared by the Research TriangleInstitute-University of North Carolina Evidence-basedPractice Center under contract No. 290-97-0011).Rockville, MD: Agency for Healthcare Research andQuality. January 2002. Available on the AHRQ Website: at: www.ahrq.gov/clinic/serfiles.htm.

6. American College of Obstetricians and Gynecologists.Guidelines for Women’s Health Care. 2nd ed. Washington,DC: ACOG;2002: 121-134, 140-141.

7. Mitchell HS, Giles GG. Cancer diagnosis after a reportof negative cervical cytology. Med J Aust.1996;164(5):270-273.

8. Sigurdsson K. Trends in cervical intra-epithelialneoplasia in Iceland through 1995: evaluation oftargeted age groups and screening intervals. Acta ObstetGynecol Scand. 1999;78(6):486-492.

This USPSTF recommendation was first published by:Agency for Healthcare Research and Quality, Rockville,MD. January 2003. www.preventiveservices.ahrq.gov.

31



n Potential screening options for colorectal cancerinclude home fecal occult blood testing (FOBT),flexible sigmoidoscopy, the combination of homeFOBT and flexible sigmoidoscopy, colonoscopy,and double-contrast barium enema. Each optionhas advantages and disadvantages that may vary forindividual patients and practice settings. The choiceof specific screening strategy should be based onpatient preferences, medical contraindications,patient adherence, and available resources for testingand follow-up. Clinicians should talk to patientsabout the benefits and potential harms associatedwith each option before selecting a screeningstrategy.

n The optimal interval for screening depends on thetest. Annual FOBT offers greater reductions inmortality rates than biennial screening but producesmore false-positive results. A 10-year interval hasbeen recommended for colonoscopy on the basis ofevidence regarding the natural history ofadenomatous polyps. Shorter intervals (5 years)

Screening for Colorectal Cancer

32


The U.S. Preventive Services Task Force(USPSTF) strongly recommends that cliniciansscreen men and women 50 years of age or older forcolorectal cancer. Rating: A Recommendation.

have been recommended for flexible sigmoidoscopyand double-contrast barium enema because of theirlower sensitivity, but there is no direct evidencewith which to determine the optimal interval fortests other than FOBT. Case-control studies havesuggested that sigmoidoscopy every 10 years may beas effective as sigmoidoscopy performed at shorterintervals.

n The USPSTF recommends initiating screening at50 years of age for men and women at average riskfor colorectal cancer, based on the incidence ofcancer above this age in the general population. Inpersons at higher risk (for example, those with afirst-degree relative who receives a diagnosis withcolorectal cancer before 60 years of age), initiatingscreening at an earlier age is reasonable.

n Expert guidelines exist for screening very high-riskpatients, including those with a history suggestive offamilial polyposis or hereditary nonpolyposiscolorectal cancer, or those with a personal history ofulcerative colitis.1 Early screening with colonoscopymay be appropriate, and genetic counseling ortesting may be indicated for patients with geneticsyndromes.

n The appropriate age at which colorectal cancerscreening should be discontinued is not known.Screening studies have generally been restricted topatients younger than 80 years of age, withcolorectal cancer mortality rates beginning todecrease within 5 years of initiating screening. Yield

33


of screening should increase in older persons(because of higher incidence of colorectal cancer),but benefits may be limited as a result of competingcauses of death. Discontinuing screening is thereforereasonable in patients whose age or comorbidconditions limit life expectancy.

n Proven methods of FOBT screening use guaiac-based test cards prepared at home by patients fromthree consecutive stool samples and forwarded tothe clinician. Whether patients need to restrict theirdiet and avoid certain medications is notestablished. Rehydration of the specimens beforetesting increases the sensitivity of FOBT butsubstantially increases the number of false-positivetest results. Neither digital rectal examination(DRE) nor the testing of a single stool specimenobtained during DRE is recommended as anadequate screening strategy for colorectal cancer.

n The combination of FOBT and sigmoidoscopy maydetect more cancers and more large polyps thaneither test alone, but the additional benefits andpotential harms of combining the 2 tests areuncertain. In general, FOBT should precedesigmoidoscopy because a positive test result is anindication for colonoscopy, obviating the need forsigmoidoscopy.

n Colonoscopy is the most sensitive and specific testfor detecting cancer and large polyps but isassociated with higher risks than other screening

34


tests for colorectal cancer. These include a small riskfor bleeding and risk for perforation, primarilyassociated with removal of polyps or biopsiesperformed during screening. Colonoscopy alsousually requires more highly trained personnel,overnight bowel preparation, sedation, and longerrecovery time, which may necessitate transportationfor the patient. It is not certain whether thepotential added benefits of colonoscopy relative toscreening alternatives are large enough to justify theadded risks and inconvenience for all patients.

n Initial costs of colonoscopy are higher than the costsof other tests. Estimates of cost-effectiveness,however, suggest that, from a societal perspective,compared with no screening, all methods ofcolorectal cancer screening are likely to be as cost-effective as many other clinical preventive services-less than $30,000 per additional year of life gained.

Reference1. Winawer SJ, Fletcher RH, Miller L, Godlee F, Stolar

MH, Mulrow CD, et al. Colorectal cancer screening:clinical guidelines and rationale. Gastroenterology.1997;112:594-642.

This USPSTF recommendation was first published in:Ann Intern Med. 2002;137:129-131.

35



n The benefit of screening for lung cancer has notbeen established in any group, includingasymptomatic high-risk populations such as oldersmokers. The balance of harms and benefitsbecomes increasingly unfavorable for persons atlower risk, such as nonsmokers.

n The sensitivity of LDCT for detecting lung canceris 4 times greater than the sensitivity of CXR.However, LDCT is also associated with a greaternumber of false-positive results, more radiationexposure, and increased costs compared with CXR.

n Because of the high rate of false-positive results,many patients will undergo invasive diagnosticprocedures as a result of lung cancer screening.Although the morbidity and mortality rates fromthese procedures in asymptomatic individuals are

Lung Cancer Screening

36


The U.S. Preventive Services Task Force(USPSTF) concludes that the evidence isinsufficient to recommend for or against screeningasymptomatic persons for lung cancer with eitherlow dose computerized tomography (LDCT),chest x-ray (CXR), sputum cytology, or acombination of these tests. Rating: IRecommendation.

not available, mortality rates due to complicationsfrom surgical interventions in symptomatic patientsreportedly range from 1.3% to 11.6%; morbidityrates range from 8.8% to 44%, with higher ratesassociated with larger resections.

n Other potential harms of screening are potentialanxiety and concern as a result of false-positive tests,as well as possible false reassurance because of false-negative results. However, these harms have notbeen adequately studied.


37

Lung Cancer Screening


n Direct inspection and palpation of the oral cavity isthe most commonly recommended method ofscreening for oral cancer, although there are littledata on the sensitivity and specificity of thismethod. Screening techniques other than inspectionand palpation are being evaluated but are stillexperimental.

n Tobacco use in all forms is the biggest risk factor fororal cancer. Alcohol abuse combined with tobaccouse increases risk.

n Clinicians should be alert to the possibility of oralcancer when treating patients who use tobacco oralcohol.

n Patients should be encouraged to not use tobaccoand to limit alcohol use in order to decrease theirrisk 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. http://www.ahrq.gov/clinic/3rduspstf/oralcan/oralcanrs.htm.

Screening for Oral Cancer

38


The U.S. Preventive Services Task Force(USPSTF) concludes that the evidence is insufficientto recommend for or against routinely screeningadults for oral cancer. Rating: I Recommendation.


n There is no existing evidence that any screeningtest, including CA-125, ultrasound, or pelvicexamination, reduces mortality from ovarian cancer.Furthermore, existing evidence that screening candetect early-stage ovarian cancer is insufficient toindicate that this earlier diagnosis will reducemortality.

n Because there is a low incidence of ovarian cancer inthe general population (age-adjusted incidence of17 per 100,000 women), screening for ovariancancer is likely to have a relatively low yield. Thegreat majority of women with a positive screeningtest will not have ovarian cancer (ie, they will have afalse-positive result). In women at average risk, thepositive predictive value of an abnormal screeningtest is, at best, approximately 2% (ie, 98% ofwomen with positive test results will not haveovarian cancer).

n The positive predictive value of an initially positivescreening test would be more favorable for womenat higher risk. For example, the lifetime probabilityof ovarian cancer increases from about 1.6% in a

Screening for Ovarian Cancer

39


The U.S. Preventive Services Task Force(USPSTF) recommends against routine screeningfor ovarian cancer. Rating: D Recommendation.

35-year-old woman without a family history ofovarian cancer to about 5% if she has 1 relative and7% if she has 2 relatives with ovarian cancer. Ifongoing clinical trials show that screening has abeneficial effect on mortality rates, then women athigher risk are likely to experience the greatestbenefit.

This USPSTF recommendation was first published in:Ann Fam Med. 2004;2:260-262.

40

Screening for Ovarian Cancer


n Due to the poor prognosis of those diagnosed withpancreatic cancer, there is an interest in primaryprevention. The evidence for diet-based preventionof pancreatic cancer is limited and conflicting.Some experts recommend lifestyle changes that mayhelp to prevent pancreatic cancer, such as stoppingthe use of tobacco products, moderating alcoholintake, and eating a balanced diet with sufficientfruit and vegetables.

n Persons with hereditary pancreatitis may have ahigher lifetime risk for developing pancreaticcancer.1 However, the USPSTF did not review theeffectiveness of screening these patients.

Screening for Pancreatic Cancer

41


The U.S. Preventive Services Task Force(USPSTF) recommends against routine screeningfor pancreatic cancer in asymptomatic adultsusing abdominal palpation, ultrasonography, orserologic markers. Rating: D Recommendation.

Reference1. Lowenfels AB, Maisonneuve P, DiMagno EP, et al.

Hereditary pancreatitis and the risk of pancreatic cancer. International Hereditary Pancreatitis StudyGroup. J Natl Cancer Inst. 1997;89:442-446.

This USPSTF recommendation was first published by:Agency for Healthcare Research and Quality, Rockville,MD. February 2004. www.preventiveservices.ahrq.gov.

42

Screening for Pancreatic Cancer


n Prostate specific antigen (PSA) testing and digitalrectal examination (DRE) can effectively detectprostate cancer in its early pathologic stages. Recentevidence suggests that radical prostatectomy canreduce prostate cancer mortality in men whosecancer is detected clinically. The balance ofpotential benefits (the reduction of morbidity andmortality from prostate cancer) and harms (false-positive results, unnecessary biopsies, and possiblecomplications) of early treatment of the types ofcancers found by screening, however, remainsuncertain. Therefore, the benefits of screening forearly prostate cancer remain unknown. Ongoingscreening trials, and trials of treatment versus“watchful waiting” for cancers detected byscreening, may help clarify the benefits of earlydetection of prostate cancer.

n Despite the absence of firm evidence ofeffectiveness, some clinicians may opt to performprostate cancer screening for other reasons. Given

Screening for Prostate Cancer

43


The U.S. Preventive Services Task Force(USPSTF) concludes that the evidence isinsufficient to recommend for or against routinescreening for prostate cancer using prostate specificantigen (PSA) testing or digital rectal examination(DRE). Rating: I recommendation.

the uncertainties and controversy surroundingprostate cancer screening, clinicians should notorder the PSA test without first discussing with thepatient the potential but uncertain benefits and thepossible harms of prostate cancer screening. Menshould be informed of the gaps in the evidence, andthey should be assisted in considering their personalpreferences and risk profile before deciding whetherto be tested.

n If early detection improves health outcomes, thepopulation most likely to benefit from screeningwill be men aged 50 to 70 who are at average risk,and men older than 45 who are at increased risk(African American men and men with a familyhistory of a first-degree relative with prostatecancer).1 Benefits may be smaller in AsianAmericans, Hispanics, and other racial and ethnicgroups that have a lower risk of prostate cancer.Older men and men with other significant medicalproblems who have a life expectancy of fewer than10 years are unlikely to benefit from screening.1

n PSA testing is more sensitive than DRE for thedetection of prostate cancer. PSA screening with theconventional cut-point of 4.0 ng/ml detects a largemajority of prostate cancers; however, a significantpercentage of early prostate cancers (10% to 20%)will be missed by PSA testing alone.2 Using a lowerthreshold to define an abnormal PSA detects morecancers at the cost of more false positives and more

44


biopsies. The yield of screening in terms of cancerdetected declines rapidly with repeated annualtesting.1 If screening were to reduce mortality,biennial PSA screening could yield as much benefitas annual screening.

References1. Harris RP, Lohr KN. Screening for prostate cancer: an

update of the evidence for the U.S. Preventive ServicesTask Force. Ann Intern Med. 2002; 137:917-929.

2. Harris RP, Lohr KN, Beck R, Fink K, Godley P, BuntonA. Screening for Prostate Cancer. Systematic EvidenceReview No. 16 (Prepared by the Research TriangleInstitute-University of North Carolina Evidence-basedPractice Center under Contract No. 290-97-0011).Rockville, MD: Agency for Healthcare Research andQuality. December 2001. (Available on the AHRQ Website at: www.ahrq.gov/clinic/serfiles.htm).


45



n Using sunscreen has been shown to preventsquamous cell skin cancer. The evidence for theeffect of sunscreen use in preventing melanoma,however, is mixed. Sunscreens that block bothultraviolet A (UV-A) and ultraviolet B (UV-B) lightmay be more effective in preventing squamous cellcancer and its precursors than those that block onlyUV-B light. However, people who use sunscreenalone could increase their risk for melanoma if theyincrease the time they spend in the sun.

n UV exposure increases the risk for skin canceramong people with all skin types, but especiallyfair-skinned people. Those who sunburn readilyand tan poorly, namely those with red or blond hairand fair skin that freckles or burns easily, are athighest risk for developing skin cancer and wouldbenefit most from sun protection behaviors. Theincidence of melanoma among whites is 20 timeshigher than it is among blacks; the incidence ofmelanoma among whites is about 4 times higherthan it is among Hispanics.

Counseling to Prevent Skin Cancer

46


The U.S. Preventive Services Task Force(USPSTF) concludes that the evidence isinsufficient to recommend for or against routinecounseling by primary care clinicians to preventskin cancer. Rating: I Recommendation.

n Observational studies indicate that intermittent orintense sun exposure is a greater risk factor formelanoma than chronic exposure. These studiessupport the hypothesis that preventing sunburn,especially in childhood, may reduce the lifetime riskfor melanoma.

n Other measures for preventing skin cancer includeavoiding direct exposure to midday sun (between thehours of 10:00 AM and 4:00 PM) to reduceexposure to ultraviolet (UV) rays and covering skinexposed to the sun (by wearing protective clothingsuch as broad-brimmed hats, long-sleeved shirts, longpants, and sunglasses).

n The effects of sunlamps and tanning beds on the riskfor melanoma are unclear due to limited study designand conflicting results from retrospective studies.

n Only a single case-control study of skin self-examination has reported a lower risk for melanomaamong patients who reported ever examining theirskin over 5 years. Although results from this studysuggest that skin self-examination may be effective inpreventing skin cancer, these results are notdefinitive.

This USPSTF recommendation was first published by:Agency for Healthcare Research and Quality, Rockville, MD.October 2003. www.preventiveservices.ahrq.gov.

47

Counseling to Prevent Skin Cancer


n Benefits from screening are unproven, even in high-risk patients. Clinicians should be aware that fair-skinned men and women aged >65, patients withatypical moles, and those with >50 moles constituteknown groups at substantially increased risk formelanoma.

n Clinicians should remain alert for skin lesions withmalignant features noted in the context of physicalexaminations performed for other purposes.Asymmetry, border irregularity, color variability,diameter >6 mm (“A,” “B,” “C,” “D”), or rapidlychanging lesions are features associated with anincreased risk of malignancy. Suspicious lesionsshould be biopsied.

Screening for Skin Cancer

48


The U.S. Preventive Services Task Force(USPSTF) concludes that the evidence isinsufficient to recommend for or against routinescreening for skin cancer using a total-body skinexamination for the early detection of cutaneousmelanoma, basal cell cancer, or squamous cell skincancer. Rating: I Recommendation.

n The USPSTF did not examine the outcomes relatedto surveillance of patients with familial syndromes,such as familial atypical mole and melanoma (FAM-M) syndrome.

