US-PSTF Flashcards
AAA (screening)
Male 65-75
• Any history of smoking
• US abd x1
The USPSTF recommends 1-time screening for abdominal aortic aneurysm (AAA) with ultrasonography in men aged 65 to 75 years who have ever smoked.
“Ever smoker” is commonly defined as smoking 100 or more cigarettes.
Aspirin to prevent CVD / ColoRectal Cancer
Aspirin low dose @ Adults 50-59 • 10% 10y CVD risk • Not at risk for bleeding • Life expectancy > 10y • Willing to take medication QD > 10y
The USPSTF recommends initiating low-dose aspirin use for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC) in adults aged 50 to 59 years who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years.
Primary risk factors for CVD are older age, male sex, race/ethnicity, abnormal lipid levels, high blood pressure, diabetes, and smoking. Risk factors for GI bleeding with aspirin use include higher aspirin dose and longer duration of use, history of GI ulcers or upper GI pain, bleeding disorders, renal failure, severe liver disease, and thrombocytopenia.
Aspirin’s anticlotting effect is useful for primary and secondary CVD prevention because it potentially decreases the accumulation of blood clots that form as a result of reduced blood flow at atherosclerotic plaques, thereby reducing hypoxic damage to heart and brain tissue. The mechanisms for inhibition of adenoma or colorectal cancer development are not yet well-understood but may result from aspirin’s anti-inflammatory properties.
A reasonable approach consistent with the evidence is to prescribe 81 mg/d (the most commonly prescribed dose in the United States), and assess CVD and bleeding risk factors starting at age 50 y and periodically thereafter, as well as when CVD and bleeding risk factors are first detected or change.
Asymptomatic Bacteriuria (screening)
UC in pregnant women
• 1st prenatal visit / 12-16w gestation
• 100k single pathogen / 10k GBS
The USPSTF recommends screening for asymptomatic bacteriuria using urine culture in pregnant persons.
This applies to adults 18 years and older and pregnant persons of any age without signs and symptoms of a urinary tract infection.
It does not apply to persons who have chronic medical or urinary tract conditions or are hospitalized or living in institutions such as nursing homes.
Screen pregnant persons for asymptomatic bacteriuria using a midstream, clean-catch urine culture at the first prenatal visit or at 12 to 16 weeks of gestation, whichever is earlier. A urine culture showing >100,000 CFU/mL of a single uropathogen or >10,000 CFU/mL if the pathogen is group B streptococcus indicates treatment.
BRCA Breast cancer (screening)
If positive?
Personal or Family History of Breast, Ovarian, Tubal, Peritoneal cancer, BRCA 1/2 in family
• Brief familial risk assessment tool
• If positive –> Genetic counseling / testing
The USPSTF recommends that primary care clinicians assess women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with breast cancer susceptibility 1 and 2 (BRCA1/2) gene mutations with an appropriate brief familial risk assessment tool. Women with a positive result on the risk assessment tool should receive genetic counseling and, if indicated after counseling, genetic testing.
Patients with family or personal histories of breast, ovarian, tubal, or peritoneal cancer or ancestry associated with harmful BRCA1/2 mutations should be assessed using a familial risk assessment tool. The USPSTF found adequate evidence that these tools are accurate in identifying women with increased likelihood of BRCA1/2 mutations. Tools evaluated by the USPSTF include the Ontario Family History Assessment Tool, Manchester Scoring System, Referral Screening Tool, Pedigree Assessment Tool, 7-Question Family History Screening Tool, International Breast Cancer Intervention Study instrument (Tyrer-Cuzick), and brief versions of BRCAPRO. These tools should be used to guide referrals to genetic counseling.
Genetic counseling about BRCA1/2 mutation testing should be done by trained health professionals, including suitably trained primary care providers. The process of genetic counseling includes detailed kindred analysis and risk assessment for potentially harmful BRCA1/2 mutations. It also includes identification of candidates for testing, patient education, discussion of the benefits and harms of genetic testing, interpretation of results after testing, and discussion of management options.
