The Principles of Screening
What do we screen for?
A disease is amenable to screening if the following criteria are met:
It is a fairly common disorder
It results in significant morbidity and mortality
It has a preclinical stage where you can detect the disease before damage is done
It has an effective, easily provided treatment that improves prognosis if started early
Types of Prevention
Primary prevention = Preventing disease or injury before it occurs
Secondary prevention = Early detection of existing disease in asymptomatic patients
Tertiary prevention = optimizing care of patients with established disease
USPSTF
The USPSTF issues recommendations on screening, counseling, and preventive medicine after review of available evidence. They also issue recommendations based on the strength of evidence of benefit or harm of these interventions.
Remember: USPSTF recommendations apply only to people who have no signs or symptoms of the specific disease or condition under evaluation. The recommendations address only services offered in the primary care setting or services referred by a primary care clinician.
Specific Screening Recommendations
Diabetes Mellitus
Screen adults aged 40 to 70 years who are overweight or obese.
Can screen earlier in a patient with 1 or more high risk characteristics
For gestational diabetes mellitus (GDM), screen in in asymptomatic pregnant women after 24 weeks of gestation.
Hypertension
Screen all adults aged 18 years or older, annually for adults aged 40 years or older and for those who are at increased risk for high blood pressure.
Adults aged 18 to 39 years with normal blood pressure (<130/85 mm Hg) who do not have other risk factors should be rescreened every 3 to 5 years.
Hyperlipidemia
There are no longer any USPSTF screening recommendations regarding when to screen for hyperlipidemia. Instead they offer recommendations for who to treat.
Low- to moderate-dose statin is recommended when all of the following criteria are met:
Aged 40 to 75 years
1 or more CVD risk factors
Calculated 10-year risk of a cardiovascular event of 10% or greater
Offer a low- to moderate-dose statin to patients without a history of CVD when all of the following criteria are met:
Aged 40 to 75 years
1 or more CVD risk factors
Calculated 10-year risk of a cardiovascular event of 7.5% to 10%
AAA
One-time screening for AAA with ultrasonography in men ages 65 to 75 years who have ever smoked (even one cigarette!).
Offer screening for AAA in men ages 65 to 75 years who have never smoked rather than routinely screening all men in this group.
USPSTF recommends against routine screening for AAA in women who have never smoked.
Osteoporosis
Screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older.
Screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in postmenopausal women younger than 65 years who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool
Breast Cancer
Biennial screening mammography for women aged 50 to 74 years.
Of all of the age groups, women aged 60 to 69 years are most likely to avoid breast cancer death through mammography screening.
Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years.
Cervical Cancer
<21 years of age: Do not screen.
Age 21-29: Every 3 years with cervical cytology alone.
Age 30-65: Screen every 3 years with cervical cytology alone OR every 5 years with high-risk HPV testing.
>65 years of age: Do not screen.
Gonorrhea & Chlamydia
Screen for chlamydia and gonorrhea in ALL sexually active women age 24 years and younger and in older women who are at increased risk for infection, defined as the following:
New sex partner
>1 sex partner
Sex partner who has an STI
Inconsistent condom use among persons who are not in mutually monogamous relationships
Previous or coexisting STI
Exchanging sex for money or drugs
Hepatitis B
Screen for hepatitis B virus infection in persons at high risk for infection, defined as:
HIV+
IVDU
Sex with HBV+ partner
MSM
Hepatitis C
Screen for hepatitis C infection in persons at high risk for infection defined as:
Long-term hemodialysis
Patient born to an HCV-infected mother
Incarceration
IV or intranasal drug use
Unregulated tattoo
Percutaneous exposures (such as in health care)
Also recommends offering 1-time screening for HCV infection to adults born between 1945 and 1965.
Prostate Cancer
Screening for men aged 55 to 69 years with PSA should be an individualized decision.
USPSTF recommends against PSA-based screening for prostate cancer in men 70 years and older.
Lung Cancer
Annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history AND currently smoke or have quit within the past 15 years.
Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.
Thanks to Dr. Butcher for an excellent noon report.
References
NCHS, National Survey of Family Growth, 2011–2015.
Schick V. Sexual behaviors, condom use, and sexual health of Americans over 50: implications for sexual health promotion for older adults. J Sex Med. 2010 Oct;7 Suppl 5:315-29
National Survey of Sexual Health and Behavior (NSSHB) Center for Sexual Health Promotion. Indiana University
Smith, T. American Sexual Behavior: Trends, Socio-Demographic Differences, and Risk Behavior. National Opinion Research Center. U Chicago: March 2006
Sanders et al. Misclassification bias: diversity in conceptualisations about having ‘had sex’. Sexual Health, 2010. 7: 31-34
State Policies on Sex Education in Schools. National Conference of State Legislatures. Dec 2016. www.ncsl.org/research/health/state-policies-on-sex-education-in-schools.aspx
Rubin ES et al. Best Practices in North American Pre-Clinical Medical Education in Sexual History Taking: Consensus From the Summits in Medical Education in Sexual Health. J Sex Med 2018;15:1414e1425.
Marwick, C. Survey Says Patients Expect Little Physician Help on Sex. JAMA. 1999; 281 (23): 2173-2174.
Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2017. Atlanta: U.S. Department of Health and Human Services; 2018.
Balon R. Burden of Sexual Dysfunction. J Sex Martial Ther. Jan 2017: 43 (1) 49-55.
HIV Fact Sheet. CDC. www.cdc.gov/hiv/library/factsheets/index.html
Miller E, McCaw B. Intimate Partner Violence. NEJM. Feb 2019. 380: 850-857
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