This USPSTF recommendation was first published in:Am J Prev Med. 2001;20(3S):44-46.

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Screening for Skin Cancer


n The low incidence of testicular cancer and favorableoutcomes in the absence of screening make itunlikely that clinical testicular examinations wouldprovide important health benefits. Clinicalexamination by a physician and self-examination arethe potential screening options for testicular cancer.However, little evidence is available to assess the accuracy, yield, or benefits of screening for testicularcancer.

n Although currently most testicular cancers arediscovered by patients themselves or their partners,either unintentionally or by self-examination, thereis no evidence that teaching young men how toexamine themselves for testicular cancer wouldimprove health outcomes, even among men at highrisk, including men with a history of undescendedtestes or testicular atrophy.

Screening for Testicular Cancer

50


The U.S. Preventive Services Task Force(USPSTF) recommends against routine screeningfor testicular cancer in asymptomatic adolescentand adult males. Rating: D Recommendation.

n Clinicians should be aware of testicular cancer as apossible diagnosis when young men present to themwith suggestive signs and symptoms. There is someevidence that patients who present initially withsymptoms of testicular cancer are frequentlydiagnosed as having epididymitis, testicular trauma,hydrocele, or other benign disorders. Efforts topromote prompt assessment and better evaluationof testicular problems may be more effective thanwidespread screening as a means of promoting earlydetection.


51

Screening for Testicular Cancer


n The USPSTF did not review evidence regardingvitamin supplementation for patients with knownor potential nutritional deficiencies, includingpregnant and lactating women, children, the elderly,and people with chronic illnesses. Dietarysupplements may be appropriate for people whosediet does not provide the recommended dietaryintake of specific vitamins. Individuals may wish toconsult a health care provider to discuss whetherdietary supplements are appropriate.

Routine Vitamin Supplementation toPrevent Cancer and CardiovascularDisease

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The U.S. Preventive Services Task Force(USPSTF) concludes that the evidence isinsufficient to recommend for or against the use ofsupplements of vitamins A, C, or E; multivitaminswith folic acid; or antioxidant combinations for theprevention of cancer or cardiovascular disease.Rating: I Recommendation.

The USPSTF recommends against the use ofbeta-carotene supplements, either alone or incombination, for the prevention of cancer orcardiovascular disease. Rating: D Recommendation.

n With the exception of vitamins for which there iscompelling evidence of net harm (eg, beta-carotenesupplementation in smokers), there is little reasonto discourage people from taking vitaminsupplements. Patients should be reminded thattaking vitamins does not replace the need to eat ahealthy diet. All patients should receive informationabout the benefits of a diet high in fruit andvegetables, as well as information on other foodsand nutrients that should be emphasized or avoidedin their diet (see 2002 USPSTF recommendationon counseling to promote a healthy diet, P. 109).

n Patients who choose to take vitamins should beencouraged to adhere to the dosages recommendedin the Dietary Reference Intakes (DRI) of theInstitute of Medicine. Some vitamins, such as A andD, may be harmful in higher doses; therefore, dosesgreatly exceeding the Recommended DietaryAllowance (RDA) or Adequate Intake (AI) shouldbe taken with care while considering whetherpotential harms outweigh potential benefits.Vitamins and minerals sold in the United States areclassified as “dietary supplements,” and there is adegree of quality control over content if they have aU.S. Pharmacopeia (USP) seal.1 Nevertheless,imprecision in the content and concentration ofingredients could pose a theoretical risk notreflected in clinical trials using calibratedcompounds.

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Vitamin Supplementation

n The adverse effects of beta-carotene on smokershave been observed primarily in those taking largesupplemental doses. There is no evidence to suggestthat beta-carotene is harmful to smokers at levelsoccurring naturally in foods.

n The USPSTF did not review evidence supportingfolic acid supplementation among pregnant womento reduce neural tube defects. In 1996, the USPSTFrecommended folic acid for all women who areplanning, or capable of, pregnancy (see 1996USPSTF chapter on screening for neural tubedefects).2

n Clinicians and patients should discuss the possibleneed for vitamin supplementation when takingcertain medications (eg, folic acid supplementationfor those patients taking methotrexate).

References1. U.S. Pharmacopeia Dietary Supplement Verification

Program. Available at: http://www.usp-dsvp.org.Accessed April 30, 2002.

2. Screening for Neural Tube Defects. U.S. PreventiveServices Task Force. Guide To Clinical Preventive Services.2nd ed. Washington, DC: Office of Disease Preventionand Health Promotion; 1996: 467-483. Available at:http://www.ahrq.gov/clinic/uspstf/uspsneur.htm.Accessed May 8, 2003.


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Vitamin Supplementation


n Decisions about aspirin therapy should take intoaccount overall risk for coronary heart disease. Riskassessment should include asking about the presenceand severity of the following risk factors: age, sex,diabetes, elevated total cholesterol levels, low levels ofhigh-density lipoprotein (HDL) cholesterol, elevatedblood pressure, family history (in younger adults),and smoking. Tools that incorporate specificinformation on multiple risk factors provide moreaccurate estimation of cardiovascular risk thancategorizations based simply on counting thenumbers of risk factors (http://www.intmed.mcw.edu/clincalc/heartrisk.html).1

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Heart and Vascular Diseases

Aspirin for the Primary Prevention ofCardiovascular Events


The U.S. Preventive Services Task Force(USPSTF) strongly recommends that cliniciansdiscuss aspirin chemoprevention with adults whoare at increased risk for coronary heart disease(CHD). Discussions with patients should addressboth the potential benefits and harms of aspirintherapy. Rating: A Recommendation.

n Men older than 40 years, postmenopausal women,and younger people with risk factors for CHD (eg,hypertension, diabetes, or smoking) are at increasedrisk for heart disease and may wish to consideraspirin therapy. Table 1 shows how estimates of thetype and magnitude of benefits and harms associatedwith aspirin therapy vary with an individual’sunderlying risk for coronary heart disease. Althoughbalance of benefits and harms is most favorable inhigh-risk people (5-year risk > 3%), some people atlower risk may consider the potential benefits ofaspirin to be sufficient to outweigh the potentialharms.

n Discussions about aspirin therapy should focus onpotential coronary heart disease benefits, such asprevention of myocardial infarction, and potentialharms, such as gastrointestinal and intracranialbleeding. Discussions should take into accountindividual preferences and risk aversions concerningmyocardial infarction, stroke, and gastrointestinalbleeding.

n Although the optimal timing and frequency ofdiscussions related to aspirin therapy are unknown,reasonable options include every 5 years in middle-aged and older people or when other cardiovascularrisk factors are detected.

n Most participants in the primary prevention trials ofaspirin therapy have been men between 40 and 75

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Aspirin

years of age. Current estimates of benefits andharms may not be as reliable for women and oldermen.

n Although older patients may derive greater benefitsbecause they are at higher risk for CHD and stroke,their risk for bleeding may be higher.

n Uncontrolled hypertension may attenuate thebenefits of aspirin in reducing CHD.

n The optimum dose of aspirin for chemopreventionis not known. Primary and secondary preventiontrials have demonstrated benefits with a variety ofregimens, including 75 mg per day, 100 mg per day,and 325 mg every other day. Doses ofapproximately 75 mg per day appear as effective ashigher doses; whether doses below 75 mg per dayare effective has not been established. Enteric-coatedor buffered preparations do not clearly reduceadverse gastrointestinal effects of aspirin.Uncontrolled hypertension and concomitant use ofother nonsteroidal anti-inflammatory agents oranticoagulants increase risk for serious bleeding.

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Aspirin

58

Aspirin

Table 1. Estimates of Benefits and Harms of Asprin TherapyGiven for 5 Years to 1,000 Individuals with Various Levels ofBaseline Risk for Coronary Heart Disease*

Baseline risk for coronary heart disease over 5 years: 1%Total mortality: No effectCHD events**: 1-4 avoidedHemorrhagic strokes***: 0-2 causedMajor gastrointestinal bleeding events****: 2-4 caused

Baseline risk for coronary heart disease over 5 years: 3%Total mortality: No effectCHD events**: 4-12 avoided Hemorrhagic strokes***: 0-2 causedMajor gastrointestinal bleeding events****: 2-4 caused

Baseline risk for coronary heart disease over 5 years: 5%Total mortality: No effectCHD events**: 6-20 avoidedHemorrhagic strokes***: 0-2 causedMajor gastrointestinal bleeding events****: 2-4 caused

* These estimates are based on a relative risk reduction of 28%for coronary heart disease events in aspirin-treated patients.They assume risk reductions do not vary significantly by age.

** Nonfatal acute myocardial infarction and fatal coronary heartdisease. Five-year risks of 1%, 3% and 5% are equivalent to10-year risks of 2%, 6%, and 10%, respectively.

*** Data from secondary prevention trials suggest that increases inhemorrhagic stroke may be offset by reduction in other typesof stroke in patients at very high risk for cardiovascular disease(CVD) (greater than or equal to 10% 5-year risk).

**** Rates may be 2 to 3 times higher in people older than 70years.

Source: Hayden M, Pignone M, Phillips C, Mulrow C. Aspirin forthe primary prevention of cardiovascular events: A summary of theevidence for the U.S. Preventive Services Task Force. Annals ofInternal Medicine. 2002;136:161-172.

Reference1. Wilson PW, D’Agostino RB, Levy D, Belanger AM,

Sibershatz H, Kannel WB. Prediction of coronary heartdisease using risk factor categories. Circulation.1998;97(18):1837-1847.

This USPSTF recommendation was first published in:Ann Intern Med. 2002;136(2):157-160.

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Aspirin


n Several factors are associated with a higher risk forCHD events (the major ones are nonfatalmyocardial infarction and coronary death),including older age, male gender, high bloodpressure, smoking, abnormal lipid levels, diabetes,obesity, and sedentary lifestyle. A person’s risk forCHD events can be estimated based on thepresence of these factors. Calculators are available to

Screening for Coronary Heart Disease

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The U.S. Preventive Services Task Force(USPSTF) recommends against routine screeningwith resting electrocardiography (ECG), exercisetreadmill test (ETT), or electron-beamcomputerized tomography (EBCT) scanning forcoronary calcium for either the presence of severecoronary artery stenosis (CAS) or the prediction ofcoronary heart disease (CHD) events in adults atlow risk for CHD events. Rating: DRecommendation.

The USPSTF found insufficient evidence torecommend for or against routine screening withECG, ETT, or EBCT scanning for coronarycalcium for either the presence of severe CAS orthe prediction of CHD events in adults atincreased risk for CHD events. Rating: IRecommendation.

ascertain a person’s risk for having a CHD event;for example, a calculator to estimate a person’s riskfor a CHD event in the next 10 years can beaccessed at http://hin.nhlbi.nih.gov/atpiii/calculator.asp?usertype=prof. Although the exact riskfactors that constitute each of these categories (lowor increased risk) have not been established,younger adults (ie, men < 50 years and women < 60years) who have no other risk factors for CHD (<5%-10% 10-year risk) are considered to be at lowrisk. Older adults, or younger adults with 1 or morerisk factors (> 15% -20% 10-year risk), areconsidered to be at increased risk.

n Screening with ECG, ETT, and EBCT couldpotentially reduce CHD events in 2 ways: either bydetecting people at high risk for CHD events whocould benefit from more aggressive risk factormodification, or by detecting people with existingsevere CAS whose life could be prolonged bycoronary artery bypass grafting (CABG) surgery.However, the evidence is inadequate to determinethe extent to which people detected throughscreening in either situation would benefit fromeither type of intervention.

n The consequences of false-positive tests maypotentially outweigh the benefits of screening. False-positive tests are common among asymptomaticadults, especially women, and may lead tounnecessary diagnostic testing, over-treatment, andlabeling.

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n Because the sensitivity of these tests is limited,screening could also result in false-negative results.A negative test does not rule out the presence ofsevere CAS or a future CHD event.

n For people in certain occupations, such as pilotsand heavy equipment operators (for whom suddenincapacitation or sudden death may endanger thesafety of others), considerations other than thehealth benefit to the individual patient mayinfluence the decision to screen for CHD.

n Although some exercise programs initially screenasymptomatic participants with ETT, there is notenough evidence to determine the balance ofbenefits and harms of this practice.


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n Office measurement of blood pressure is mostcommonly done with a sphygmomanometer. Highblood pressure (hypertension) is usually defined inadults as a systolic blood pressure (SBP) of 140 mmHg or higher, or a diastolic blood pressure (DBP) of90 mm Hg or higher. Due to variability inindividual blood pressure measurements (occurringas a result of instrument, observer, and patientfactors), it is recommended that hypertension bediagnosed only after 2 or more elevated readings areobtained on at least 2 visits over a period of 1 toseveral weeks.

n There are some data to suggest that ambulatoryblood pressure measurement (that provides ameasure of the average blood pressure over 24hours) may be a better predictor of clinical

Screening for High Blood Pressure

63


The U.S. Preventive Services Task Force(USPSTF) strongly recommends that cliniciansscreen adults aged 18 and older for high bloodpressure. Rating: A Recommendation.

The USPSTF concludes that the evidence isinsufficient to recommend for or against routinescreening for high blood pressure in children andadolescents to reduce the risk of cardiovasculardisease. Rating: I Recommendation.

cardiovascular outcome than clinic-basedapproaches; however, ambulatory blood pressuremeasurement is subject to many of the same errorsas office blood pressure measurement.

n The relationship between SBP and DBP andcardiovascular risk is continuous and graded. Theactual level of blood pressure elevation should notbe the sole factor in determining treatment.Clinicians should consider the patient’s overallcardiovascular risk profile, including smoking,diabetes, abnormal blood lipids, age, sex, sedentarylifestyle, and obesity, in making treatment decisions.

n Hypertension in children has been defined as bloodpressure above the 95th percentile for age, sex, andheight. Up to 28% of children have secondaryhypertension, ie, high blood pressure due to causessuch as coarctation of the aorta, renal parenchymaldisease, renal artery stenosis, and other congenitalmalformations. On the basis of expert opinion,several organizations, including the AmericanAcademy of Pediatrics (AAP), American HeartAssociation (AHA), and American MedicalAssociation (AMA), recommend routine screeningof asymptomatic adolescents and children duringpreventive care visits, based on the potential foridentifying treatable causes of secondaryhypertension, such as coarctation of aorta. However,there are limited data on the benefits or risks ofscreening and treating such underlying causes ofhypertension in children. The decision to screen

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children and adolescents for hypertension remains amatter of clinical judgment.

n Evidence is lacking to recommend an optimalinterval for screening adults for high blood pressure.The sixth report of the Joint National Committeeon Prevention, Detection, Evaluation, andTreatment of High Blood Pressure (JNC 6)recommends screening every 2 years for personswith SBP and DBP below 130 mm Hg and 85 mmHg, respectively, and more frequent intervals forscreening those with blood pressure at higher levels.

n A variety of pharmacological agents are available totreat high blood pressure. JNC 6 guidelines fortreatment of high blood pressure can be accessed atwww.nhlbi.nih.gov/guidelines/hypertension/jncintro.htm. The JNC 6-recommended goal of treatmentis to achieve and maintain SBP below 140 mm Hgand DBP below 90 mm Hg, and lower if tolerated.Evidence indicates that reducing DBP to below 80mm Hg appears to be beneficial for patients withhypertension and diabetes. In considering theeffectiveness of treatment for hypertension, it mustbe noted that a given treatment’s ability to lowerblood pressure may not correspond directly to itsability to reduce cardiovascular events.

n Nonpharmacological therapies, such as reducingdietary sodium intake, potassium supplementation,increased physical activity, weight loss, stressmanagement, and reducing alcohol intake, areassociated with a reduction in blood pressure, but

65


their impact on cardiovascular outcomes has notbeen studied. For those who consume largeamounts of alcohol (more than 20 drinks in aweek), studies have shown that reduced drinkingdecreases blood pressure. There is insufficientevidence to recommend single or multipleinterventions or to guide the clinician in selectingamong nonpharmacological therapies.

This USPSTF recommendation was first published by:Agency for Healthcare Research and Quality, Rockville,MD. July 2003. www.preventiveservices.ahrq.gov.

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Screening for Lipid Disorders in Adults

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The U.S. Preventive Services Task Force(USPSTF) strongly recommends that cliniciansroutinely screen men aged 35 years and older andwomen aged 45 years and older for lipid disordersand treat abnormal lipids in people who are atincreased risk for coronary heart disease. Rating: ARecommendation.