Tests for BRCA1/2 mutations are highly sensitive and specific for known mutations. Testing for BRCA1/2 mutations should be done when an individual has personal or family history that suggests an inherited cancer susceptibility, when an individual is willing to see a health professional who is suitably trained to provide genetic counseling and interpret test results, and when test results will aid in decision making.
In general, women with harmful BRCA1/2 mutations are managed with a variety of interventions to lower future cancer risk. This includes intensive screening, risk-reducing medications, and risk-reducing mastectomy and salpingo-oophorectomy.
Breast cancer medication use to reduce risk
- Women at increased risk for breast cancer > 35yo
- Offer to prescribe (ex: tamoxifen, raloxifene, aromatase inhibitor)
The USPSTF recommends that clinicians offer to prescribe risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, to women who are at increased risk for breast cancer and at low risk for adverse medication effects.
The National Cancer Institute Breast Cancer Risk Assessment Tool and the Breast Cancer Surveillance Consortium Risk Calculator are based on models tested in US populations and are publicly available. There is no single cutoff for defining increased risk for all women.
When considering prescribing breast cancer risk-reducing medications, the potential benefit of risk reduction of breast cancer must be balanced against the potential harms of adverse medication effects
Tamoxifen, raloxifene, and aromatase inhibitors all reduce primary breast cancer risk in post-menopausal women. Use of raloxifene and aromatase inhibitors is indicated only in postmenopausal women; only tamoxifen is indicated for risk-reduction of primary breast cancer in premenopausal women.
Breast cancer (screening)
Women 50-74 yo
• Mammogram q2y
The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.
These recommendations apply to asymptomatic women aged ≥40 y who do not have preexisting breast cancer or a previously diagnosed high-risk breast lesion and who are not at high risk for breast cancer because of a known underlying genetic mutation (such as a BRCA1 or BRCA2 gene mutation or other familial breast cancer syndrome) or a history of chest radiation at a young age. Increasing age is the most important risk factor for most women.
For women who are at average risk for breast cancer, most of the benefit of mammography results from biennial screening during ages 50 to 74 y. While screening mammography in women aged 40 to 49 y may reduce the risk for breast cancer death, the number of deaths averted is smaller than that in older women and the number of false-positive results and unnecessary biopsies is larger. The balance of benefits and harms is likely to improve as women move from their early to late 40s.
For most women, biennial mammography screening provides the best overall balance of benefit and harms
BreastFeeding (intervention)
• Provide interventions during pregnancy & after birth
The USPSTF recommends providing interventions during pregnancy and after birth to support breastfeeding.
Primary care clinicians can support women before and after childbirth by providing interventions directly or by referral to help them make an informed choice about how to feed their infants and to be successful in their choice. Interventions include promoting the benefits of breastfeeding, providing practical advice and direct support on how to breastfeed, and providing psychological support.
Interventions can be categorized as professional support, peer support, and formal education, although none of these categories are mutually exclusive, and interventions may be combined within and between categories. Interventions may also involve a woman’s partner, other family members, and friends.
Cervical Cancer (screening)
• Women 21-29: Cervical cytology q3y • Women 30-65 (either one) o Cervical cytology q3y o High risk HPV testing q5y o [Cytology + HPV] q5y
The USPSTF recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years. For women aged 30 to 65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting). See the Clinical Considerations section for the relative benefits and harms of alternative screening strategies for women 21 years or older.
All women aged 21 to 65 years are at risk for cervical cancer because of potential exposure to high-risk HPV types (hrHPV) through sexual intercourse and should be screened. Certain risk factors further increase risk for cervical cancer, including HIV infection, a compromised immune system, in utero exposure to diethylstilbestrol, and previous treatment of a high-grade precancerous lesion or cervical cancer. Women with these risk factors should receive individualized follow-up.
Screening with cervical cytology alone, primary testing for hrHPV alone, or both at the same time (cotesting) can detect high-grade precancerous cervical lesions and cervical cancer. Clinicians should focus on ensuring that women receive adequate screening, appropriate evaluation of abnormal results, and indicated treatment, regardless of which screening strategy is used.
