Alisa Holland, PGY-2 1/11/11

USPSTF Grade Definitions  A – Strongly Recommended Benefits outweigh harms. Good evidence of improvement in health outcomes.  B – Recommended Benefits outweigh harms. Fair evidence of improvement in health outcomes.  C – No Recommendation Fair evidence of improvement in health outcomes. Benefits and harms are too close to recommend intervention.  D – Not Recommended Risks outweigh harms or fair evidence to suggest that intervention is ineffective.  I – Insufficient Evidence to Recommend Cannot determine balance of benefits and harms.

Cancer  Breast  Cervical  Colorectal

Breast Cancer Recommendations (USPSTF)  Last Update: December 2009  Screening mammogram every other year from ages 50 to 74 (Grade B)  Recommends against teaching breast self- exam (Grade D)  Insufficient evidence to recommend performing clinical breast exam after age 40 if patient receives a screening mammogram  Insufficient evidence to assess benefits and harms of digital mammogram and breast MRI

Breast Cancer Recommendations (USPSTF)  Refer women with family history of BRCA1 and BRCA2 mutations for genetic counseling and BRCA testing (Grade B).  Recommends against referring women for BRCA testing who have no family history of BRCA mutations (Grade D)  Recommends against routine use of tamoxifen or raloxifene for chemoprevention in low or average risk patients (Grade D)  Discuss chemoprevention with patients at high risk for breast cancer and low risk for therapy side effects (Grade B).

USPSTF Evidence  Screening every other year on average has 81% of the benefit of annual screening. 50% fewer false positive results  Screening annually reduces mortality from breast cancer by additional 3%.  SBE and CBE are shown not to reduce mortality and result in increase of benign biopsy results.  Chemoprevention with tamoxifen in high risk women showed a significant reduction in invasive and non-invasive breast cancers (BCPT trial).

Breast Cancer Recommendation (ACS)  Screening mammogram every year starting at age 40 and continuing as long as the patient is in good health.  SBE is an option for women starting in their 20s.  CBE should be performed every 3 years between ages Annual CBEs starting at age 40 years.  Women with high risk of breast cancer should have mammogram and MRI every year.

Cervical Cancer Recommendations (USPSTF)  Released: January 2003  Screen patients who are sexually active and who have a cervix (Grade A).  Recommends against screening women over age 65 who have a history of normal pap smears (10 years per ACS guidelines) and are not high risk (Grade D)  Recommends against routine pap smears in patients who have had a total hysterectomy for benign reasons (Grade D)  Insufficient evidence to recommend computerized screening and HPV testing as primary screening tests.

Cervical Cancer Recommendations (ACS)  Begin screening within three years of onset of sexual activity or age 21 and screen at least every three years.  Lengthen screening interval starting no sooner than age 30 if patient has had 2- 3 consecutive normal results. Continue annual screening if patient has risk factors such as cervical neoplasia, HPV, STDs, or high risk sexual behavior.

Colorectal Cancer Recommendations (USPSTF)  Released: October 2008  Screen using FOBT, sigmoidoscopy, or colonoscopy between ages 50 and 75 (Grade A).  Recommends against screening between ages 76 and 85 (Grade C)  Recommends against screening after age 85 (Grade D)  Insufficient evidence to assess benefits and harms of CT colonography or fecal DNA testing for screening purposes

Colorectal Cancer Recommendations (USPSTF)  Recommended screening intervals: FOBT annually Sigmoidoscopy every 5 years with FOBT every 3 years Screening colonoscopy every 10 years

Colorectal Cancer Recommendations (ACS)  Options for screening include: Flexible sigmoidoscopy every 5 years Colonoscopy every 10 years Double-contrast barium enema every 5 years CT colonography every 5 years FOBT annually Fecal immunochemical test (FIT) annually Stool DNA (sDNA) test, unknown interval

USPSTF No Screen List  Bladder cancer  Lung cancer  Oral cancers  Ovarian cancer  Pancreatic cancer  Testicular cancer  Prostate cancer*  Skin cancer

Heart and Vascular Disease  AAA  Aspirin use  Hypertension  Lipids  Tobacco use

Abdominal Aortic Aneurysm (USPSTF)  Released: February 2005  One time screening using abdominal ultrasound for men between the ages of 65 and 75 with a history of tobacco use (Grade B)  Recommends against routine screening in women (Grade D)  Abdominal palpation not recommended for screening given poor accuracy

Aspirin Use (USPSTF)  Released: March 2009  Use in men aged 45 to 79 if benefit from reduction of MI outweighs potential harm of GI hemorrhage (Grade A).  Use in women 55 to 79 if benefit from reduction in ischemic strokes outweighs potential harm of GI hemorrhage (Grade A).  Insufficient evidence to recommend use in patients aged 80 years and over.  Recommends against routine use for MI prevention in men under age 45 and for stroke prevention in women under age 55 (Grade D).