The USPSTF recommends that cliniciansroutinely screen younger adults (men aged 20 to 35years and women aged 20 to 45 years) for lipiddisorders if they have other risk factors for coronaryheart disease. (See Clinical Considerations for adiscussion of risk factors.) Rating: BRecommendation.

The USPSTF makes no recommendation for oragainst routine screening for lipid disorders inyounger adults (men aged 20 to 35 years or womenaged 20 to 45 years) in the absence of known riskfactors for coronary heart disease. Rating: CRecommendation.

The USPSTF recommends that screening forlipid disorders include measurement of totalcholesterol (TC) and high-density lipoproteincholesterol (HDL-C). Rating: B Recommendation.

The USPSTF concludes that the evidence isinsufficient to recommend for or against triglyceridemeasurement as a part of routine screening for lipiddisorders. Rating: I Recommendation.


n TC and HDL-C can be measured on nonfasting orfasting samples.

n Abnormal results should be confirmed by a repeatedsample on a separate occasion, and the average ofboth results should be used for risk assessment.Although measuring both TC and HDL-C is moresensitive and specific for assessing coronary heartdisease risk, TC alone is an acceptable screening testif available laboratory services cannot providereliable measurements of HDL. In conjunction withHDL-C, low-density lipoprotein cholesterol (LDL-C) and TC provide comparable information, butmeasuring LDL-C requires a fasting sample and ismore expensive. In patients with elevated risk onscreening results, lipoprotein analysis, includingfasting triglycerides, may provide information thatis useful in choosing optimal treatments.

n Screening is recommended for men aged 20 to 35years and for women aged 20 to 45 years in thepresence of any of the following:

n Diabetes.

n A family history of cardiovascular diseasebefore age 50 years in male relatives or age60 years in female relatives.

n A family history suggestive of familialhyperlipidemia.

n Multiple coronary heart disease risk factors(eg, tobacco use, hypertension).

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n The optimal interval for screening is uncertain. Onthe basis of other guidelines and expert opinion,reasonable options include every 5 years, shorterintervals for people who have lipid levels close tothose warranting therapy, and longer intervals forlow-risk people who have had low or repeatedlynormal lipid levels.

n An age to stop screening is not established. Screeningmay be appropriate in older people who have neverbeen screened, but repeated screening is lessimportant in older people because lipid levels are lesslikely to increase after age 65 years.

n Treatment decisions should take into account overallrisk of heart disease rather than lipid levels alone.Overall risk assessment should include the presenceand severity of the following risk factors: age, gender,diabetes, elevated blood pressure, family history (inyounger adults), and smoking. Tools that incorporatespecific information on multiple risk factors providemore accurate estimation of cardiovascular risk thancategorizations based on counting the numbers ofrisk factors.1,2

n Treatment choices should take into account costs andpatient preferences. Drug therapy is usually moreeffective than diet alone, but choice of treatmentshould consider overall risk, costs of treatment, andpatient preferences. Guidelines for treating highcholesterol are available from the NationalCholesterol Education Program of the NationalInstitutes of Health.3 Although diet therapy is anappropriate initial therapy for most patients, aminority achieve substantial reductions in lipid levels

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from diet alone; drugs are frequently needed toachieve therapeutic goals, especially for high-riskpeople. Lipid-lowering treatments should beaccompanied by interventions addressing allmodifiable risk factors for heart disease, includingsmoking cessation, treatment of blood pressure,diabetes, and obesity, as well as promotion of ahealthy diet and regular physical activity. Long-termadherence to therapies should be emphasized.

n All patients, regardless of lipid levels, should beoffered counseling about the benefits of a diet lowin saturated fat and high in fruits and vegetables,regular physical activity, avoiding tobacco use, andmaintaining a healthy weight.

References1. Wilson PW, D’Agostino RB, Levy D, Belanger AM,

Silbershatz H, Kannel WB. Prediction of coronary heartdisease using risk factor categories. Circulation.1998,97:1837-1847.

2. Jackson R. Updated New Zealand cardiovascular diseaserisk-benefit prediction guide. BMJ. 2000;320:709-710.Also available at: www.bmj.com/cgi/content/full/320/7236/709.

3. Summary of the second report of the NationalCholesterol Education Program (NCEP) Expert Panelon the Detection, Evaluation, and Treatment of HighBlood Cholesterol in Adults (Adult Treatment Panel II).JAMA. 1993;269:3015-3023.


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n The screening tests used commonly in the primarycare setting (dipstick analysis and directmicroscopy) have poor positive and negativepredictive value for detecting bacteriuria inasymptomatic persons. Urine culture is the goldstandard for detecting asymptomatic bacteriuria butis expensive for routine screening in populationswith a low prevalence of this condition. Resultsfrom one study done with a new enzymatic urine-screening test (Uriscreen™) showed that the test hasa sensitivity of 100% and a specificity of 81%.

n Good evidence exists that screening pregnantwomen for asymptomatic bacteriuria with urine

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Infectious Diseases

Screening for Asymptomatic Bacteriuria


The U.S. Preventive Services Task Force(USPSTF) strongly recommends that all pregnantwomen be screened for asymptomatic bacteriuriausing urine culture at 12-16 weeks’ gestation.Rating: A Recommendation.

The USPSTF recommends against the routinescreening of men and nonpregnant women forasymptomatic bacteriuria. Rating: DRecommendation.

culture (rather than urinalysis) significantly reducessymptomatic urinary tract infections, low birthweight, and preterm delivery. A specimen obtainedat 12-16 weeks’ gestation will detect approximately80% of patients with asymptomatic bacteriuria. Theoptimal frequency of subsequent urine testingduring pregnancy is uncertain.

n Good evidence exists that screening individuals otherthan pregnant women for asymptomatic bacteriuriadoes not significantly improve clinical outcomes.Results from a study of women with diabetes whowere treated for asymptomatic bacteriuriademonstrated no reduction in complications.1

Although there were short-term results in clearingbacteriuria with antimicrobial therapy, there was nodecrease in the number of symptomatic episodes orhospitalizations over the long term. Furthermore, thehigh rate of recurrence of bacteriuria in those whowere screened and treated resulted in a markedincrease in the use of antimicrobial agents.

Reference1. Harding GKM, Zhanel GG, Nicolle LE, Cheang M.

Antimicrobial treatment in diabetic women withasymptomatic bacteriuria. N Engl J Med. 2002;347(20):1576-1583.

This USPSTF recommendation was first published by:Agency for Healthcare Research and Quality, Rockville, MD.February 2004. www.preventiveservices.ahrq.gov.

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Screening for Asymptomatic Bacteriuria

Screening for Chlamydial Infection

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The U.S. Preventive Services Task Force(USPSTF) strongly recommends that cliniciansroutinely screen all sexually active women aged 25years and younger, and other asymptomaticwomen at increased risk for infection, forchlamydial infection (see Clinical Considerationsfor discussion of risk factors). Rating: ARecommendation.

The USPSTF makes no recommendation for oragainst routinely screening asymptomatic low-riskwomen in the general population for chlamydialinfection. Rating: C Recommendation.

The USPSTF recommends that cliniciansroutinely screen all asymptomatic pregnant womenaged 25 years and younger and others at increasedrisk for chlamydial infection (see ClinicalConsiderations for discussion of risk factors inpregnancy). Rating: B Recommendation.

The USPSTF makes no recommendation for oragainst routine screening of asymptomatic, low-riskpregnant women aged 26 years and older forchlamydial infection. Rating: C Recommendation.

The USPSTF concludes that the evidence isinsufficient to recommend for or against routinelyscreening asymptomatic men for chlamydialinfection. Rating: I Recommendation.


n Women and adolescents through age 20 years are athighest risk for chlamydial infection, but mostreported data indicate that infection is prevalentamong women aged 20-25.

n Age is the most important risk marker. Otherpatient characteristics associated with a higherprevalence of infection include being unmarried,African-American race, having a prior history ofsexually transmitted disease (STD), having new ormultiple sexual partners, having cervical ectopy, andusing barrier contraceptives inconsistently.Individual risk depends on the number of riskmarkers and local prevalence of the disease. Specificrisk-based screening protocols need to be tested atthe local level.

n Clinicians should consider the characteristics of thecommunities they serve in determining appropriatescreening strategies for their patient population.

n More targeted screening may be indicated inspecific settings as better prevalence data becomeavailable. Prevalence of chlamydial infection varieswidely among communities and patientpopulations. Knowledge of the patient population isthe best guide to developing a screening strategy.Local public health authorities can be a source ofvaluable information.

n The optimal interval for screening is uncertain. Forwomen with a previous negative screening test, theinterval for rescreening should take into account

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changes in sexual partners. If there is evidence that awoman is at low risk for infection (eg, in a mutuallymonogamous relationship with a previous history ofnegative screening tests for chlamydial infection), itmay not be necessary to screen frequently.Rescreening at 6 to 12 months may be appropriatefor previously infected women because of high ratesof reinfection.

n The optimal timing of screening in pregnancy isalso uncertain. Screening early in pregnancyprovides greater opportunities to improve pregnancyoutcomes, including low birth weight andpremature delivery; however, screening in the thirdtrimester may be more effective at preventingtransmission of chlamydial infection to the infantduring birth. The incremental benefit of repeatedscreening is unknown.

n Screening high-risk young men is a clinical option.Until the advent of urine-based screening tests,routine screening of men was rarely performed. As aresult, very little evidence regarding the efficacy ofscreening in men in reducing infection amongwomen exists. Trials are underway to assess theeffectiveness of screening asymptomatic men.

n The choice of specific screening technique is left toclinical judgment. Choice of test will depend onissues of cost, convenience, and feasibility, whichmay vary in different settings. Although specificityis high with most approved tests, false-positiveresults can occur with all non-culture tests andrarely with culture tests. Subsequent to initial release

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of this recommendation, the Centers for DiseaseControl and Prevention (CDC) released laboratoryguidelines that outline the advantages anddisadvantages of available tests. These guidelines areavailable at http://www.cdc.gov/STD/LabGuidelines.

n Partners of infected individuals should be tested andtreated if infected or treated presumptively.

n Clinicians should remain alert for findingssuggestive of chlamydial infection during pelvicexamination of asymptomatic women (eg,discharge, cervical erythema, and cervical friability).

n Clinicians should be sensitive to the potential effectof diagnosing a sexually transmitted disease on acouple. To prevent false-positive results,confirmatory testing may be appropriate in settingswith low population prevalence.


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n Routine hepatitis vaccination has had significantimpact in reducing the number of new HBVinfections per year, with the greatest decline amongchildren and adolescents. Programs that vaccinatehealth care workers also reduce the transmission ofHBV infection.

n Most people who become infected as adults or olderchildren recover fully from HBV infection anddevelop protective immunity to the virus.

n The main risk factors for HBV infection in theUnited States include diagnosis with a sexuallytransmitted disease, intravenous drug use, sexualcontact with multiple partners, male homosexualactivity, and household contacts of chronicallyinfected persons. However, screening strategies to

Screening for Hepatitis B VirusInfection

77


The U.S. Preventive Services Task Force(USPSTF) strongly recommends screening forhepatitis B virus (HBV) infection in pregnantwomen at their first prenatal visit. Rating: ARecommendation.

The USPSTF recommends against routinelyscreening the general asymptomatic population forchronic hepatitis B virus infection. Rating: DRecommendation.

identify individuals at high risk have poor predictivevalue, since 30% to 40% of infected individuals donot have any easily identifiable risk factors.

n Important predictors of progressive HBV infectioninclude longer duration of infection and thepresence of comorbid conditions such as alcoholabuse, HIV, or other chronic liver disease.Individuals with HBV infection identified throughscreening may benefit from interventions designedto reduce liver injury from other causes, such ascounseling to avoid alcohol abuse andimmunization against hepatitis A. However, there islimited evidence on the effectiveness of theseinterventions.


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Screening for Hepatitis B Virus Infection


n Established risk factors for HCV infection includecurrent or past intravenous drug use, transfusionbefore 1990, dialysis, and being a child of an HCV-infected mother. Surrogate markers, such as high-risk sexual behavior (particularly sex with someoneinfected with HCV) and the use of illegal drugs,such as cocaine or marijuana, have also beenassociated with increased risk for HCV infection.The proportion of people who received blood orblood product transfusions before 1990 willcontinue to decline, and HCV infection will beassociated mainly with intravenous drug use and, tosome extent, unsafe sexual behaviors.

n Initial testing for HCV infection is typically doneby enzyme immunoassay (EIA). In a populationwith a low prevalence of HCV infection (eg, 2%),

Screening for Hepatitis C in Adults

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The U.S. Preventive Services Task Force(USPSTF) recommends against routine screeningfor hepatitis C virus (HCV) infection inasymptomatic adults who are not at increased risk(general population) for infection. Rating: DRecommendation.

The USPSTF found insufficient evidence torecommend for or against routine screening forHCV infection in adults at high risk for infection.Rating: I Recommendation.

approximately 59% of all positive tests using thethird-generation EIA test with 97% specificitywould be false positive. As a result, confirmatorytesting is recommended with the strip recombinantimmunoblot assay (third-generation RIBA).

n Important predictors of progressive HCV infectioninclude older age at acquisition; longer duration ofinfection; and presence of comorbid conditions,such as alcohol misuse, HIV infection, or otherchronic liver disease. Asymptomatic individualswith HCV infection identified through screeningmay benefit from interventions designed to reduceliver injury from other causes, such as counseling toavoid alcohol misuse and immunization againsthepatitis A and hepatitis B. However, there islimited evidence of the effectiveness of theseinterventions.


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Screening for Hepatitis C in Adults


n Populations at increased risk for syphilis infection(as determined by incident rates) include men whohave sex with men and engage in high-risk sexualbehavior, commercial sex workers, persons whoexchange sex for drugs, and those in adultcorrectional facilities. There is no evidence tosupport an optimal screening frequency in thispopulation. Clinicians should consider thecharacteristics of the communities they serve indetermining appropriate screening strategies.Prevalence of syphilis infection varies widely amongcommunities and patient populations. For example,the prevalence of syphilis infection differs by region

Screening for Syphilis Infection

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The U.S. Preventive Services Task Force(USPSTF) strongly recommends that cliniciansscreen persons at increased risk for syphilisinfection. Rating: A Recommendation.

The USPSTF strongly recommends thatclinicians screen all pregnant women for syphilisinfection. Rating: A Recommendation.

The USPSTF recommends against routinescreening of asymptomatic persons who are not atincreased risk for syphilis infection. Rating: DRecommendation.

(the prevalence of infection is higher in thesouthern U.S. and in some metropolitan areas thanit is in the U.S. as a whole) and by ethnicity (theprevalence of syphilis infection is higher in Hispanicand African American populations than it is in thewhite population).

n Persons diagnosed with other sexually transmitteddiseases (STDs) (ie, chlamydia, gonorrhea, genitalherpes simplex, human papilloma virus, and HIV)may be more likely than others to engage in high-risk behavior, placing them at increased risk forsyphilis; however, there is no evidence that supportsthe routine screening of individuals diagnosed withother STDs for syphilis infection. Clinicians shoulduse clinical judgment to individualize screening forsyphilis infection based on local prevalence andother risk factors (see above).

n Nontreponemal tests commonly used for initialscreening are the Venereal Disease ResearchLaboratory (VDRL) or Rapid Plasma Reagin(RPR), followed by a confirmatory fluorescenttreponemal antibody absorbed (FTA-ABS) or T.pallidum particle agglutination (TP-PA). Theoptimal screening interval in average- and high-riskpersons has not been determined.

n All pregnant women should be tested at their firstprenatal visit. For women in high-risk groups,repeat serologic testing may be necessary in thethird trimester and at delivery. Follow-up serologic

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tests should be obtained to document declineinitially after treatment. These follow-up testsshould be performed using the same nontreponemaltest initially used to document infections (eg,VDRL or RPR) to ensure comparability.

This USPSTF recommendation was first published in:Ann Fam Med. 2004;2(4):362-365.

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n The USPSTF did not review the evidence for theeffectiveness of case-finding tools; however, allclinicians examining children and adults should bealert to physical and behavioral signs and symptomsassociated with abuse or neglect. Patients in whomabuse is suspected should receive properdocumentation of the incident and physicalfindings (e.g., photographs, body maps); treatmentfor physical injuries; arrangements for skilledcounseling by a mental health professional; and thetelephone numbers of local crisis centers, shelters,and protective service agencies.