High-grade cervical lesions may be treated with excisional and ablative therapies. Early-stage cervical cancer may be treated with surgery (hysterectomy) or chemotherapy.
Chlamydia + Gonorrhea (screening)
- Women < 24: Sexually active
- Women > 25: high risk for infection
The USPSTF recommends screening for gonorrhea in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection.
Sexually active adolescents and adults, including pregnant persons, without signs and symptoms of chlamydia or gonorrhea infection.
- Assess Risk.
o Women aged 15 to 24 years have the highest infection rates.
o Women 25 years or older are at increased risk if they have
A previous or coexisting STI
A new or more than 1 sex partner
A sex partner having sex with other partners at the same time
A sex partner with an STI
Inconsistent condom use when not in a mutually monogamous relationship
A history of exchanging sex for money or drugs
A history of incarceration
Clinicians should consider the communities they serve and may want to consult local public health authorities for information about local epidemiology and guidance on determining who is at increased risk. - Screen for chlamydia and gonorrhea in sexually active women:
o 24 years or younger
o 25 years or older and at increased risk for infection
Screen for chlamydia and gonorrhea using a NAAT. NAATs can test for infection at urogenital and extragenital sites, including urine, endocervical, vaginal, male urethral, rectal, and pharyngeal. Both chlamydia and gonorrhea can be tested for at the same time with the same specimen.
Colorectal cancer (screening)
- Adults 45-49 (grade B)
- Adults 50-75: (grade A)
The USPSTF recommends screening for colorectal cancer in all adults aged 50 to 75 years.
The USPSTF recommends screening for colorectal cancer in adults aged 45 to 49 years.
Adults 45 years and older who do not have signs or symptoms of colorectal cancer and who are at average risk for colorectal cancer (ie, no prior diagnosis of colorectal cancer, adenomatous polyps, or inflammatory bowel disease; no personal diagnosis or family history of known genetic disorders that predispose them to a high lifetime risk of colorectal cancer [such as Lynch syndrome or familial adenomatous polyposis]).
Screen all adults aged 45 to 75 years for colorectal cancer. Several recommended screening tests are available. Clinicians and patients may consider a variety of factors in deciding which test may be best for each person. For example, the tests require different frequencies of screening, location of screening (home or office), methods of screening (stool-based or direct visualization), preprocedure bowel preparation, anesthesia or sedation during the test, and follow-up procedures for abnormal findings.
Recommended screening strategies include:
• High-sensitivity guaiac fecal occult blood test (HSgFOBT) or fecal immunochemical test (FIT) every year
• Stool DNA-FIT every 1 to 3 years
• Computed tomography colonography every 5 years
• Flexible sigmoidoscopy every 5 years
• Flexible sigmoidoscopy every 10 years + annual FIT
• Colonoscopy screening every 10 years
Dental caries (screening)
Birth through 5yo
• Oral fluoride supplement @ age 6m IF water supply deficient in fluoride.
• Apply fluoride varnish to primary teeth of all infants & children starting at the age of primary tooth eruption.
The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride.
The USPSTF recommends that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption.
All children are at potential risk for dental caries; those whose primary water supply is deficient in fluoride (defined as <0.6 ppm F) are at particular risk. While there are no validated multivariate screening tools to determine which children are at higher risk for dental caries, there are a number of individual factors that elevate risk, such as low socioeconomic status, being an ethnic minority, frequent sugar exposure or snacking, inappropriate bottle feeding, developmental defects of the tooth enamel, dry mouth, history of previous caries (in the child, a sibling, or mother), lack of access to dental care, and inadequate preventive measures (such as failure to use fluoride toothpaste).
Oral fluoride supplementation prevents dental caries in children with inadequate water fluoridation. All children with erupted primary teeth can benefit from the periodic application of fluoride varnish, regardless of the levels of fluoride in their water.
Depression in Adults (screening)
General adult population, including pregnant and post partum women.
The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.
Women, young and middle-aged adults, and nonwhite persons have higher rates of depression, as do persons who are undereducated, previously married, or unemployed. Persons with chronic illnesses, other mental health disorders, or a family history of psychiatric disorders are also at increased risk.
