Routine Preventative Screening
Author / Curator: Christopher Steele, MD MPH MS
Faculty Advisor: Rachel Kruzan, MD
(1) Be concise.
(2) Be evidence-based. (Everything should have a reputable citation and resource)(3) Be clinically relevant. (Avoid unnecessary discussion of pathophysiology and epidemiology if it does not help clinical decision-making).
- Understand what preventative screening is and what resources are available to ensure your patients are getting the proper care.
- Compare and review the 3 types of prevention.
- Review the common intervals for laboratory monitoring for patients on common medications.
- Discuss the United States Preventative Services Task Force (USPSTF) recommendation scale and how it should influence your ordering practices of certain tests.
- Reference how to adjust routine cancer screening guidelines based on previous pathological findings.
Top Teaching Points
- Clinicians should offer Grade A and Grade B USPSTF recommendations to their patients when they meet age, gender and other characteristics.
- Grade C recommendations should be offered on a case by case basis by the provider while grade D recommendations are not recommended for general screening.
- All healthcare providers should use the USPSTF calculator when determining what screening tests to offer their patients.
- Patients who come back with screening tests of pre-cancer to cancer should have adjusted guidelines from the typical recommendations of the USPSTF.
Preventative screening allows for early detection and treatment of common health problems of society. Primary care is unique to all other forms of medicine because its whole purpose is to focus on providing all forms of prevention for a patient.
There are three types of prevention termed primary, secondary and tertiary. Primary prevention are modalities to prevent illness in healthy individuals. The flu shot and baby aspirin for cardiovascular prevention are examples of primary prevention. Secondary prevention is screening or treating disease in asymptomatic individuals. For example, this would be most cancer screening and the use of iron pills in someone who is asymptomatic with iron deficient anemia. Finally, tertiary prevention is providing management to an established disease already effecting an individual such as giving antiretroviral therapy to someone with HIV.
The USPSTF provides a thorough list of all preventive services primary care providers could offer their patients. Each of these preventative services is graded a certain strength for recommendation to offer the service. The grading is as follows:
- Grade A - highly recommended with substantial benefit.
- Grade B - highly recommended with moderate benefit.
- Grade C - Selectively should be offered based on the providers best judgement.
- Grade D - Should not offer this to patients as a means of general screening.
- Grade I - Insufficient evidence to offer a recommendation that the service could harm or benefit a patient.
It is important to note that Grade A and Grade B recommendations have to be paid for by insurance due to the ACA while Grade C or lower do not. Payment models are now starting to tie reimbursement to a provider's success rate at getting their patient panel screened appropriately.
The USPSTF recommends that all patients meeting age and gender criteria should be offered Grade A and B services. Grade C services should be considered by the provider and offered depending on the clinicians best judgement if it is beneficial to that patient.
The following calculator can be used during a patient's visit to determine which screening tests are recommended, including Grade C services that are not listed below: https://epss.ahrq.gov/ePSS/search.jsp
|United States Preventative Services Task Force Grade A and B Recommendations for Adult Patients*|
|Category||Disease||Recommendation||Age||Grade||Date of Recommendation|
|General||Healthy Diet and Physical Activity||All patients who have BMI >25 who have additional cardiovascular risk factors (e.g. diabetes, hypertension, smoking etc.) should be counseled on healthy eating and increased physical activity.||18+||B||August 2014|
|Domestic Abuse||All women of childbearing age should be screened during their annual visit or whenever suspected.||18+||B||January 2013|
|Obesity Screening||All adults should be screened for BMI and intervention should start with BMI 30 or greater||18+||B||June 2012|
|Cardiovascular||Abdominal Aortic Aneurysm||Men ages 65-75 who have ever smoked||65 to 75||B||June 2014|
|Aspirin to reduce 10-year CVD Mortality||Patients over 50 with ASCVD risk greater than 10% in 10 years
|Statins therapy and hyperlipidemia**||
||35+ Men; 45+ Women; 20+ High Risk Patients||B||November 2016|
|Cancer Screening||BRCA assessment and genetic testing||Women should be screened further if they or a first degree relative meet one of the following: 1) Breast cancer before age 50; 2) Ovarian cancer; 3) Both breast and ovarian in the same person; 4) Bilateral or multiple breast cancers; 5) Ashkenazi Jews; 6) Male breast cancer; 7) Known BRCA1 or BRCA2 gene mutation; 8) Breast cancer diagnosed before 60 that's negative for ER, PR and HER2||18+||B||December 2013|
|Offering tamoxifen or raloxifene for high risk patients for breast cancer||Clinicians should have an open discussion with patients who are at high risk for breast cancer to take medications that reduce the risk of developing the disease.||N/A||B||September 2013|
|Breast Cancer Screening (general)||
||40 to 75||B||September 2002|
|Cervical Cancer Screening (general)||
||21 to 65||A||March 2012|
|Colon Cancer Screening||All patients age 50 or older or 10 years less than a first-degree relative developing colon cancer. This does not count for familial cancers.||50 to 75||A||June 2016|