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Injury and Violence

Screening for Family and IntimatePartner Violence


The U.S. Preventive Services Task Force(USPSTF) found insufficient evidence torecommend for or against routine screening ofparents or guardians for the physical abuse orneglect of children, of women for intimate partnerviolence, or of older adults or their caregivers forelder abuse. Rating: I Recommendation.

n Victims of family violence are primarily children,female spouses/intimate partners, and older adults.Numerous risk factors for family violence have beenidentified, although some may be confounded bysocioeconomic factors. Factors associated with childabuse or neglect include low income status, lowmaternal education, non-white race, large familysize, young maternal age, single-parent household,parental psychiatric disturbances, and presence of astepfather. Factors associated with intimate partnerviolence include young age, low income status,pregnancy, mental health problems, alcohol orsubstance use by victims or perpetrators, separatedor divorced status, and history of childhood sexualand/or physical abuse. Factors associated with theabuse of older adults include increasing age, non-white race, low income status, functionalimpairment, cognitive disability, substance use, pooremotional state, low self-esteem, cohabitation, andlack of social support.

n Several instruments to screen parents for child abusehave been studied, but their ability to predict childabuse or neglect is limited. Instruments to screenfor intimate partner violence have also beendeveloped, and although some have demonstratedgood internal consistency (eg, the HITS [Hurt,Insulted, Threatened, Screamed at] instrument, thePartner Abuse Interview, and the Women’sExperience with Battering [WEB] Scale), none havebeen validated against measurable outcomes. Only a

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few screening instruments (the Caregiver AbuseScreen [CASE] and the Hwalek-Sengstock ElderAbuse Screening Test [HSEAST]) have beendeveloped to identify potential older victims ofabuse or their abusive caretakers. Both of these toolscorrelated well with previously validatedinstruments when administered in the community,but have not been tested in the primary care clinicalsetting.1

n Home visit programs directed at high-risk mothers(identified on the basis of sociodemographic riskfactors) have improved developmental outcomesand decreased the incidence of child abuse andneglect, as well as decreased rates of maternalcriminal activity and drug use.

Reference1. Nelson HD, Nygren P, Qazi Y. Screening for Family and

Intimate Partner Violence. Systematic Evidence ReviewNo. 28. (Prepared by the Oregon Health & ScienceEvidence-based Practice Center under Contract No.290-97-0018). Rockville, MD: Agency for HealthcareResearch and Quality. February 2004. (Available on theAHRQ Web site at: www.ahrq.gov/clinic/serfiles.htm).


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Screening for Family and Intimate Partner Violence


n Alcohol misuse includes “risky/hazardous” and“harmful” drinking that places individuals at riskfor future problems. “Risky” or “hazardous”drinking has been defined in the United States asmore than 7 drinks per week or more than 3 drinksper occasion for women, and more than 14 drinksper week or more than 4 drinks per occasion for

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Mental Health Conditions andSubstance Abuse

Screening and Behavioral CounselingInterventions in Primary Care toReduce Alcohol Misuse


The U.S. Preventive Services Task Force(USPSTF) recommends screening and behavioralcounseling interventions to reduce alcohol misuse(go to Clinical Considerations) by adults,including pregnant women, in primary caresettings. Rating: B Recommendation.

The USPSTF concludes that the evidence isinsufficient to recommend for or against screeningand behavioral counseling interventions to preventor reduce alcohol misuse by adolescents in primarycare settings. Rating: I Recommendation.

men. “Harmful drinking” describes persons who arecurrently experiencing physical, social, orpsychological harm from alcohol use but do notmeet criteria for dependence.1,2 Alcohol abuse anddependence are associated with repeated negativephysical, psychological, and social effects fromalcohol.3 The USPSTF did not evaluate theeffectiveness of interventions for alcoholdependence because the benefits of theseinterventions are well established and referral orspecialty treatment is recommended for thosemeeting the diagnostic criteria for dependence.

n Light to moderate alcohol consumption in middle-aged or older adults has been associated with somehealth benefits, such as reduced risk for coronaryheart disease.4 Moderate drinking has been definedas 2 standard drinks (eg, 12 ounces of beer) or lessper day for men and 1 drink or less per day forwomen and persons older than 65,5 but recent datasuggest comparable benefits from as little as 1 drink3 to 4 times a week.6

n The Alcohol Use Disorders Identification Test(AUDIT) is the most studied screening tool fordetecting alcohol-related problems in primary caresettings. It is sensitive for detecting alcohol misuseand abuse or dependence and can be used alone orembedded in broader health risk or lifestyleassessments.7,8 The 4-item CAGE (feeling the needto Cut down, Annoyed by criticism, Guilty aboutdrinking, and need for an Eye-opener in themorning) is the most popular screening test for

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detecting alcohol abuse or dependence in primarycare.9 The TWEAK, a 5-item scale, and the T-ACEare designed to screen pregnant women for alcoholmisuse. They detect lower levels of alcoholconsumption that may pose risks duringpregnancy.10 Clinicians can choose screeningstrategies that are appropriate for their clinicalpopulation and setting.8,11-14 Screening tools areavailable at the National Institute on Alcohol Abuseand Alcoholism Web site: http://www.niaaa.nih.gov/.

n Effective interventions to reduce alcohol misuseinclude an initial counseling session of about 15minutes, feedback, advice, and goal-setting. Mostalso include further assistance and follow-up. Multi-contact interventions for patients ranging widely inage (12-75 years) are shown to reduce mean alcoholconsumption by 3 to 9 drinks per week, with effectslasting up to 6 to 12 months after the intervention.They can be delivered wholly or in part in theprimary care setting, and by one or more membersof the health care team, including physician andnon-physician practitioners. Resources that helpclinicians deliver effective interventions includebrief provider training or access to specially trainedprimary care practitioners or health educators, andthe presence of office-level systems supports(prompts, reminders, counseling algorithms, andpatient education materials).

n Primary care screening and behavioral counselinginterventions for alcohol misuse can be describedwith reference to the 5-As behavioral counseling

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framework: assess alcohol consumption with a briefscreening tool followed by clinical assessment asneeded; advise patients to reduce alcoholconsumption to moderate levels; agree on individualgoals for reducing alcohol use or abstinence (ifindicated); assist patients with acquiring themotivations, self-help skills, or supports needed forbehavior change; and arrange follow-up support andrepeated counseling, including referring dependentdrinkers for specialty treatment.15 Common practicesthat complement this framework includemotivational interviewing,16 the 5 Rs used to treattobacco use,17 and assessing readiness to change.18

n The optimal interval for screening and interventionis unknown. Patients with past alcohol problems,young adults, and other high-risk groups (e.g.,smokers) may benefit most from frequent screening.

n All pregnant women and women contemplatingpregnancy should be informed of the harmful effectsof alcohol on the fetus. Safe levels of alcoholconsumption during pregnancy are not known;therefore, pregnant women are advised to abstainfrom drinking alcohol. More research into theefficacy of primary care screening and behavioralintervention for alcohol misuse among pregnantwomen is needed.

n The benefits of behavioral intervention forpreventing or reducing alcohol misuse in adolescentsare not known. The CRAFFT questionnaire wasrecently validated for screening adolescents forsubstance abuse in the primary care setting.19 The

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benefits of screening this population will need to beevaluated as more effective interventions becomeavailable in the primary care setting.

References 1. Reid MC, Fiellin DA, O’Connor PG. Hazardous and

harmful alcohol consumption in primary care. ArchIntern Med. 1999;159(15):1681-1689.

2. WHO. The ICD-10 Classification of Mental andBehavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva, Switzerland: WorldHealth Organization; 1992.

3. American Psychiatric Association. Diagnostic andStatistical Manual of Mental Disorders. 4th Ed. Washington, DC: American Psychiatric Association;1994.

4. Tenth special report to the U.S. Congress on alcohol andhealth from the Secretary of Health and HumanServices. U.S. Department of Health and HumanServices. Washington, DC: National Institutes ofHealth, National Institute on Alcohol Abuse andAlcoholism (NIAAA). NIH Publication No. 00-1583;June 2000.

5. The Physician’s Guide to Helping Patients with AlcoholProblems. National Institute on Alcohol Abuse andAlcoholism (NIAAA). NIH Pub. No. 95-3769.Bethesda, MD; 1995.

6. Mukamal KJ, Conigrave KM, Mittleman MA, et al.Roles of drinking pattern and type of alcohol consumed in coronary heart disease in men. N Engl JMed. 2003;348(2):109-118.

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7. Saunders JB, Aasland OG, Babor TF, de la Fuente JR,Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHOCollaborative Project on Early Detection of Persons withHarmful Alcohol Consumption-II. Addiction.1993;88(6):791-804.

8. Fiellin DA, Reid MC, O’Connor PG. Screening foralcohol problems in primary care: a systematic review. Arch Intern Med. 2000;160(13):1977-1989.

9. Ewing JA. Detecting Alcoholism: The CAGEquestionnaire. JAMA. 1984;252(14):1905-1907.

10. Chang G. Alcohol-screening instruments for pregnantwomen. Alcohol Res Health. 2001;25(3):204-209.

11. Babor TF, Higgins-Biddle JC. Brief Intervention forHazardous and Harmful Drinking. A Manual for Usein Primary Care. World Health Organization; 2001.

12. Training Physicians in Techniques for Alcohol Screeningand Brief Intervention. National Institutes of Health. National Institute on Alcohol Abuse andAlcoholism (NIAAA). Bethesda, MD; 1997.

13. Whaley SE, O’Conner MJ. Increasing the report ofalcohol use among low-income pregnant women. American Journal of Health Promot. 2003;17(6):369-372.

14. Fleming MF. Identification of at-Risk Drinking andIntervention with Women of Childbearing Age: Guide forPrimary Care Providers. National Institute on AlcoholAbuse and Alcoholism (NIAAA). NIH. Bethesda,Maryland; 2000.

15. Whitlock EP, Orleans CT, Pender N, Allan J. Evaluating

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primary care behavioral counseling interventions. Anevidence-based approach. Am J Prev Med.2002;22(4):267-284.

16. Miller WR, Rollnick S, Con K. MotivationalInterviewing: Preparing People for Change. 2nd ed. NewYork: Guilford Press; 2002.

17. Anderson JE, Jorenby DE, Scott WJ, Fiore MC.Treating tobacco use and dependence: an evidence-based clinical practice guideline for tobacco cessation.Chest. 2002;121(3):932-941.

18. Prochaska JO, Velicer WF. The transtheoretical model ofhealth behavior change. Am J Health Promot.1997;12(1):38-48.

19. Knight JR, Sherritt L, Harris SK, Gates EC, Chang G.Validity of brief alcohol screening tests among adolescents: A comparison of the AUDIT, POSIT,CAGE, and CRAFFT. Alcohol Clin Exp Res.2003;27(1):67-73.


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n The Mini-Mental Status Examination (MMSE) isthe best-studied instrument for screening forcognitive impairment. When the MMSE is used toscreen unselected patients, the predictive value of apositive result is only fair. The accuracy of theMMSE depends upon a person’s age andeducational level: using an arbitrary cut-point maypotentially lead to more false-positives among olderpeople with lower educational levels, and morefalse-negatives among younger people with highereducational levels. Tests that assess functionallimitations rather than cognitive impairment, suchas the Functional Activities Questionnaire (FAQ),can detect dementia with sensitivity and specificitycomparable to that of the MMSE.

n Early recognition of cognitive impairment, inaddition to helping make diagnostic and treatmentdecisions, allows clinicians to anticipate problemsthe patients may have in understanding and

Screening for Dementia

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The U.S. Preventive Services Task Force(USPSTF) concludes that the evidence isinsufficient to recommend for or against routinescreening for dementia in older adults. Rating: IRecommendation.

adhering to recommended therapy. Thisinformation may also be useful to the patient’scaregiver(s) and family member(s) in helping toanticipate and plan for future problems that maydevelop as a result of progression of cognitiveimpairment.

n Although current evidence does not support routinescreening of patients in whom cognitive impairmentis not otherwise suspected, clinicians should assesscognitive function whenever cognitive impairmentor deterioration is suspected, based on directobservation, patient report, or concerns raised byfamily members, friends, or caretakers.


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n Many formal screening tools are available (e.g.,the Zung Self-Assessment Depression Scale, BeckDepression Inventory, General HealthQuestionnaire [GHQ], Center for EpidemiologicStudy Depression Scale [CES-D]).1 Asking 2simple questions about mood and anhedonia(“Over the past 2 weeks, have you felt down,depressed, or hopeless?” and “Over the past 2weeks, have you felt little interest or pleasure indoing things?”) may be as effective as using longerinstruments.2 There is little evidence torecommend one screening method over another,so clinicians can choose the method that best fits

Screening for Depression

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The U.S. Preventive Services Task Force(USPSTF) recommends screening adults fordepression in clinical practices that have systemsin place to assure accurate diagnosis, effectivetreatment, and follow-up. Rating: BRecommendation.

The USPSTF concludes the evidence isinsufficient to recommend for or against routinescreening of children or adolescents fordepression. Rating: I Recommendation.

their personal preference, the patient populationserved, and the practice setting.

n All positive screening tests should trigger fulldiagnostic interviews that use standard diagnosticcriteria (ie, those from the fourth edition of theDiagnostic and Statistical Manual of MentalDisorders [DSM-IV]) to determine the presenceor absence of specific depressive disorders, such asmajor depression and/or dysthymia.3 The severityof depression and comorbid psychologicalproblems (eg, anxiety, panic attacks, or substanceabuse) should be addressed.

n Many risk factors for depression (eg, female sex,family history of depression, unemployment, andchronic disease) are common, but the presence ofrisk factors alone cannot distinguish depressedfrom nondepressed patients.

n The optimal interval for screening is unknown.Recurrent screening may be most productive inpatients with a history of depression, unexplainedsomatic symptoms, comorbid psychologicalconditions (eg, panic disorder or generalizedanxiety), substance abuse, or chronic pain.

n Clinical practices that screen for depressionshould have systems in place to ensure thatpositive screening results are followed by accuratediagnosis, effective treatment, and careful follow-

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up. Benefits from screening are unlikely to berealized unless such systems are functioning well.

n Treatment may include antidepressants or specificpsychotherapeutic approaches (eg, cognitivebehavioral therapy or brief psychosocialcounseling), alone or in combination.

n The benefits of routinely screening children andadolescents for depression are not known. Theexisting literature suggests that screening testsperform reasonably well in adolescents and thattreatments are effective, but the clinical impact ofroutine depression screening has not been studiedin pediatric populations in primary care settings.Clinicians should remain alert for possible signsof depression in younger patients. The predictivevalue of positive screening tests is lower inchildren and adolescents than in adults, andresearch on the effectiveness of primary care-basedinterventions for depression in this age group islimited.

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References

1. Williams JW, Hitchcock Noel P, Cordes JA, Ramirez G,Pignone M. Rational clinical examination. Is this patientclinically depressed? JAMA. 2002;287:1160-1167.

2. Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression: Two questions are asgood as many. J Gen Intern Med. 1997;12:439-445.

3. American Psychiatric Association. Diagnostic andStatistical Manual of Mental Disorders: DSM-IV. 4thed. Washington, DC: American Psychiatric Association;1994.


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Clinical Considerationsn The strongest risk factors for attempted suicide

include mood disorders or other mental disorders,comorbid substance abuse disorders, history ofdeliberate self-harm (DSH), and a history of suicideattempts. DSH refers to intentionally initiated actsof self-harm with a non-fatal outcome (includingself-poisoning and self-injury). Suicide risk isassessed along a continuum ranging from suicidalideation alone (relatively less severe) to suicidalideation with a plan (more severe). Suicidal ideationwith a specific plan of action is associated with asignificant risk for attempted suicide.

n Screening instruments are commonly used inspecialty clinics and mental health settings. The testcharacteristics of most commonly-used screeninginstruments (Scale for Suicide Ideation [SSI], Scalefor Suicide Ideation-Worst [SSI-W], and theSuicidal Ideation Questionnaire [SIQ)]) have notbeen validated to assess suicide risk in primary caresettings. There has been limited testing of the

Screening for Suicide Risk

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The U.S. Preventive Services Task Force(USPSTF) concludes that the evidence isinsufficient to recommend for or against routinescreening by primary care clinicians to detectsuicide risk in the general population. Rating: IRecommendation.