Risk factors in older adults include disability and poor health status related to medical illness, complicated grief, chronic sleep disturbance, loneliness, and history of depression. Risk factors during pregnancy and postpartum include poor self-esteem, childcare stress, prenatal anxiety, life stress, decreased social support, single/unpartnered relationship status, history of depression, difficult infant temperament, previous postpartum depression, lower socioeconomic status, and unintended pregnancy.
Commonly used depression screening instruments include the Patient Health Questionnaire in various forms and the Hospital Anxiety and Depression Scales in adults, the Geriatric Depression Scale in older adults, and the Edinburgh Postnatal Depression Scale in postpartum and pregnant women. Positive screening results should lead to additional assessment that considers severity of depression and comorbid psychological problems, alternate diagnoses, and medical conditions.
Effective treatment of depression in adults generally includes antidepressants or specific psychotherapy approaches, alone or in combination. Given the potential harms to the fetus and newborn child from certain pharmacologic agents, clinicians are encouraged to consider evidence-based counseling interventions when managing depression in pregnant or breastfeeding women.
Depression in Children (screening)
Age 12-18
The USPSTF recommends screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.
Risk factors for MDD include female sex; older age; family (especially maternal) history of depression; prior episode of depression; other mental health or behavioral problems; chronic medical illness; overweight and obesity; and, in some studies, Hispanic race/ethnicity. Other psychosocial risk factors include childhood abuse or neglect, exposure to traumatic events (including natural disasters), loss of a loved one or romantic relationship, family conflict, uncertainty about sexual orientation, low socioeconomic status, and poor academic performance.
Two instruments which have been most often studied are the Patient Health Questionnaire for Adolescents and the primary care version of the Beck Depression Inventory.
Treatment options for MDD include pharmacotherapy, psychotherapy, collaborative care, psychosocial support interventions, and complementary and alternative medicine approaches.
Fall (prevention)
- Adult > 65 in community dwelling
- Increased risk for falls (age, prior history, function, mobility)
The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls.
Age is strongly related to risk for falls. A pragmatic approach to identifying older persons at high risk for falls would be to assess for a history of falls or physical function/mobility limitation problems. Clinicians could also use assessments of gait and mobility, such as the Timed Up and Go test.
Effective exercise interventions include supervised individual and group classes and physical therapy. Given the heterogeneity of these interventions, it is difficult to identify specific components of exercise that are particularly efficacious.
Multifactorial interventions include an initial assessment of modifiable risk factors for falls and subsequent customized interventions for each patient based on issues identified in the initial assessment. The initial assessment could include a multidisciplinary comprehensive geriatric assessment or an assessment using a combination of various components, such as balance, gait, vision, postural blood pressure, medication, environment, cognition, and psychological health.
Folic acid for NTD prevention
- All women planning/capable of pregnancy
- Folate 0.4-0.8mg QD
The USPSTF recommends that all women who are planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid.
All women of childbearing age are at risk of having a pregnancy affected by neural tube defects. Some factors increase this risk, including a personal or family history of neural tube defects, use of particular antiseizure medications, maternal diabetes, obesity, and mutations in folate-related enzymes.
Folic acid is the synthetic form of folate, a water-soluble B vitamin. Folic acid is usually given as a multivitamin, prenatal vitamin, or single supplement, and is also used to fortify cereal grain products. Folate occurs naturally in foods such as dark green leafy vegetables, legumes, and oranges. However, most women do not receive the recommended daily intake of folate from diet alone.
The critical period for supplementation starts at least 1 month before conception and continues through the first 2 to 3 months of pregnancy.
GDM (screening)
Asymptomatic pregnancy > 24w x1
• Fasting glucose
• Oral glucose tolerance test
The USPSTF recommends screening for gestational diabetes in asymptomatic pregnant persons at 24 weeks of gestation or after.
Pregnant persons who have not been previously diagnosed with type 1 or type 2 diabetes.