|Lung Cancer Screening||Patients 55-80 years of age with a 30 pack-year smoking history who currently smoke or quit less than 15 years ago should get a low dose CT scan.||18+||B||December 2013|
|40 to 70||B||October 2015|
|Infectious Disease/Sexually Transmitted Infections||Chlamydia and Gonorrhea||
|Hepatitis B (HBV) screening||All patients who are at high risk (e.g. IV drug use, high risk sexual behaviors, pregnant women, HIV patients, patients immunosuppressive therapy, dialysis, concurrent HCV disease and/or from an endemic area with HBV.||18+||B||May 2014|
|Hepatitis C (HCV) Screening||Patients born from 1945-1965 and patients who are IV drug users, concurrent HBV infection, HIV infected patients, immunosuppressive therapy, dialysis or who have high-risk sexual behaviors.||18+||B||June 2013|
|HIV Screening||All patients should be offered a 1-time screening, and should be offered again in high-risk patients||18+||A||April 2013|
|Tuberculosis Screening||High risk adults (health care workers, those exposed to TB, from an endemic area with TB, HIV or immunocompromised patients, homelessness, previous TB infection in the last 2 years, illegal drug users. ||18+||B||September 2016|
|Syphilis Screening||All patients should be screened who meet the following criteria: A) pregnant, B) high risk social behaviors C) Been exposed to syphilis D) Show signs and symptoms of syphilis||18+||A||June 2016|
|Pregnancy Specific||Asymptomatic Bacturia||All pregnant women at 12-16 weeks should be screened with a urine culture||N/A||A||July 2008|
|Breast Feeding||All women should be encouraged to breast feed when possible.||N/A||B||October 2016|
|Folic Acid Supplementation||All women who are pregnant or plan to be pregnant should take 0.4-0.8 mg of folic acid daily.||N/A||A||January 2017|
|Gestational Diabetes Screen||All women should get the initial screen for diabetes at the 24 week appointment||N/A||B||January 2014|
|Rh (D) Incompatibility screening||Should be done the first visit for pregnancy related care.
Should be done at 24-28 weeks unless father is Rh (D) negative.
|Social History Specific||Alcohol Use Disorders Screening||Screen for misuse (AUDIT-C) each wellness visit or if suspected at a follow-up visit.||18+||B||May 2013|
|Depression Screening||Every wellness visit and those at high risk.
|Fall Risk||All adults over 65 should be screened annually for falls and if at high risk, should be prescribed physical therapy and vitamin D supplementation.||65+||B||May 2012|
|Sexually Transmitted Infections||All patients should be counseled on reducing high-risk behaviors and screened for STIs should be offered to high-risk patients.||18+||B||September 2014|
|Tobacco Use||All physicians should advise against smoking and offer interventions to aid in efforts to quit.||18+||A||September 2015|
*Other guidelines other than the USPSTF's are indicated as such an appropriately cited.
**STATIN THERAPY GUIDELINES
- High Dose Statin: Atrovastatin 40-80 mg or Rosuvastatin 20-40 mg
- Moderate-Dose Statin: Atorvastatin 10-20 mg, Rouvastatin 5-10 mg, Simvastatin 20-40 mg, Pravastatin 40-80 mg, Lovastatin 40mg, Fluvastatin XL 80 mg and Pitavastatin 2-4 mg.
Abnormal Cancer Screening
Patients will most likely have an adjusted screening interval if there are abnormal findings on a colonoscopy, mammogram or pap smear. The adjusted guidelines usually come from other organizations other than the USPSTF. These recommendations are often complex, and it is best that a practitioner references them as needed.
The following are links to the adjusted guidelines for each of the three common cancer screenings:
- Colon Cancer (American College of Gastroenterology): https://gi.org/guideline/guidelines-for-colonoscopy-surveillance-after-screening-and-polypectomy-a-consensus-update-by-the-us-multi-society-task-force-on-colorectal-cancer/
- Cervical Cancer (American College of Obstetricians and Gynecologists): https://www.acog.org/Patients/FAQs/Abnormal-Cervical-Cancer-Screening-Test-Results
- Breast Cancer (National Comprehensive Cancer Network): https://ww5.komen.org/BreastCancer/RecommendationsforWomenwithHigherRisk.html
- The National Lung Screening Trail (NLST) NEJM 2011: This study looked at low-dose CT scan as a means to lower mortality from lung cancer. ~54,000 people were studied from 33 U.S. medical centers which found that nearly 96% of positive screens were false positive in the low-dose CT scan group compared to 94.5% in the radiography group. The incidence rate of lung cancer identified through the low dose CT scan was 645 compared to 572 in the radiography group. The all-cause rate of death was reduced by 6.7% and 62 less deaths in the low dose CT scan group compared to the radiography group. Ultimately, it was determined that low-dose CT scans had a high false-positive rate, however, saved a significant number of lives making it a valid method for lung cancer screening the select patient groups. 
Ongoing controversies / New updates
- United States Services Protective Task Force. USPSTF A and B Recommendations. Accessed on 5 March 2018.https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/
- WHO http://www.euro.who.int/en/health-topics/Health-systems/public-health-services/policy/the-10-essential-public-health-operations/epho5-disease-prevention,-including-early-detection-of-illness2
- . Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 (2010).
- U.S. PREVENTIVE SERVICES TASK FORCE. Screening for Lipid Disorders in Adults: Recommendations and Rationale. Am Fam Physician. 2002 Jan 15;65(2):273-277.
- Raymond C et al. New guidelines for reduction of blood cholesterol: Was it worth the wait? Cleve Clin J Med. 2014 Jan; 81(1): 11–19.
- The National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011; 365:395-409