Symptom-Driven Diagnostic System for PrimaryCare (SDDS-PC) screening instrument in aprimary care setting.


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n Brief tobacco cessation counseling interventions,including screening, brief counseling (3 minutes orless), and/or pharmacotherapy, have proven toincrease tobacco abstinence rates, although there is adose-response relationship between quit rates andthe intensity of counseling. Effective interventionsmay be delivered by a variety of primary careclinicians.

Counseling to Prevent Tobacco Use andTobacco-Caused Disease

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The U.S. Preventive Services Task Force(USPSTF) strongly recommends that cliniciansscreen all adults for tobacco use and providetobacco cessation interventions for those who usetobacco products. Rating: A Recommendation.

The USPSTF strongly recommends thatclinicians screen all pregnant women for tobaccouse and provide augmented pregnancy-tailoredcounseling to those who smoke. Rating: ARecommendation.

The USPSTF concludes that the evidence isinsufficient to recommend for or against routinescreening for tobacco use or interventions toprevent and treat tobacco use and dependenceamong children or adolescents. Rating: IRecommendation.

n The 5-A behavioral counseling framework providesa useful strategy for engaging patients in smokingcessation discussions:

1. Ask about tobacco use.

2. Advise to quit through clear personalizedmessages.

3. Assess willingness to quit.

4. Assist to quit.

5. Arrange follow-up and support.

Helpful aspects of counseling include providingproblem-solving guidance for smokers to develop aplan to quit and to overcome common barriers toquitting and providing social support within andoutside of treatment. Common practices thatcomplement this framework include motivationalinterviewing, the 5-R’s used to treat tobacco use(relevance, risks, rewards, roadblocks, repetition), assessingreadiness to change, and more intensive counselingand/or referrals for quitters needing extra help.1-3

Telephone “quit lines” have also been found to bean effective adjunct to counseling or medicaltherapy.4

n Clinics that implement screening systems designedto regularly identify and document a patient’stobacco use status increased their rates of clinicianintervention, although there is limited evidence forthe impact of screening systems on tobaccocessation rates.5

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Tobacco Use and Tobacco-Caused Disease

n FDA-approved pharmacotherapy that has beenidentified as safe and effective for treating tobaccodependence includes several forms of nicotinereplacement therapy (ie, nicotine gum, nicotinetransdermal patches, nicotine inhaler, and nicotinenasal spray) and sustained-release bupropion. Othermedications, including clonidine and nortriptyline,have been found to be efficacious and may beconsidered.

n Augmented pregnancy-tailored counseling (eg, 5-15minutes) and self-help materials are recommendedfor pregnant smokers, as brief interventions are lesseffective in this population. There is limitedevidence to evaluate the safety or efficacy ofpharmacotherapy during pregnancy. Tobaccocessation at any point during pregnancy can yieldimportant health benefits for the mother and thebaby, but there are limited data about the optimaltiming or frequency of counseling interventionsduring pregnancy.

n There is little evidence addressing the effectivenessof screening and counseling children or adolescentsto prevent the initiation of tobacco use and topromote its cessation in a primary care setting, butclinicians may use their discretion in conductingtobacco-related discussions with this population,since the majority of adult smokers begin tobaccouse as children or adolescents.

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References1. Miller W, Rolnick S. Motivational Interviewing:

Preparing People to Change Addictive Behavior. New York:Guilford, 1991.

2. Anderson JE, Jorenby DE, Scott WJ, Fiore MC.Treating tobacco use and dependence: an evidence-basedclinical practice guideline for tobacco cessation. Chest.2002;121(3):932-941.

3. Prochaska JO, Velicer WF. The transtheoretical model ofhealth behavior change. Am J Health Promot.1997;12(1):38-48.

4. CDC. Strategies for reducing exposure to environmentaltobacco smoke, tobacco-use cessation, and reducinginitiation in communities and health-care systems. Areport on recommendations of the Task Force onCommunity Preventive Services. MMWR. 2000:49(No.RR-12);1-11.

5. Fiore MC, Bailey WC, Cohen SJ, et al. Treating TobaccoUse and Dependence. Rockville MD: Department ofHealth and Human Services, Public Health Service,2000.

This USPSTF recommendation was first published by:Agency for Healthcare Research and Quality, Rockville,MD. November 2003. www.preventiveservices.ahrq.gov.

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n Several brief dietary assessment questionnaires havebeen validated for use in the primary care setting.1,2

These instruments can identify dietary counselingneeds, guide interventions, and monitor changes inpatients’ dietary patterns. However, theseinstruments are susceptible to the bias of the

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Metabolic, Nutritional, andEndocrine Conditions

Behavioral Counseling in Primary Careto Promote a Healthy Diet


The U.S. Preventive Services Task Force(USPSTF) concludes that the evidence isinsufficient to recommend for or against routinebehavioral counseling to promote a healthy diet inunselected patients in primary care settings.Rating: I Recommendation.

The USPSTF recommends intensive behavioraldietary counseling for adult patients withhyperlipidemia and other known risk factors forcardiovascular and diet-related chronic disease.Intensive counseling can be delivered by primarycare clinicians or by referral to other specialists,such as nutritionists or dietitians. Rating: BRecommendation.

respondent. Therefore, when used to evaluate theefficacy of counseling, efforts to verify self-reportedinformation are recommended since patientsreceiving dietary interventions may be more likelyto report positive changes in dietary behavior thancontrol patients.3-6

n Effective interventions combine nutrition educationwith behaviorally-oriented counseling to helppatients acquire the skills, motivation, and supportneeded to alter their daily eating patterns and foodpreparation practices. Examples of behaviorally-oriented counseling interventions include teachingself monitoring, training to overcome commonbarriers to selecting a healthy diet, helping patientsto set their own goals, providing guidance inshopping and food preparation, role playing, andarranging for intra-treatment social support. Ingeneral, these interventions can be described withreference to the 5-A behavioral counselingframework7:

1. Assess dietary practices and related riskfactors.

2. Advise to change dietary practices.

3. Agree on individual diet change goals.

4. Assist to change dietary practices or addressmotivational barriers.

5. Arrange regular follow-up and support orrefer to more intensive behavioralnutritional counseling (e.g., medicalnutrition therapy) if needed.

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n Two approaches appear promising for the generalpopulation of adult patients in primary caresettings:

1. Medium-intensity face-to-face dietarycounseling (2 to 3 group or individualsessions) delivered by a dietitian ornutritionist or by a specially trained primarycare physician or nurse practitioner.

2. Lower-intensity interventions that involve 5minutes or less of primary care provider counseling supplemented by patient self-help materials, telephone counseling, orother interactive health communications.

However, more research is needed to assess thelong-term efficacy of these treatments and thebalance of benefits and harms.

n The largest effect of dietary counseling inasymptomatic adults has been observed with moreintensive interventions (multiple sessions lasting 30minutes or longer) among patients withhyperlipidemia or hypertension, and among othersat increased risk for diet-related chronic disease.Effective interventions include individual or groupcounseling delivered by nutritionists, dietitians, orspecially trained primary care practitioners or healtheducators in the primary care setting or in otherclinical settings by referral. Most studies of theseinterventions have enrolled selected patients, manyof whom had known diet-related risk factors such ashyperlipidemia or hypertension. Similar approaches

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may be effective with unselected adult patients, butadherence to dietary advice may be lower, andhealth benefits smaller, than in patients who havebeen told they are at higher risk for diet-relatedchronic disease.8

n Office-level systems supports (prompts, reminders,and counseling algorithms) have been found tosignificantly improve the delivery of appropriatedietary counseling by primary care clinicians.9-11

n Possible harms of dietary counseling have not beenwell defined or measured. Some have raisedconcerns that if patients focus only on reducingtotal fat intake without attention to reducing caloricintake, an increase in carbohydrate intake (eg,reduced-fat or low-fat food products) may lead toweight gain, elevated triglyceride levels, or insulinresistance. Nationally, obesity rates have increaseddespite declining fat consumption, but studies didnot consistently examine effects of counseling onoutcomes such as caloric intake and weight.

n Little is known about effective dietary counselingfor children or adolescents in the primary caresetting. Most studies of nutritional interventions forchildren and adolescents have focused on non-clinical settings (such as schools) or have usedphysiologic outcomes such as cholesterol or weightrather than more comprehensive measures of ahealthy diet.12,13

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References 1. Calfas KJ, Zabinski MF, Rupp J. Practical nutrition

assessment in primary care settings: a review. Am J PrevMed. 2000;18(4):289-299.

2. Rockett HR, Colditz GA. Assessing diets of children andadolescents. Am J Clin Nutr. 1997;65(4):1116-1122.

3. Beresford SA, Farmer EM, Feingold L, Graves KL,Sumner SK, Baker RM. Evaluation of a self-help dietary intervention in a primary care setting. Am JPublic Health. 1992;82(1):79-84.

4. Coates RJ, Bowen DJ, Kristal AR, et al. The Women’sHealth Trial Feasibility Study in Minority Populations:changes in dietary intakes. Am J Epidemiol.1999;149(12):1104-1112.

5. Kristal AR, Curry SJ, Shattuck AL, Feng Z, Li S. Arandomized trial of a tailored, self-help dietaryintervention: the Puget Sound Eating Patterns study.Prev Med. 2000;31(4):380-389.

6. Little P, Barnett J, Margetts B, et al. The validity ofdietary assessment in general practice. J EpidemiolCommun Health. 1999;53(3):165-172.

7. Whitlock EP, Orleans CT, Pender N, Allan J. Evaluatingprimary care behavioral counseling interventions: anevidence-based approach. Am J Prev Med.2002;22(4):267-284.

8. Maskarinec G, Chan CL, Meng L, Franke AA, CooneyRV. Exploring the feasibility and effects of a high-fruitand -vegetable diet in healthy women. Cancer EpidemiolBiomarkers Prev. 1999;8(10):919-924.

9. Beresford SA, Curry SJ, Kristal AR, Lazovich D, Feng Z,Wagner EH. A dietary intervention in primary care

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practice: the Eating Patterns Study. Am J Public Health.1997;87(4):610-616.

10. Ockene IS, Hebert JR, Ockene JK, et al. Effect ofphysician-delivered nutrition counseling training and anoffice-support program on saturated fat intake, weight,and serum lipid measurements in a hyperlipidemicpopulation: Worcester Area Trial for Counseling inHyperlipidemia (WATCH). Arch Int Med.1999;159(7):725-731.

11. Ockene IS, Hebert JR, Ockene JK, Merriam PA, HurleyTG, Saperia GM. Effect of training and a structuredoffice practice on physician-delivered nutritioncounseling: the Worcester-Area Trial for Counseling inHyperlipidemia (WATCH). Am J Prev Med.1996;12(4):252-258.

12. Obarzanek E, Hunsberger SA, Van Horn L, et al. Safetyof a fat-reduced diet: the Dietary Intervention Study inChildren (DISC). Pediatrics. 1997;100(1):51-59.

13. Obarzanek E, Kimm SY, Barton BA, et al. Long-termsafety and efficacy of a cholesterol-lowering diet inchildren with elevated low-density lipoproteincholesterol: seven-year results of the Dietary InterventionStudy in Children (DISC). Pediatrics. 2001;107(2):256-264.

This USPSTF recommendation was first published in:Am J Prev Med. 2003;24(1):93-100.

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n The balance of benefits and harms for a woman willbe influenced by her personal preferences, her risksfor specific chronic diseases, and the presence ofmenopausal symptoms. A shared decisionmakingapproach to preventing chronic diseases inperimenopausal and postmenopausal womeninvolves consideration of individual risk factors andpreferences in selecting effective interventions forreducing the risks for fracture, heart disease, andcancer. See other USPSTF recommendations forprevention of chronic diseases (screening forosteoporosis, high blood pressure, lipid disorders,breast cancer, and colorectal cancer; and counseling

Hormone Therapy for the Prevention ofChronic Conditions in PostmenopausalWomen

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The U.S. Preventive Services Task Force(USPSTF) recommends against the routine use ofcombined estrogen and progestin for theprevention of chronic conditions inpostmenopausal women. Rating: Drecommendation.

The U.S. Preventive Services Task Force(USPSTF) recommends against the routine use ofunopposed estrogen for the prevention of chronicconditions in postmenopausal women who havehad a hysterectomy. Rating: D recommendation.

to prevent tobacco use) available at:www.preventiveservices.ahrq.gov.

n The USPSTF did not consider the use of hormonetherapy for the management of menopausalsymptoms, which is the subject ofrecommendations by other expert groups. Womenand their clinicians should discuss the balance ofrisks and benefits before deciding to initiate orcontinue hormone therapy for menopausalsymptoms. For example, for combined estrogen andprogestin, some risks (such as the risks for venousthromboembolism, coronary heart disease [CHD],and stroke) arise within the first 1 to 2 years oftherapy, and other risks (such as the risk for breastcancer) appear to increase with longer-termhormone therapy. The populations of women usinghormone therapy for symptom relief may differfrom those who would use hormone therapy forprevention of chronic disease (eg, age differences).Other expert groups have recommended thatwomen who decide to take hormone therapy torelieve menopausal symptoms use the lowesteffective dose for the shortest possible time.

n Although estrogen alone or in combination withprogestin reduces the risk for fractures in women,other effective medications (eg, bisphosphonatesand calcitonin) are available for treating womenwith low bone density to prevent fractures. The

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role of chemopreventive agents in preventingfractures in women without low bone density isunclear. The USPSTF addressed screening forosteoporosis in postmenopausal women in 2002.1

n Unopposed estrogen increases the risk forendometrial cancer in women who have an intactuterus. Clinicians should use a shared decision-making approach when discussing the possibility ofusing unopposed estrogen in women who have nothad a hysterectomy.2

References1. U.S. Preventive Services Task Force. Screening for

osteoporosis in postmenopausal women:recommendations from the U.S. Preventive Services TaskForce. Ann Intern Med. 137(6):526-528.

2. Sheridan SL, Harris RP, Woolf SH, for the SharedDecisionmaking Workgroup, Third U.S. PreventiveServices Task Force. Shared decision-making aboutscreening and chemoprevention: a suggested approachfrom the U. S. Preventive Services Task Force. Am J PrevMed. 2004;26(1):56-66.


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n A number of techniques, such as bioelectricalimpedance, dual-energy x-ray absorptiometry, andtotal body water can measure body fat, but it isimpractical to use them routinely. Body mass index(BMI), which is simply weight adjusted for height,is a more practical and widely-used method toscreen for obesity. Increased BMI is associated withan increase in adverse health effects. Centraladiposity increases the risk for cardiovascular and

Screening for Obesity in Adults

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The USPSTF recommends that clinicians screenall adult patients for obesity and offer intensivecounseling and behavioral interventions topromote sustained weight loss for obese adults.Rating: B Recommendation.

The USPSTF concludes that the evidence isinsufficient to recommend for or against the use ofmoderate- or low-intensity counseling togetherwith behavioral interventions to promote sustainedweight loss in obese adults. Rating: IRecommendation.