Hypertension and Hyperlipidemia (USPSTF)  Released: December 2007 (HTN) and June 2008 (HLD)  Screen for HTN in patients aged 18 and older (Grade A).  Screen men age 35 and older for HLD (Grade A).  Screen men aged 20 to 35 for HLD if they are at increased risk for CHD (Grade B).  Screen women age 45 and older for HLD if they are at increased risk for CHD (Grade A).  Screen women aged 20 to 45 if they are at increased risk for CHD (Grade B).

Tobacco Use Recommendations (USPSTF)  Released: April 2009  Ask all adults about tobacco use and provide cessation interventions (Grade A).  Ask all pregnant women about tobacco use and provide tailored cessation counseling (Grade A).

Tobacco Use Counseling Guidelines  “5-A” framework: Ask about tobacco use Advise to quit with a clear personalized message Assess willingness to quit Assist in quitting Arrange for follow-up and support  Use multiple counseling sessions and telephone quit lines (1-877-YES-QUIT).

USPSTF No Screen List  Coronary Artery Stenosis  Coronary Heart Disease*  Peripheral Artery Disease*

Infectious Disease  Chlamydia  Gonorrhea  Hepatitis B  HIV  STD counseling  Syphilis  TB

Chlamydia Recommendations (USPSTF)  Released: June 2007  Screen all sexually active women age 24 and younger and women over age of 24 if they are at increased risk (Grade A).  Screen all pregnant women under age 24 and pregnant women over age 24 if they are at increased risk (Grade B).  Recommends against screening women age 25 or older if they are not at increased risk (Grade D)  Insufficient evidence to recommend screening men

Chlamydia Recommendations (CDC)  Screen all sexually active women under age 25.  Screen older women with risk factors.  Consider screening sexually active young men in populations with high incidences of infection.

Gonorrhea Recommendations (USPSTF/CDC)  Released: May 2005  Screen all sexually active women at increased risk (Grade B).  Recommends against screening women and men at low risk for infection (Grade D)  Insufficient evidence to recommend screening men at increased risk for infection  Insufficient evidence to recommend screening pregnant women at low risk

Hepatitis B Recommendations (USPSTF)  Released: February 2004  Screen pregnant women at their first prenatal visit (Grade A).  Recommends against screening asymptomatic patients routinely (Grade D)

Hepatitis B Recommendations (CDC)  Populations recommended for testing: Patients born in Eastern Europe, Asia, Africa, Middle East, and Pacific Islands MSM IVDU Patients receiving cytotoxic or immunosuppressive therapy Patients with persistently elevated AST/ALT Hemodialysis patients Pregnant women

HIV Recommendations (USPSTF)  Released: July 2005  Screen all adults at increased risk for infection (Grade A).  Screen all pregnant women (Grade A).  No recommendation for screening adults not at increased risk (Grade C)

HIV Recommendations (CDC)  Screen all patients aged 13 to 64.  Screen patients at high risk for infection annually.  Screen all pregnant women at their first prenatal visit. Re-screen in third trimester in areas with high rates of HIV.

STD Counseling Recommendations (USPSTF/CDC)  Released: October 2008  Use high-intensity counseling to prevent STDs for all adults at increased risk for STDs (Grade B).  Insufficient evidence to recommend counseling to adults not sexually active or at low risk for infection

Syphilis Recommendations (USPSTF/CDC)  Released: July 2004  Screen patients at increased risk for infection (Grade A).  Screen all pregnant women (Grade A).  Recommends against screening patients not at increased risk for infection (Grade D).