If the person is pregnant and is at least 24 weeks of gestation, screen for gestational diabetes by using 1 of several methods:
• A 2-step process that involves a screening test (oral glucose challenge test) followed by a diagnostic test (oral glucose tolerance test). This is the most common approach in the US.
• A 1-step process where the diagnostic test (oral glucose tolerance test) is administered to all patients.
• Fasting plasma glucose measurement.
One-time screening should be performed at 24 weeks of gestation or after. Typically in the US, screening occurs prior to 28 weeks of gestation; however, it can occur later in persons who enter prenatal care after 28 weeks of gestation.
CVD prevention in adults with CVD risk factors (behavioral counseling intervention)
Behavioral counseling for healthy diet & physical activity
• HTN / HLD / CVD risk > 7.5%
• Diet & physical activity
The USPSTF recommends offering or referring adults with cardiovascular disease risk factors to behavioral counseling interventions to promote a healthy diet and physical activity.
Adults 18 years or older at increased risk of CVD, defined as those with 1 or more of the following:
- Hypertension or elevated blood pressure
- Dyslipidemia
- Mixed or multiple risk factors such as the metabolic syndrome or an estimated 10-year CVD risk of ≥7.5%
This recommendation does not apply to adults with other known modifiable cardiovascular risk factors such as abnormal blood glucose levels, obesity, and smoking; these populations are incorporated in other USPSTF recommendations.
- Assess risk. Determine if the adult is at increased risk of CVD. This can be done by
a. Assessing whether a single risk factor or multiple risk factors are present. Risk factors include: dyslipidemia, elevated blood pressure or hypertension, or multiple or mixed risk factors such as the metabolic syndrome or an estimated 10-year CVD risk of ≥7.5%.
b. Using a risk tool such as the Pooled Cohort Equations or the Framingham Risk Score. - Provide behavioral counseling to adults at increased risk for CVD. While effective behavioral counseling interventions vary, they often include
a. Combination of counseling on a healthy diet and physical activity, which is usually intensive, with multiple contacts that include either individual or group counseling sessions over extended periods.
i. Dietary counseling advice includes reductions in saturated fats, sodium, and sweets/sugars and increased consumption of fruits, vegetables, and whole grains.
ii. Physical activity counseling focuses on patients achieving 90 to 180 minutes per week of moderate to vigorous activity.
b. A median of 12 contacts, with an estimated 6 hours of contact over 12 months.
c. Some 1-on-1 time with an interventionist, and motivational interviewing and behavioral change techniques such as goal setting, active use of self-monitoring, and addressing barriers related to diet, physical activity, or weight change.
d. Counseling that is done in person, referred to outside counseling services, or informed about media-based interventions.
e. Interventions carried out by non-physicians, including nurses, registered dietitians, nutritionists, exercise specialists, physical therapists, masters- and doctoral-level counselors trained in behavioral methods, and lifestyle coaches.
f. Family members as well as the individual with CVD risk factors.
Healthy weight and weight gain in Pregnancy (behavioral counseling intervention)
Behavioral counseling interventions
• Promote healthy weight gain
• Prevent excess gestational weight gain
The USPSTF recommends that clinicians offer pregnant persons effective behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy.
Pregnant adolescents and adults
- Identify patients (adolescents and adults) who are pregnant.
- Offer effective behavioral counseling or refer patients to behavioral counseling in other settings.
Effective behavioral counseling interventions varied in the following:
• Content:
o Individual focus on nutrition, physical activity, or lifestyle and behavioral change
o Multiple components, most commonly including active/supervised exercise or counseling about diet and physical activity
• When to start/stop: Generally started at the end of the first trimester or the beginning of the second trimester and ended prior to delivery
• Duration and intensity: Varied from 15 to 120 minutes and consisted of <2 contacts to ≥12 contacts
• Who delivered the intervention: Highly diverse and included clinicians, registered dietitians, qualified fitness specialists, physiotherapists, and health coaches across different settings (eg, local community fitness center)
• How the intervention was delivered: Delivery methods included individual or group counseling that was delivered in person, by computer/internet, or by telephone calls