The USPSTF concludes that the evidence isinsufficient to recommend for or against the use ofcounseling of any intensity and behavioralinterventions to promote sustained weight loss inoverweight adults. Rating: I Recommendation.

other diseases independent of obesity. Cliniciansmay use the waist circumference as a measure ofcentral adiposity. Men with waist circumferencesgreater than 102 cm (> 40 inches) and women withwaist circumferences greater than 88 cm (> 35inches) are at increased risk for cardiovasculardisease. The waist circumference thresholds are notreliable for patients with a BMI greater than 35.

n Expert committees have issued guidelines definingoverweight and obesity based on BMI. Persons witha BMI between 25 and 29.9 are overweight andthose with a BMI of 30 and above are obese. Thereare 3 classes of obesity: class I (BMI 30-34.9), classII (BMI 35-39.9), and class III (BMI 40 andabove). BMI is calculated either as weight inpounds divided by height in inches squaredmultiplied by 703, or as weight in kilogramsdivided by height in meters squared. The NationalInstitutes of Health (NIH) provides a BMIcalculator at www.nhlbisupport.com/bmi/ and atable at www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm.

n The most effective interventions combine nutritioneducation and diet and exercise counseling withbehavioral strategies to help patients acquire theskills and supports needed to change eating patternsand to become physically active. The 5-Aframework (Assess, Advise, Agree, Assist, andArrange) has been used in behavioral counselinginterventions such as smoking cessation and may bea useful tool to help clinicians guide interventions

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for weight loss. Initial interventions paired withmaintenance interventions help ensure that weightloss will be sustained over time.

n It is advisable to refer obese patients to programsthat offer intensive counseling and behavioralinterventions for optimal weight loss. The USPSTFdefined intensity of counseling by the frequency ofthe intervention. A high-intensity intervention ismore than 1 person-to-person (individual or group)session per month for at least the first 3 months ofthe intervention. A medium-intensity interventionis a monthly intervention, and anything lessfrequent is a low-intensity intervention. There arelimited data on the best place for theseinterventions to occur and on the composition ofthe multidisciplinary team that should deliver high-intensity interventions.

n The USPSTF concluded that the evidence on theeffectiveness of interventions with obese people maynot be generalizable to adults who are overweightbut not obese. The evidence for the effectiveness ofinterventions for weight loss among overweightadults, compared with obese adults, is limited.

n Orlistat and sibutramine, approved for weight lossby the Food and Drug Administration, can producemodest weight loss (2.6-4.8 kg) that can besustained for at least 2 years if the medication iscontinued. The adverse effects of orlistat includefecal urgency, oily spotting, and flatulence; theadverse effects of sibutramine include an increase in

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blood pressure and heart rate. There are no data onthe long-term (longer than 2 years) benefits oradverse effects of these drugs. Experts recommendthat pharmacological treatment of obesity be usedonly as part of a program that also includes lifestylemodification interventions, such as intensive dietand/or exercise counseling and behavioralinterventions.

n There is fair to good evidence to suggest thatsurgical interventions such as gastric bypass, verticalbanded gastroplasty, and adjustable gastric bandingcan produce substantial weight loss (28 to > 40 kg)in patients with class III obesity. Clinical guidelinesdeveloped by the National Heart, Lung, and BloodInstitute (NHLBI) Expert Panel on theidentification, evaluation, and treatment ofoverweight and obesity in adults recommend thatthese procedures be reserved for patients with classIII obesity and for patients with class II obesity whohave at least 1 other obesity-related illness. Thepostoperative mortality rate for these procedures is0.2 percent. Other complications include woundinfection, re-operation, vitamin deficiency, diarrhea,and hemorrhage. Re-operation may be necessary inup to 25 percent of patients. Patients should receivea psychological evaluation prior to undergoing theseprocedures. The long-term health effects of surgeryfor obesity are not well characterized.

n The data supporting the effectiveness ofinterventions to promote weight loss are derived

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mostly from women, especially white women. Theeffectiveness of the interventions is less wellestablished in other populations, including theelderly. The USPSTF believes that, although thedata are limited, these interventions may be usedwith obese men, physiologically mature olderadolescents, and diverse populations, taking intoaccount cultural and other individual factors.


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n Regular physical activity helps preventcardiovascular disease, hypertension, type 2diabetes, obesity, and osteoporosis. It may alsodecrease all-cause morbidity and lengthen life-span.1

n Benefits of physical activity are seen at even modestlevels of activity, such as walking or bicycling 30minutes per day on most days of the week. Benefitsincrease with increasing levels of activity.2

n Whether routine counseling and follow-up byprimary care physicians results in increased physicalactivity among their adult patients is unclear.Existing studies limit the conclusions that can bedrawn about efficacy, effectiveness, and feasibility ofprimary care physical activity counseling. Moststudies have tested brief, minimal, and low-intensityprimary care interventions, such as 3 to 5 minutecounseling sessions in the context of a routineclinical visit.

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The U.S. Preventive Services Task Force(USPSTF) concludes that the evidence isinsufficient to recommend for or against behavioralcounseling in primary care settings to promotephysical activity. Rating: I Recommendation.

n Multi-component interventions combining provideradvice with behavioral interventions to facilitate andreinforce healthy levels of physical activity appear themost promising. Such interventions often includepatient goal setting, written exercise prescriptions,individually tailored physical activity regimens, andmailed or telephone follow-up assistance provided byspecially trained staff. Linking primary care patientsto community-based physical activity and fitnessprograms may enhance the effectiveness of primarycare clinician counseling.3

n Potential harms of physical activity counseling havenot been well defined or studied. They may includemuscle and fall-related injuries or cardiovascularevents.4 It is unclear whether more extensive patientscreening, certain types of physical activity (eg,moderate vs vigorous exercise), more gradualincreases in exercise, or more intensive counselingand follow-up monitoring will decrease the likelihoodof injuries related to physical activity. Existing studiesprovide insufficient evidence regarding the potentialharms of various activity protocols, such as moderatecompared with vigorous exercise.

References 1. U.S. Department of Health and Human Services. Healthy

People 2010, conference edition. Washington DC: U.S.Department of Health and Human Services; 2000.Available at: http://www.health.gov/healthypeople/Document/HTML/Volume2/22Physical.htm. AccessedMay 30, 2002.

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2. U.S. Department of Health and Human Services.Physical Activity and Health: A Report of the SurgeonGeneral. Atlanta, GA: U.S. Department of Health andHuman Services, Centers for Disease Control andPrevention. National Center for Chronic DiseasePrevention and Health Promotion; 1996. Available at:http://www.cdc.gov/nccdphp/sgr/pdf/sgrfull.pdf.Accessed May 30, 2002.

3. Task Force on Community Preventive Services.Recommendations to increase physical activity in communities. Am J Prev Med. 2002;22(4S):67-72.Available at: http://www.thecommunityguide.org/.Accessed June 7, 2002.

4. The Writing Group for the Activity Counseling TrialResearch Group. Effects of physical activity counseling in primary care: The activity counseling trial:a randomized controlled trial. JAMA. 2001;286:677-687.


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n Subclinical thyroid dysfunction is defined as anabnormal biochemical measurement of thyroidhormones without any specific clinical signs orsymptoms of thyroid disease and no history ofthyroid dysfunction or therapy. This includesindividuals who have mildly elevated TSH andnormal thyroxine (T4) and triiodothyronine (T3)levels (subclinical hypothyroidism), or low TSH andnormal T4 and T3 levels (subclinicalhyperthyroidism). Individuals with symptoms ofthyroid dysfunction, or those with a history ofthyroid disease or treatment, are excluded from thisdefinition and are not the subject of theserecommendations.

n When used to confirm suspected thyroid disease inpatients referred to a specialty endocrine clinic,TSH has a high sensitivity (98%) and specificity(92%). When used for screening primary carepopulations, the positive predictive value (PPV) ofTSH in detecting thyroid disease is low; further, theinterpretation of a positive test result is often

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The U.S. Preventive Services Task Force(USPSTF) concludes the evidence is insufficient torecommend for or against routine screening forthyroid disease in adults. Rating: IRecommendation.

complicated by an underlying illness or by frailty ofthe individual. In general, values for serum TSHbelow 0.1 mU/L are considered low and valuesabove 6.5 mU/L are considered elevated.

n Clinicians should be aware of subtle signs of thyroiddysfunction, particularly among those at high risk.People at higher risk for thyroid dysfunctioninclude the elderly, post-partum women, those withhigh levels of radiation exposure (>20 mGy), andpatients with Down syndrome. Evaluating forsymptoms of hypothyroidism is difficult in patientswith Down syndrome because some symptoms andsigns (eg, slow speech, thick tongue, and slowmentation) are typical findings in both conditions.

n Subclinical hyperthyroidism has been associatedwith atrial fibrillation, dementia, and, less clearly,with osteoporosis. However, progression fromsubclinical to clinical disease in patients without ahistory of thyroid disease is not clearly established.

n Subclinical hypothyroidism is associated with poorobstetric outcomes and poor cognitive developmentin children. Evidence for dyslipidemia,atherosclerosis, and decreased quality of life inadults with subclinical hypothyroidism in thegeneral population is inconsistent and lessconvincing.

This USPSTF recommendation was first published in:Ann Intern Med. 2004;125-127.

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n In the absence of evidence of direct benefits ofroutine screening for type 2 diabetes, the decision toscreen individual patients is a matter of clinicaljudgment. Patients at increased risk forcardiovascular disease may benefit most fromscreening for type 2 diabetes, since management ofcardiovascular risk factors leads to reductions inmajor cardiovascular events. Clinicians should assistpatients in making that choice. In addition,clinicians should be alert to symptoms suggestive ofdiabetes (ie, polydipsia and polyuria) and testanyone with these symptoms.

n Screening for diabetes in patients with hypertensionor hyperlipidemia should be part of an integratedapproach to reduce cardiovascular risk. Lowertargets for blood pressure (ie, diastolic blood

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The U.S. Preventive Services Task Force(USPSTF) concludes that the evidence isinsufficient to recommend for or against routinelyscreening asymptomatic adults for type 2 diabetes,impaired glucose tolerance, or impaired fastingglucose. Rating: I Recommendation.

The USPSTF recommends screening for type 2diabetes in adults with hypertension orhyperlipidemia. Rating: B Recommendation.

pressure <80 mm Hg) are beneficial for patientswith diabetes and high blood pressure. The reportof the Adult Treatment Panel III of the NationalCholesterol Education Program recommends lowertargets for low-density lipoprotein cholesterol forpatients with diabetes. Attention to other riskfactors such as physical inactivity, diet, andoverweight is also important, both to decrease riskfor heart disease and to improve glucose control.

n Three tests have been used to screen for diabetes:fasting plasma glucose (FPG), 2-hour post-loadplasma glucose (2-hour PG), and hemoglobin A1c(HbA1c). The American Diabetes Association(ADA) has recommended the FPG test (>126mg/dL) for screening because it is easier and fasterto perform, more convenient and acceptable topatients, and less expensive than other screeningtests. The FPG test is more reproducible than the 2-hour PG test, has less intraindividual variation, andhas similar predictive value for development ofmicrovascular complications of diabetes. Comparedwith the FPG test, the 2-hour PG test may lead tomore individuals being diagnosed as diabetic.HbA1c is more closely related to FPG than to 2-hour PG, but at the usual cut-points it is lesssensitive in detecting lower levels of hyperglycemia.The random capillary blood glucose (CBG) test hasbeen shown to have reasonable sensitivity (75% at acut-point of >120 mg/dL) in detecting persons whohave either an FPG level >126 mg/dL or a 2-hourPG level >200 mg/dL, if results are interpreted

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according to age and time since last meal; however,the random blood glucose test is less wellstandardized for screening for diabetes.

n The ADA recommends confirmation of a diagnosisof diabetes with a repeated FPG test on a separateday, especially for patients with borderline FPGresults and patients with normal FPG levels forwhom suspicion of diabetes is high. The optimalscreening interval is not known. The ADA, on thebasis of expert opinion, recommends an interval ofevery 3 years but shorter intervals in high-riskpersons.

n Regardless of whether the clinician and patientdecide to screen for diabetes, patients should beencouraged to exercise, eat a healthy diet, andmaintain a healthy weight, choices that may preventor forestall the development of type 2 diabetes.More aggressive interventions to establish andmaintain these behaviors should be considered forpatients at increased risk for developing diabetes,such as those who are overweight, have a familyhistory of diabetes, or have a racial or ethnicbackground associated with an increased risk (e.g.,American Indians). Intensive programs of lifestylemodification (diet, exercise, and behavior) shouldalso be considered for patients who have impairedfasting glucose or impaired glucose tolerance, sinceseveral large trials have demonstrated that theseprograms can significantly reduce the incidence of

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diabetes in these patients. Evidence andrecommendations regarding counseling about diet,physical activity, and obesity are provided in theUSPSTF evidence summaries “Counseling toPromote a Healthy Diet,” “Counseling to PromotePhysical Activity,” and “Screening and Treatmentfor Obesity in Adults,” available on the Agency forHealthcare Research and Quality Web site atwww.preventiveservices.ahrq.gov.

This USPSTF recommendation was first published in:Ann Intern Med. 2003; 138:212-214.

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n Although exercise has not been shown to preventlow back pain, regular physical activity has otherproven health benefits, including prevention ofcardiovascular disease, hypertension, type 2diabetes, obesity, and osteoporosis.

n Neither lumbar supports nor back belts appear tobe effective in reducing the incidence of low backpain.

n Worksite interventions, including educationalinterventions, have some short-term benefit inreducing the incidence of low back pain. However,their applicability to the primary care setting isunknown.

Musculoskeletal Conditions

Primary Care Interventions to PreventLow Back Pain in Adults

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The U.S. Preventive Services Task Force(USPSTF) concludes that the evidence isinsufficient to recommend for or against theroutine use of interventions to prevent low backpain in adults in primary care settings. Rating: IRecommendation.

n Back schools may prevent further back injury forindividuals with recurrent or chronic low back pain,but their long-term effectiveness has not been wellstudied.


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n Modeling analysis suggests that the absolutebenefits of screening for osteoporosis amongwomen aged 60-64 who are at increased risk forosteoporosis and fracture are comparable to thoseof routine screening in older women. The exactrisk factors that should trigger screening in thisage group are difficult to specify based onevidence. Lower body weight (weight < 70 kg ) is

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The U.S. Preventive Services Task Force(USPSTF) recommends that women aged 65 andolder be screened routinely for osteoporosis. TheUSPSTF recommends that routine screeningbegin at age 60 for women at increased risk forosteoporotic fractures (see Clinical Considerationsfor discussion of women at increased risk). Rating: BRecommendation.

The USPSTF makes no recommendation foror against routine osteoporosis screening inpostmenopausal women who are younger than 60or in women aged 60-64 who are not at increasedrisk for osteoporotic fractures. Rating: CRecommendation.

the single best predictor of low bone mineraldensity.1,2 Low weight and no current use ofestrogen therapy are incorporated with age intothe 3-item Osteoporosis Risk AssessmentInstrument (ORAI).1,2 There is less evidence tosupport the use of other individual risk factors (forexample, smoking, weight loss, family history,decreased physical activity, alcohol or caffeine use,or low calcium and vitamin D intake) as a basisfor identifying high-risk women younger than 65.At any given age, African-American women onaverage have higher bone mineral density (BMD)than white women and are thus less likely tobenefit from screening.

n Among different bone measurement testsperformed at various anatomical sites, bonedensity measured at the femoral neck by dual-energy x-ray absorptiometry (DXA) is the bestpredictor of hip fracture and is comparable toforearm measurements for predicting fractures atother sites. Other technologies for measuringperipheral sites include quantitativeultrasonography (QUS), radiographicabsorptiometry, single energy x-ray absorptiometry,peripheral dual-energy x-ray absorptiometry, andperipheral quantitative computed tomography.Recent data suggest that peripheral bone density

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testing in the primary care setting can alsoidentify postmenopausal women who have ahigher risk for fracture over the short term (1year). Further research is needed to determine theaccuracy of peripheral bone density testing incomparison with dual-energy x-rayabsorptiometry (DXA). The likelihood of beingdiagnosed with osteoporosis varies greatlydepending on the site and type of bonemeasurement test, the number of sites tested, thebrand of densitometer used, and the relevance ofthe reference range.

n Estimates of the benefits of detecting and treatingosteoporosis are based largely on studies ofbisphosphonates. Some women, however, mayprefer other treatment options (for example,hormone replacement therapy, selective estrogenreceptor modulators, or calcitonin) based onpersonal preferences or risk factors. Cliniciansshould review with patients the relative benefitsand harms of available treatment options, anduncertainties about their efficacy and safety, tofacilitate an informed choice.

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n No studies have evaluated the optimal intervalsfor repeated screening. Because of limitations inthe precision of testing, a minimum of 2 yearsmay be needed to reliably measure a change inbone mineral density; however, longer intervalsmay be adequate for repeated screening toidentify new cases of osteoporosis. Yield ofrepeated screening will be higher in older women,those with lower BMD at baseline, and thosewith other risk factors for fracture.

n There are no data to determine the appropriateage to stop screening and few data onosteoporosis treatment in women older than 85.Patients who receive a diagnosis of osteoporosisfall outside the context of screening but mayrequire additional testing for diagnostic purposesor to monitor response to treatment.

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References

1. Cadarette SM, Jaglal SB, Kreiger N, et al. Developmentand validation of the Osteoporosis Risk AssessmentInstrument to facilitate selection of women for bonedensitometry. Can Med Assoc J. 2000;162:1289-1294.