TB Recommendations  USPSTF Recs Released: 1996 – defers to CDC for screening recommendations.  CDC Recommends testing patients who: Have been in contact with a person with known or suspected TB Are immunosuppressed Are from Latin America, Caribbean, Africa, Asia, Eastern Europe, or Russia Live in an area of high TB prevalence IVDU

USPSTF No Screen List  Bacteriuria*  Hepatitis C  HSV

Mental Health and Substance Abuse Recommendations (USPSTF)  Depression Released: December 2009 Screen when support is in place to assure diagnosis, treatment, and follow-up (Grade B). Recommends against screening when support is not in place (Grade C) 2 Question mood assessment: mood and anhedonia  Alcohol Abuse Released: April 2004 Screen and counsel adults and pregnant women to reduce alcohol misuse (Grade B). CAGE

Tobacco/Alcohol/Drug Use Tool  5 “R”s Relevance Risks Rewards Roadblocks Repeat

USPSTF No Screen List  Dementia  Illegal drug use  Suicidality

Metabolic, Nutritional, and Endocrinology  Diabetes Mellitus  Diet  Obesity  Physical Activity  Iron Deficiency Anemia  Osteoporosis

Diabetes Mellitus Recommendations (USPSTF)  Released: June 2008  Screen adults with blood pressure greater than 135/80 mmHg (Grade B).  Insufficient evidence to recommend screening in patients with BPs less than 135/80 mmHg

Diabetes Mellitus Recommendations (ADA)  Screen patients of any age every three years if they are overweight and who have at least one risk factor for DM.  Screen patients without risk factors starting at age 45 and repeat every three years.  Risk factors: Physical inactivity Family history (first degree) High-risk race Women delivering babies > 9 lbs. or diagnosed with GDM HTN HLD PCOS

Nutrition Recommendations (USPSTF)  Diet Released: January 2003 Counsel patients with HLD and other risk factors for heart disease or other diet related disease (Grade B). Insufficient evidence to recommend routine diet counseling  Obesity Released: December 2003 Screen all patients and counsel to promote sustained weight loss

Physical Activity (AHA)  Aerobic activity Moderate: 30 minutes per day for five days per week Vigorous: 20 minutes per day for three days per week  Muscle strengthening exercises 2 days per week

Iron Deficiency Anemia Recommendations (USPSTF)  Released: May 2006  Screen pregnant women (Grade B).  Insufficient evidence to recommend use of iron supplementation in non-anemic pregnant women.

Osteoporosis Recommendations (USPSTF)  Released: September 2002  Screen women aged 65 and older routinely or starting at age 60 with increased risk factors for fractures (Grade B).  No recommendation for or against postmenopausal women under age 60 (Grade C).

Osteoporosis Recommendations  Use older age and non hormone use after menopause to help determine screening population.  Screen women over 65 every 2 years.  Screen women under 65 every 5 years.

USPSTF No Screen List  Hemochromatosis  Thyroid Disease  Glaucoma  COPD

Immunizations  Influenza  Pneumococcal  Td/Tdap  Hepatitis B  Hepatitis A  HPV  MMR  Varicella  Meningococcal  Zoster

Influenza Vaccine Recommendations (CDC)  Updated: 2010  IM vaccine contains killed virus  Nasal spray vaccine contains live attenuated virus Use in healthy patients ages 2-49 Not for use in pregnant patients  Give to all patients over 6 months of age annually starting in September.  Patients over age 65 can receive standard dose vaccine or Fluzone High-Dose (higher percentage of antigen per virus strain).  Do not give to patients allergic to eggs.

Pneumococcal (PPSV23) Vaccine Recommendations (CDC)  Indications for administration to patients under 65:  Revaccinate once after five years or at age 65  Vaccinate all patients at age 65 years. Chronic heart dzImmunodeficiencyMultiple myeloma Chronic lung dzHIVAsthma Diabetes MellitusChronic renal failureEmphysema CSF leaksNephrotic syndromeOrgan transplantation Cochlear implantsLeukemiaImmunosuppressant use AlcoholismLymphomaSplenic dysfunction Chronic liver dzHodgkin diseaseSickle Cell disease Cigarette smokingMalignancy

Tetanus/Tetanus, Diptheria, and Pertussis (Tdap) Recommendations (CDC)  Update tetanus vaccine status every 10 years.  Revaccinate if patient has major or dirty wound and five years have elapsed since last vaccine.  Replace tetanus booster with Tdap for one occurrence to lower burden of pertussis among adults and decrease exposure to infants.  Vaccinate healthcare professionals with Tdap as soon as 2 years after previous Td booster for additional pertussis protection.