2. Cadarette SM, Jaglal SB, Murray T, et al. Evaluation ofdecision rules for referring women for bonedensitometry by dual-energy x-ray absorptiometry.JAMA. 2001;286(1):57-63.



n For women with a history of preterm delivery,screening for BV is an option. A single previousepisode of preterm delivery by itself may notreliably identify a population of women who willbenefit from screening and treatment. Nevertheless,screening may be appropriate in specificcircumstances. Studies demonstrating a benefit ofscreening and treatment were performed amongpopulations of women at especially high risk (35%to 57%) of preterm birth. Clinicians should

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The U.S. Preventive Services Task Force(USPSTF) concludes that the evidence isinsufficient to recommend for or against routinelyscreening high-risk pregnant women for bacterialvaginosis (BV). (See Clinical Considerations fordiscussion of populations at high risk.) Rating: IRecommendation.

The USPSTF recommends against routinelyscreening average-risk asymptomatic pregnantwomen for BV. Rating: D Recommendation.

Obstetric and GynecologicConditions

Screening for Bacterial Vaginosis inPregnancy

consider previous history of preterm delivery, otherrisk factors, and time of presentation in making thedecision whether or not to screen for BV in womenat high risk.

n For clinicians electing to screen high-risk women,the optimal screening test is not certain. Acceptedclinical criteria for BV include vaginal pH >4.5,amine odor on the application of KOH, appearanceof a homogeneous vaginal discharge, and presenceof clue cells on a microscopic examination of a wetmount. Presence of at least 3 of these 4 criteria isgenerally considered diagnostic of BV. The use ofmore limited criteria (e.g., clue cells alone) has notbeen evaluated.

n Neither the optimal time to screen high-riskpregnant women nor the optimal treatmentregimen for pregnant women with BV is clear. The3 trials that demonstrated a reduction in pretermbirth screened in the second trimester (13 to 24weeks of pregnancy) used various regimens of oralmetronidazole alone or oral metronidazole anderythromycin.

n Treatment is appropriate for pregnant women withsymptomatic BV infection. These women wereexcluded from most screening trials and may be athigher risk than those without symptoms.Treatment can relieve symptoms such as vaginaldischarge.


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n Effective breastfeeding education and behavioralcounseling programs use individual or groupsessions led by specially trained nurses or lactationspecialists, usually lasting 30 to 90 minutes.Sessions generally begin during the prenatalperiod and cover the benefits of breastfeeding forinfant and mother, basic physiology, equipment,technical training in positioning and latch-ontechniques, and behavioral training in skills

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The U.S. Preventive Services Task Force(USPSTF) recommends structured breastfeedingeducation and behavioral counseling programs topromote breastfeeding. Rating: BRecommendation.

The USPSTF found insufficient evidence torecommend for or against the followinginterventions to promote breastfeeding: briefeducation and counseling by primary careproviders; peer counseling used alone andinitiated in the clinical setting; and writtenmaterials, used alone or in combination withother interventions. Rating: I Recommendation.

required to overcome common situational barriersto breastfeeding and to garner needed socialsupport.

n Hospital practices that may help supportbreastfeeding include early maternal contact withthe newborn, rooming-in, and avoidance of formulasupplementation for breastfeeding infants.

n Commercial discharge packs provided by hospitalsthat include samples of infant formula and/orbottles and nipples are associated with reducing therates of exclusive breastfeeding.

n Mothers who wish to continue breastfeeding afterreturning to work, especially those working full-time, may need to use an electric or mechanicalpump to maintain a sufficient breast milk supply.

n Few contraindications to breastfeeding exist. Indeveloped countries, infection with humanimmunodeficiency virus (HIV) in the mother isconsidered a contraindication to breastfeeding, as isthe presence of current alcohol and druguse/dependence. Some medications (prescriptionand non-prescription) are contraindicated oradvised for use “with caution” and appropriateclinical monitoring among lactating women.1

Clinicians should consult appropriate references forinformation on specific medications, includingherbal remedies.

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Reference1. American Academy of Pediatrics and American College

of Obstetricians and Gynecologists. Guidelines forPerinatal Care, 5th ed. October 2002:220-229.

This USPSTF recommendation statement was firstpublished in: Am J Fam Med. 2003;1(2):79-80.

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n Better quality evidence is needed to determinewhether the benefits of screening for gestationaldiabetes mellitus (GDM) outweigh the harms.Until such evidence is available, clinicians mightreasonably choose either not to screen at all or toscreen only women at increased risk for GDM.

n Patient characteristics most strongly associated withincreased risk for GDM include maternal obesity(usually defined as a body mass index [BMI] of 25or more), older age (usually defined as older than25 years), family or personal history of diabetes, ora history of GDM in a prior pregnancy. Expertgroups have also identified certain ethnic groups asbeing at increased risk for GDM (such as Hispanic,African American, American Indian, and South orEast Asian). Using all the above criteria, however,would identify 90 percent of all pregnant women asbeing at increased risk for GDM.

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The U.S. Preventive Services Task Force(USPSTF) concludes that the evidence isinsufficient to recommend for or against routinescreening for gestational diabetes. Rating: IRecommendation.

n The optimal approach to screening and diagnosis isuncertain. Expert panels in the United Statesrecommend a 50-g 1-hour glucose challenge test(GCT) at 24 to 28 weeks’ gestation, followed by a100-g 3-hour oral glucose tolerance test (OGTT)for women who screen positive on the GCT.Different screening and diagnostic strategiesrecommended by the World Health Organization(WHO) are commonly used outside of NorthAmerica. The American Diabetes Association(ADA) and the WHO have published specificcriteria for diagnosis, but the USPSTF could notdetermine the relative benefits of any specificapproach.1,2

References1. WHO Consultation: Definition, diagnosis and

classification of diabetes mellitus and its complications:report of a WHO Consultation. Part 1: diagnosis andclassification of diabetes mellitus. Geneva,WHO/NCD/NCS/99.2, World Health Org., 1999.

2. American Diabetes Association. Gestational diabetesmellitus. Diabetes Care. 2002;25(Suppl 1):S94-S96.

This USPSTF recommendation was first published in:Obstet Gynecol. 2003;101:393-395.

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n Administration of a full (300µg) dose of Rh (D)immunoglobulin is recommended for allunsensitized Rh (D)-negative women after repeatedantibody testing at 24-28 weeks’ gestation.

n If an Rh (D)-positive or weakly Rh (D)-positive (eg,Du-positive) infant is delivered, a dose of Rh (D)immunoglobulin should be repeated postpartum,preferably within 72 hours after delivery.Administering Rh (D) immunoglobulin at otherintervals after delivery has not been studied.

n Unless the biological father is known to be Rh (D)-negative, a full dose of Rh (D) immunoglobulin isrecommended for all unsensitized Rh (D)-negativewomen after amniocentesis and after induced or

Screening for Rh (D) Incompatibility

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The U.S. Preventive Services Task Force(USPSTF) strongly recommends Rh (D) bloodtyping and antibody testing for all pregnantwomen during their first visit for pregnancy-relatedcare. Rating: A Recommendation.

The USPSTF recommends repeated Rh (D)antibody testing for all unsensitized Rh (D)-negative women at 24-28 weeks’ gestation, unlessthe biological father is known to be Rh (D)-negative. Rating: B Recommendation.

spontaneous abortion; however, if the pregnancy isless than 13 weeks, a 50 µg dose is sufficient.

n The benefit of routine administration of Rh (D)immunoglobulin after other obstetric procedures orcomplications such as chorionic villus sampling,ectopic pregnancy termination, cordocentesis, fetalsurgery or manipulation (including externalversion), antepartum placental hemorrhage,abdominal trauma, antepartum fetal death, orstillbirth is uncertain due to inadequate evidence.


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Section 3.

Recommendations for Children


n Dental disease is prevalent among young children,particularly those from lower socioeconomicpopulations; however, few preschool-aged childrenever visit a dentist. Primary care clinicians are oftenthe first and only health professionals whomchildren visit. Therefore, they are in a uniqueposition to address dental disease in these children.

n Fluoride varnishes, professionally applied topicalfluorides approved to prevent dental caries in youngchildren, are adjuncts to oral supplementation.Their advantages over other topical fluoride agents(mouth-rinse and gel) include ease of use, patient

Prevention of Dental Caries inPreschool Children

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The U.S. Preventive Services Task Force(USPSTF) recommends that primary careclinicians prescribe oral fluoride supplementationat currently recommended doses to preschoolchildren older than 6 months of age whoseprimary water source is deficient in fluoride.Rating: B Recommendation.

The USPSTF concludes that the evidence isinsufficient to recommend for or against routinerisk assessment of preschool children by primarycare clinicians for the prevention of dental disease.Rating: I Recommendation.

acceptance, and reduced potential for toxicity.

n Dental fluorosis (rather than skeletal fluorosis) is themost common harm of either oral fluoride orfluoride toothpaste use in children younger than 2years in the United States. Dental fluorosis istypically very mild and only of aestheticimportance. The recommended dosage of fluoridesupplementation was reduced by the AmericanDental Association in 1994, which is likely todecrease the prevalence and severity of dentalfluorosis. The current dosage recommendations arebased on the fluoride level of the local community’swater supply and are available online atwww.ada.org. The primary care clinician’sknowledge of the fluoride level of his or herpatients’ primary water supply ensures appropriatefluoride supplementation and minimizes risk forfluorosis.

This USPSTF recommendation was first published in:Am J Prev Med. 2004;26(4)326-329.

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Prevention of Dental Caries in Preschool Children


n Screening adolescents for idiopathic scoliosis isusually done by visual inspection of the spine tolook for asymmetry of the shoulders, scapulae, andhips. A scoliometer can be used to measure thecurve. If idiopathic scoliosis is suspected,radiography can be used to confirm the diagnosisand to quantify the degree of curvature.

n The health outcomes of adolescents with idiopathicscoliosis differ from those of adolescents withsecondary scoliosis (ie, congenital, neuromuscular,or early onset idiopathic scoliosis). Idiopathicscoliosis with onset in adolescence may have amilder clinical course.1

n Conservative interventions to treat curves detectedthrough screening include spinal orthoses (braces)and exercise therapy, but they may not significantlyimprove back pain or the quality of life foradolescents diagnosed with idiopathic scoliosis.

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The U.S. Preventive Services Task Force(USPSTF) recommends against the routinescreening of asymptomatic adolescents foridiopathic scoliosis. Rating: D Recommendation.

n The potential harms of screening and treatingadolescents for idiopathic scoliosis includeunnecessary follow-up visits and evaluations due tofalse positive test results and psychological adverseeffects, especially related to brace wear. Althoughroutine screening of adolescents for idiopathicscoliosis is not recommended, clinicians should beprepared to evaluate idiopathic scoliosis when it isdiscovered incidentally or when the adolescent orparent expresses concern about scoliosis.

Reference1. Weinstein SL, Dolan LA, Spratt KF, Peterson KK,

Spoonamore MJ, Ponseti IV. Health and function of patients with untreated idiopathic scoliosis: a 50-yearnatural history study. JAMA. 2003;289(5):559-567.

This USPSTF recommendation was first published by:Agency for Healthcare Research and Quality, Rockville,MD. June 2004. www.preventiveservices.ahrq.gov.

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n Currently, universal newborn hearing screening(UNHS) is required by law in more than 30 Statesand is performed routinely in some health caresystems in other States. Selective screening ofinfants in the NICU and those with other riskfactors for hearing loss (see below) is conducted inmany settings that do not follow a policy ofuniversal screening. Clinicians should be aware ofsuch screening policies in their practiceenvironments.

n Risk factors for sensorineural hearing loss (SNHL)among newborns include NICU admission for 2days or more; syndromes known to include hearingloss (eg, Usher’s syndrome, Waardenburg’ssyndrome); family history of childhood SNHL;congenital infections (eg, toxoplasmosis, bacterialmeningitis, syphilis, rubella, cytomegalovirus,herpes virus); and craniofacial abnormalities(especially morphologic abnormalities of the pinnaand ear canal).

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The U.S. Preventive Services Task Force(USPSTF) concludes the evidence is insufficient torecommend for or against routine screening ofnewborns for hearing loss during the postpartumhospitalization. Rating: I Recommendation.

n If a program for routine hearing screening ofnewborns is implemented, it should includesystematic education to fully inform parents andclinicians about the potential benefits and harms ofthe testing protocol. Most infants with positive in-hospital screening tests will subsequently be found tohave normal hearing, and clinicians should beprepared to provide reassurance and support toparents of infants who need follow-up audiologicevaluation.

n If any program for newborn hearing screening isimplemented, screening should be conducted using avalidated protocol, usually requiring 2 screening tests.Equipment used should be well maintained, staffshould be thoroughly trained, and quality controlprograms to reduce avoidable false-positive testsshould be in place. Programs should develop protocolsto ensure that infants with positive screening testsreceive appropriate audiologic evaluation and follow-up after discharge.

This USPSTF recommendation statement was firstpublished by: Agency for Healthcare Research and Quality,Rockville, MD. October 2001. www.preventiveservices.ahrq.gov.

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n The most common causes of visual impairment inchildren are: (1) amblyopia and its risk factors and(2) refractive error not associated with amblyopia.Amblyopia refers to reduced visual acuity without adetectable organic lesion of the eye and is usuallyassociated with amblyogenic risk factors thatinterfere with normal binocular vision, such asstrabismus (ocular misalignment), anisometropia (alarge difference in refractive power between the 2eyes), cataract (lens opacity), and ptosis (eyeliddrooping). Refractive error not associated withamblyopia principally includes myopia(nearsightedness) and hyperopia (farsightedness);both remain correctable regardless of the age atdetection.

n Various tests are used widely in the United States toidentify visual defects in children, and the choice oftests is influenced by the child’s age. During thefirst year of life, strabismus can be assessed by thecover test and the Hirschberg light reflex test.

Screening for Visual Impairment inChildren Younger Than Age 5 Years

159


The U.S. Preventive Services Task Force(USPSTF) recommends screening to detectamblyopia, strabismus, and defects in visual acuityin children younger than age 5 years. Rating: BRecommendation.

Screening children younger than age 3 years forvisual acuity is more challenging than screeningolder children and typically requires testing byspecially trained personnel. Newer automatedtechniques can be used to test these children.Photoscreening can detect amblyogenic risk factorssuch as strabismus, significant refractive error, andmedia opacities; however, photoscreening cannotdetect amblyopia.

n Traditional vision testing requires a cooperative,verbal child and cannot be performed reliably untilages 3 to 4 years. In children older than age 3 years,stereopsis (the ability of both eyes to functiontogether) can be assessed with the Random Dot Etest or Titmus Fly Stereotest; visual acuity can beassessed by tests such as the HOTV chart, Leasymbols, or the tumbling E. Some of these testshave better test characteristics than others.

n Based on their review of current evidence, theUSPSTF was unable to determine the optimalscreening tests, periodicity of screening, or technicalproficiency required of the screening clinician.Based on expert opinion, the American Academy ofPediatrics (AAP) recommends the following visionscreening be performed at all well-child visits forchildren starting in the newborn period to 3 years:ocular history, vision assessment, external inspectionof the eyes and lids, ocular motility assessment,pupil examination, and red reflex examination. Forchildren aged 3 to 5 years, the AAP recommendsthe aforementioned screening in addition to age-

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appropriate visual acuity measurement (usingHOTV or tumbling E tests) and ophthalmoscopy.1

n The USPSTF found that early detection andtreatment of amblyopia and amblyogenic riskfactors can improve visual acuity. These treatmentsinclude surgery for strabismus and cataracts; use ofglasses, contact lenses, or refractive surgerytreatments to correct refractive error; and visualtraining, patching, or atropine therapy of thenonamblyopic eye to treat amblyopia.

n These recommendations do not address screeningfor other anatomic or pathologic entities, such asmacro cornea, cataracts, retinal abnormalities, orneonatal neuroblastoma, nor do they address newerscreening technologies currently underinvestigation.

Reference1. American Academy of Pediatrics Committee on Practice

and Ambulatory Medicine and Section onOphthalmology, American Association of CertifiedOrthoptists, American Association of PediatricOphthalmology and Strabismus, American Academy ofOphthalmology. Eye examination in infants, children,and young adults by pediatricians: policy statement.Pediatrics. 2003;111(4):902-907.