Hepatitis B Vaccine Recommendations (CDC)  In areas of high HBV incidence, vaccinate all patients with Hepatitis B vaccine who have not had complete series 3 IM doses of Hep B vaccine at 0, 1, and 6 months  Combined Hep A-Hep B vaccine (Twinrix) available for any adult with risk factors for both viruses.

Hepatitis A Vaccine Recommendations (CDC)  Hepatitis A administered as two series schedule at 0 and 6 months.  Indications for Hepatitis A vaccination: Patients traveling to areas with high or intermediate endemicity of Hepatitis A MSM Chronic liver disease Drug use (IV and non-IV) Occupational exposure Patients with clotting factor disorders

HPV Vaccine Recommendations  Recommended for girls aged 11 or 12 years but can be given to women up to age 26  Can also be administered to males aged 9 to 26 years to prevent condyloma acuminatum (10/09)  Given in 3 shot series at 0, 1-2, and 6 months  HPV4: 6, 11, 16, 18  HPV2 (released October 2009): 16, 18

MMR Vaccine Recommendations (CDC)  Schedule: 2 doses, given at 0 and 4 weeks  Vaccinate adults with one dose unless they have evidence of immunity, have previously been vaccinated, or have had documented measles.  Vaccinate women of childbearing age who do not have laboratory evidence of immunity or documentation of previous vaccination. Contraindicated during pregnancy  Give additional dose if patient was recently exposed to an outbreak, are in college, work in a healthcare facility, or are travelling internationally.  Do not give to individuals allergic to gelatin or neomycin.

Varicella Vaccine Recommendations (CDC)  Schedule: 2 doses at 0 and 4 weeks  Test pregnant women for immunity and vaccinate if indicated starting after delivery. Contraindicated during pregnancy  Vaccinate all non-immune adults.  Do not give to individuals allergic to gelatin or neomycin.

Meningococcal Vaccine Recommendations (CDC)  Vaccinate following populations: Sickle Cell Disease Splenic dysfunction Complement deficiencies College students living in dorms Microbiologists routinely exposed to N. meningitidis Military recruits Residents of or visitors to countries with high prevalence of meningococcal disease  MCV4 for patients 55 and under Better immunologic response  MPSV for patients 56 and older  Revaccinate after five years with MCV4 if risk still exists

Zoster Vaccine Recommendations (CDC)  Vaccinate all patients aged 60 and older with single dose.  Most effective in patients aged 60 to 69 (64% risk reduction). Risk reduction decreases with increasing age (18% risk reduction for 80 year old patient).  Patients with chronic medical conditions may be vaccinated prior to age 60. Contraindications: pregnancy, HIV with CD4 count < 200, immunocompromising conditions  Decreases incidence of postherpetic neuralgia and shortens duration of illness.

References  USPreventiveServicesTaskForce.org  Cancer.org  CDC.gov  Diabetes.org  Effects of Mammography Screening Under Different Screening Schedules: Model Estimates of Potential Benefits and Harms. Mandelblatt, et al. Ann Intern Med 2009;151:  Screening for Breast Cancer: An Update for the U.S. Preventive Services Task Force. Nelson, et al. Ann Intern Med 2009;151:  Fisher B, et al. Tamoxifen for prevention of breast cancer: report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study. J Natl Cancer Inst 1998;90:  Smith RA, et al. American Cancer Society Guideline for the Early Detection of Cervical Neoplasia and Cancer. CA Cancer J Clin 2002;52(1):8-22.  American College of Obstetricians and Gynecologists. Guidelines for Women's Health Care. 2nd ed. Washington, DC: ACOG;2002: ,  Ridker PM, et al. A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. N Engl J Med 2005;352:  Berger JS, et al. Aspirin for the primary prevention of cardiovascular events in women and men: a sex-specific meta-analysis of randomized controlled trials. JAMA 2006; 295:  Recommendations for Identification and Public Health Management of Persons with Chronic Hepatitis B Virus Infection, CDC.gov, MMWR 2008;57(RR-8).  Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings, CDC.gov, MMWR 2006; 55(RR14);1-17  Centers for Disease Control and Prevention. Recommended adult immunization schedule—United States, MMWR 2010;59(1).