This USPSTF recommendation was first published in:Ann Fam Med. 2004;2:263-266.

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Visual Impairment in Children Younger Than Age 5 Years

Appendixesand Index

164

Appendix A

How the U.S. Preventive Services TaskForce Grades Its RecommendationsThe U.S. Preventive Services Task Force (USPSTF) gradesits recommendations based on the strength of evidenceand magnitude of net benefit (benefits minus harms).

A. The USPSTF strongly recommends that cliniciansprovide [the service] to eligible patients. The USPSTFfound good evidence that [the service] improves importanthealth outcomes and concludes that benefits substantiallyoutweigh harms.

B. The USPSTF recommends that clinicians provide [theservice] to eligible patients. The USPSTF found at leastfair evidence that [the service] improves important healthoutcomes and concludes that benefits outweigh harms.

C. The USPSTF makes no recommendation for or againstroutine provision of [the service]. The USPSTF found atleast fair evidence that [the service] can improve healthoutcomes but concludes that the balance of benefits andharms is too close to justify a general recommendation.

D. The USPSTF recommends against routinely providing[the service] to asymptomatic patients. The USPSTFfound at least fair evidence that [the service] is ineffective orthat harms outweigh benefits.

I. The USPSTF concludes that the evidence is insufficientto recommend for or against routinely providing [theservice]. Evidence that [the service] is effective is lacking, ofpoor quality, or conflicting, and the balance of benefits andharms cannot be determined.

165

Appendix A

The USPSTF grades the quality of the overall evidencefor a service on a 3-point scale (good, fair, poor).

Good: Evidence includes consistent results from well-designed, well-conducted studies in representativepopulations that directly assess effects on healthoutcomes.

Fair: Evidence is sufficient to determine effects on healthoutcomes, but the strength of the evidence islimited by the number, quality, or consistency ofthe individual studies, generalizability to routinepractice, or indirect nature of the evidence onhealth outcomes.

Poor: Evidence is insufficient to assess the effects onhealth outcomes because of limited number orpower of studies, important flaws in their design orconduct, gaps in the chain of evidence, or lack ofinformation on important health outcomes.

Strength ofOverall Estimate of Net Benefit (Benefit Minus Harms)Evidence of Effectiveness Substantial Moderate Small Zero/

Negative

Good A B C D

Fair B B C D

Poor I – Insufficient Evidence

Strength of Overall Evidence and Estimate of NetBenefit Determine the Grade.

166

Appendix B

Members of the U.S. Preventive ServicesTask Force 2001-2004

Janet D. Allan, Ph.D.,R.N., C.S.School of NursingUniversity of Maryland,

BaltimoreBaltimore, MD

Alfred O. Berg, M.D.,M.P.H.Department of Family

MedicineUniversity of WashingtonSeattle, WA

Ned Calonge, M.D.,M.P.H.Colorado Department of

Public Health and Environment

Denver, CO

Paul S. Frame, M.D.Tri-County Family MedicineCohocton, NY

Joxel Garcia, M.D., M.B.A. Pan American Health

Organization Washington, DC

Leon Gordis, M.D., M.P.H.,Dr. P.H.Epidemiology DepartmentJohns Hopkins Bloomberg

School of Public HealthBaltimore, MD

Kimberly D. Gregory,M.D., M.P.H.Department of Obstetrics

and GynecologyCedars-Sinai Medical

CenterLos Angeles, CA

Russell Harris, M.D.,M.P.H.University of

North CarolinaSchool of Medicine

Chapel Hill, NC

Charles J. Homer, M.D.,M.P.H. National Initiative for

Children's Healthcare Quality

Boston, MA

167

Appendix B

Mark S. Johnson, M.D.,M.P.H.Department of Family

MedicineNew Jersey Medical SchoolUniversity of Medicine and

Dentistry of New JerseyNewark, NJ

Jonathan D. Klein, M.D.,M.P.H.Department of PediatricsUniversity of RochesterRochester, NY

Tracy A. Lieu, M.D.,M.P.H. Department of Ambulatory

Care and PreventionHarvard Pilgrim

Health Care and Harvard Medical School

Boston, MA

Carol Loveland-Cherry,Ph.D., R.N. Office of Academic AffairsUniversity of MichiganSchool of NursingAnn Arbor, MI

Virginia A. Moyer, M.D.,M.P.H.Department of PediatricsUniversity of Texas

Health Science CenterHouston, TX

Cynthia D. Mulrow, M.D.,M.Sc.University of Texas

Health Science CenterAudie L. Murphy Memorial

Veterans Hospital San Antonio, TX

Judith K. Ockene, Ph.D.,M.Ed.Division of Preventive and

Behavioral MedicineUniversity of Massachusetts

Medical SchoolWorcester, MA

C. Tracy Orleans, Ph.D.Department of Research

and Evaluation The Robert Wood Johnson

Foundation Princeton, NJ

Jeffrey F. Peipert, M.D.,M.P.H.Women and Infants'

Hospital Providence, RI

Nola J. Pender, Ph.D., R.N. School of Nursing University of Michigan Ann Arbor, MI

Diana B. Petitti, M.D.,M.P.H.Kaiser Permanente

Southern CaliforniaPasadena, CA

Harold C. Sox, Jr., M.D. Department of MedicineDartmouth-Hitchcock

Medical Center Lebanon, NH

Albert L. Siu, M.D.,M.S.P.H.Brookdale Department of

Geriatrics and AdultDevelopment

Mount Sinai Medical Center

New York, NY

Steven M. Teutsch, M.D.,M.P.H.Merck and Company, Inc.West Point, PA

Carolyn Westhoff, M.D.,M.Sc.Department of Obstetrics

and Gynecology Columbia University New York, NY

Steven H. Woolf, M.D.,M.P.H. Department of Family

Practice, Preventive Medicine, and Community Health

Virginia Commonwealth University

Fairfax, VA

Barbara P. Yawn, M.D.,M.Sc.Olmstead Research CenterRochester, MN

168

Appendix B

169

Appendix C

AcknowledgmentsAHRQ Staff Supporting the USPSTF2001-2004David Atkins, M.D., M.P.H. Dana Best, M.D., M.P.H. Joel BochesHelen Burstin, M.D., M.P.H. Mackenzie Cross Sandra K. CummingsElizabeth Edgerton, M.D., M.P.H. Kenneth Fink, M.D., M.G.A., M.P.H. Barbara Gordon Margi GradyJanelle Guirguis-Blake, M.D. Patrik Johansson, M.D.Heather Johnson, M.S.Douglas Kamerow, M.D., M.P.H. Hazel Keimowitz, M.A. Claire Kendrick, M.S. Ed.David Lanier, M.D. Iris Mabry, M.D., M.P.H.David Meyers, M.D.Tess Miller, Dr.P.H. Kevin Murray Barbara Najar, M.P.H.Bridget O’Connell Nilam Patel, M.P.H. Amy Pfeiffer Gurvaneet Randhawa, M.D., M.P.H. Stacia Sanvick

Eve Shapiro Randie Siegel, M.S. Jean Slutsky, P.A., M.S.P.H. Kristie SmithTricia Trinité, M.S.P.H., A.P.R.N.

Evidence-Based Practice Centers Supporting the USPSTF 2001-2004

The following researchers working through two AHRQEvidence-Based Practice Centers prepared systematicevidence reviews and evidence summaries as resources ontopics under consideration by the USPSTF.

Oregon Health & Science University Evidence-Based Practice CenterMikel Aickin, Ph.D.; Benjamin K.S. Chan, M.S.; RogerChou, M.D.; Elizabeth Clark, M.D., M.P.H.; Robert Davis,M.D., M.P.H.; Stephanie Detlefsen, M.D.; Karen B. Eden,Ph.D.; Nancy Glass, Ph.D., M.P.H., R.N.; Carla A. Green,Ph.D., M.P.H.; Jeanne-Marie Guise, M.D., M.P.H.; AndrewHamilton, M.S.; Mark Helfand, M.D., M.P.H.; LaurieHuffman, M.S.; Linda Humphrey, M.D., M.P.H.; KathrynPyle Krages, M.A.; Erin Leblanc, M.D., M.P.H.; SusanMahon, M.P.H.; Heather McPhillips, M.D., M.P.H.; JillMiller, M.D.; Heidi D. Nelson, M.D., M.P.H.; ValeriePalda, M.D., M.P.H.; Michael R. Polen, M.A.; CherylRitenbaugh, Ph.D., M.P.H.; Kelly Streit, M.S., R.D.; LinaM.A. Takano, M.D., M.S.; Diane Thompson, M.S.; KimVillemyer; David Wheeler, M.D.; Evelyn P. Whitlock,M.D., M.P.H.

170

Appendix C

Research Triangle Institute/University of North CarolinaEvidence-Based Practice CenterAlice Ammerman, Dr.P.H., R.D.; James D. Bader, D.D.S.,M.P.H.; Rainer Beck, M.D.; John F. Boggess, M.D.; MalazBoustani, M.D., M.P.H.; Seth Brody, M.D.; Audrina J.Bunton; Katrina Donahue, M.D., M.P.H.; LouiseFernandez, PA-C, R.D., M.P.H.; Kenneth Fink, M.D.,M.G.A., M.P.H.; Carol Ford, M.D.; Angela Fowler-Brown,M.D.; Bradley N. Gaynes, M.D., M.P.H.; Paul Godley,M.D., M.P.H.; Susan A. Hall, M.S.; Laura Hanson, M.D.,M.P.H.; Russell Harris, M.D., M.P.H.; Katherine E.Hartmann, M.D., Ph.D.; Michael Hayden, M.D.; M.Brian Hemphill, M.D.; Alissa Driscoll Jacobs, M.S., R.D.;Jana Johnson; Linda Kinsinger, M.D., M.P.H.; CarolKrasnov; Ramesh Krishnaraj; Carole M. Lannon, M.D.,M.P.H.; Carmen Lewis, M.D., M.P.H.; Kathleen N. Lohr,Ph.D.; Linda J. Lux, M.P.A. ; Kathleen McTigue, M.D.,M.P.H.; Catherine Mills, M.A.; Kavita Nanda, M.D.,M.H.S.; Carla Nester, M.D.; Britt Peterson, M.D.,M.P.H.; Christopher J. Phillips, M.D., M.P.H.; MichaelPignone, M.D., M.P.H.; Mark Pletcher, M.D., M.P.H.;Saif S. Rathore; Melissa Rich, M.D.; Gary Rozier, D.D.S.;Jerry L. Rushton, M.D., M.P.H.; Lucy A. Savitz; JoeScattoloni; Stacey Sheridan, M.D., M.P.H.; Sonya Sutton,B.S.P.H.; Jeffrey A. Tice, M.D.; Suzanne L. West, Ph.D.; B. Lynn Whitener, Dr.P.H., M.S.L.S.; Margaret Wooddell,M.A.; Dennis Zolnoun, M.D.

171

Appendix C

Liaisons to the USPSTF

Professional OrganizationsAmerican Academy of Family PhysiciansAmerican Academy of PediatricsAmerican Academy of Physician AssistantsAmerican Cancer SocietyAmerican College of Obstetricians and GynecologistsAmerican College of PhysiciansAmerican College of Preventive MedicineThe American Medical AssociationAmerica’s Health Insurance Plans

Federal AgenciesArmy Center for Health Promotion and Preventive

Medicine Canadian Task Force on Preventive Health CareCenters for Disease Control and PreventionCenters for Medicare & Medicaid ServicesDepartment of Veterans AffairsHealth Resources and Services AdministrationIndian Health ServicesNational Institutes of HealthU.S. Food and Drug Administration

172

Appendix C

173

Index

Index of Recommendations (Alphabetical by Topic)

Alcohol Misuse, Screening and Behavioral Counseling Interventions in Primary Care to Reduce.................................................................89

Aspirin for the Primary Prevention of Cardiovascular Events ..........................................55

Back Pain, Primary Care Interventions to Prevent Low.......................................................133

Bacterial Vaginosis in Pregnancy, Screening for.......141Bacteriuria, Screening for Asymptomatic ..................71Bladder Cancer in Adults, Screening for ...................15Breast Cancer, Chemoprevention of .........................17Breast Cancer, Screening for .....................................23Breastfeeding, Behavioral Interventions

to Promote.........................................................143

Cervical Cancer, Screening for ..................................26Chlamydial Infection, Screening for .........................73Colorectal Cancer, Screening for...............................32Coronary Heart Disease, Screening for .....................60

Dementia, Screening for ...........................................96Dental Caries in Preschool Children,

Prevention of ....................................................153Depression, Screening for .........................................98Diabetes Mellitus in Adults, Screening for

Type 2 ...............................................................128Diet, Behavioral Counseling in Primary Care to

Promote a Healthy ............................................109

Family and Intimate Partner Violence, Screening for .......................................................85

Gestational Diabetes Mellitus, Screening for ..........146

Hepatitis B Virus Infection, Screening for ................77Hepatitis C in Adults, Screening for .........................79High Blood Pressure, Screening for...........................63Hormone Therapy for the Prevention of Chronic

Conditions in Postmenopausal Women.............115

Lipid Disorders in Adults, Screening for...................67Lung Cancer Screening.............................................36

Newborn Hearing Screening...................................157

Obesity in Adults, Screening for .............................118Oral Cancer, Screening for........................................38Osteoporosis in Postmenopausal Women,

Screening for .....................................................135Ovarian Cancer, Screening for ..................................39

Pancreatic Cancer, Screening for ...............................41Physical Activity, Behavioral Counseling in

Primary Care to Promote...................................123Prostate Cancer, Screening for ..................................43

Rh (D) Incompatibility, Screening for ....................148

Scoliosis in Adolescents, Screening for Idiopathic ...155Skin Cancer, Counseling to Prevent..........................46Skin Cancer, Screening for........................................48Suicide Risk, Screening for .....................................102Syphilis Infection, Screening for ...............................81

174

Index of Recommendations

Testicular Cancer, Screening for................................50Thyroid Disease, Screening for ...............................126Tobacco Use and Tobacco-Caused Disease,

Counseling to Prevent .......................................104

Visual Impairment in Children Younger Than Age 5 Years, Screening for .................................159

Vitamin Supplementation to Prevent Cancer and Cardiovascular Disease, Routine..........................52

175

Index of Recommendations

More Resources on Preventive Services

Prevention Dissemination and Implementation (PutPrevention Into Practice) aims to improve the delivery ofappropriate clinical preventive services. The programdisseminates the USPSTF recommendations in multipleformats and facilitates health care delivery systems’implementation of evidence-based preventive servicesthrough partnerships, communication, user-driven tools,and outreach.

AHRQ’s Interactive Preventive Services Selector forPDA devices allows users to search USPSTFrecommendations by patient age, sex, and pregnancy status.Available for download at http://pda.ahrq.gov.

The Advisory Committee on Immunization Practices(ACIP) makes recommendations on the routineadministration of vaccines to the pediatric and adultpopulations. For recommendations, go tohttp://www.cdc.gov/nip/publications/acip-list.htm.

The Guide to Community Preventive Services providesrecommendations on population-based interventions topromote health and prevent disease, injury, disability, andpremature death. Recommendations are promulgated by theTask Force on Community Preventive Services, anindependent group appointed by the Director of the Centersfor Disease Control and Prevention. For information, go tohttp://www.thecommunityguide.org.

The National Guideline Clearinghouse™ (NGC) is adatabase of evidence-based clinical practice guidelines andrelated documents. To access, go to www.guideline.gov.

U.S. Department of Health and Human Services

Agency for Healthcare Research and Qualitywww.ahrq.gov

AHRQ Pub. No. 05-0570June 2005

In This Guide…

t Section 1. Preventive Services Recommended by the USPSTF

t Section 2. Recommendations for Adults

t Cancer (P. 15)

t Heart and Vascular Diseases (P. 55)

t Infectious Diseases (P. 71)

t Injury and Violence (P. 85)

t Mental Health Conditions and Substance Abuse (P. 89)

t Metabolic, Nutritional, and Endocrine Conditions (P. 109)

t Musculoskeletal Conditions (P. 133)

t Obstetric and Gynecologic Conditions (P. 141)

t Section 3. Recommendations for Children

t Appendixes and Index

Documents

The Guide to Clinical Preventive Services 2005