Online access to the Guide is available through the HSTAT (Health
Services/Technology Assessment Text) data base of the
National Library of Medicine and the Office of Disease
Prevention and Health Promotion. For information on
downloading, see Frequently Asked
Questions.
Overview
In December 1995, the U.S. Preventive Services Task Force
released the Guide to Clinical Preventive Services, 2nd
Edition, a thoroughly updated and expanded version of its widely
used 1989 edition. The latest Guide recommends that
doctors and nurses offer more frequent patient counseling on
personal health and safety habits, change the use of some
screening tests significantly, and ensure that several newer
immunizations are routinely provided.
The independent Task Force panel—a group of prominent
primary care and preventive health specialists—made its
recommendations after careful review of the scientific evidence.
The 1995 Guide includes findings on preventive
interventions for more than 70 diseases and conditions.
The report includes some important new recommendations based
on new scientific—evidence for example, recommendations on
screening for colorectal cancer, counseling older women about
hormone replacement therapy, and screening for high cholesterol
in middle-aged women. Other changes in the 1995 Guide reflect a more critical look at the balance of benefits and harms
of screening tests now in wide use. The report also reaffirms
many disease and injury prevention practices recommended in the
1989 edition.
Principal Findings
Along with specific clinical recommendations, the Guide offers
several broad conclusions about effective preventive care,
including:
- Counseling patients about personal health practices (for
example, counseling to prevent tobacco use, to promote
physical activity, and to prevent accidental injuries)
remains one of the most underused, but important, parts
of the health visit.
- Clinicians should tailor preventive services to the
specific behaviors and risk factors of individual
patients rather than offer preventive services as a
standard routine checkup given to all patients.
- Patients should share in decisions about preventive
services. Their personal preferences are important in
determining an approach to prevention that is optimal for
them as individuals. This is especially true when the
evidence of benefit is weak.
- During every encounter with their patients, doctors and
nurses should try to deliver prevention messages and
services, especially for high-risk patients, who are
often the least likely to see clinicians for routine
checkups.
Several specific examples of the Task Force's recommendations
follow.
Examples of Preventive Services Recommended for Routine Use
Counseling to Prevent Tobacco Use
Periodic counseling to stop tobacco use is recommended for
everyone who uses tobacco. Delivering antitobacco messages is
recommended as part of health promotion counseling for children,
adolescents, and young adults. Prescription of nicotine patches
or gum is recommended as an adjunct to counseling to help
selected patients quit using tobacco.
- Use of tobacco causes one of every five deaths in the
United States each year, making it the most important
preventable cause of premature death. Simple, direct
advice from clinicians and nicotine replacement products
(gum, patches, or nasal spray) can each significantly
increase the number of smokers who successfully quit.
Screening for Colorectal Cancer
For everyone age 50 and above, the Task Force recommends
colorectal cancer screening with sigmoidoscopy, annual fecal
occult blood testing, or both. The best interval between
sigmoidoscopic exams is not established; a 10-year interval may
be adequate.
- Colorectal cancer causes 55,000 deaths each year and is
the second most common form of cancer in the United
States. Routine screening with fecal blood tests or
sigmoidoscopy could reduce mortality by more than
one-third.
Screening for Breast Cancer
Periodic breast cancer screening is recommended for all women
50-69 years of age with mammography every 1 or 2 years (with or
without clinical breast examination). Although the Task Force
found insufficient evidence to recommend for or against routine
mammography or clinical breast examination for women age 40-49
and those over age 70, it concluded that continued screening of
healthy women after age 70 and screening of young women with a
family history of breast cancer could be justified by their
increased risk of cancer.
- Breast cancer is the leading cause of cancer in women,
accounting for 46,000 deaths annually. Periodic
mammography in women over age 50 can reduce breast cancer
deaths by one-third, yet many such women have not
received a recent mammogram.
Examples of Preventive Services Recommended for Targeted Use
Screening for High Blood Cholesterol and Other Lipid
Abnormalities
Periodic screening for high blood cholesterol is recommended
for all men ages 35-65 and women ages 45-65. Because of an
increased risk of heart disease, cholesterol screening may also
be appropriate for older people and for adolescents and young
adults with other coronary risk factors (smoking, hypertension,
diabetes, or family history). The Task Force found insufficient
evidence to recommend for or against routine cholesterol
screening in children.
- Elevated blood cholesterol is one of the major modifiable
risk factors for coronary heart disease, which is the
leading cause of death in the United States. For
adolescents and low-risk young adults, however,
clinicians should emphasize the benefits of a diet low in
fat and high in fruits and vegetables, and other measures
to prevent heart disease (for example, not smoking,
maintaining a healthy weight, and getting regular
exercise). These measures are important for everyone,
regardless of their cholesterol level, and do not require
screening.
Screening for Chlamydial Infection
Screening for chlamydia is recommended for sexually active
female adolescents and for older women at increased risk of
infection (for example, those having new or multiple sex partners
or a history of previous sexually transmitted disease). In
settings where infection is widespread, such as urban family
planning clinics, routine screening of all women may be
appropriate.
- Chlamydial infection is the most common sexually
transmitted disease in the United States and can result
in pelvic inflammatory disease (PID), infertility, or
ectopic pregnancy. A recent study demonstrated that
routine chlamydia screening can reduce the incidence of
PID by 50 percent in at-risk women.
Examples of Preventive Services Not Recommended for Routine
Use
Routine Urine Tests in the General Population
Routine examination of urine specimens for blood or bacteria
is not recommended for the general population of asymptomatic
children or nonpregnant adults. Although such findings may
indicate a serious condition (cancer in adults or underlying
urinary tract abnormality in children), the large majority of
people with abnormal urine tests have no important disorders.
- Bladder cancer causes 11,000 deaths a year, primarily in
older men, and urinary tract infections (UTIs) are a
leading cause of outpatient visits. There is no evidence,
however, that routine urine tests in asymptomatic people
is effective in reducing deaths from bladder cancers or
symptoms from UTIs.
Screening for Prostate Cancer
The 1995 Guide does not recommend routine screening of
asymptomatic men for prostate cancer by measurement of
prostate-specific antigen (PSA) or performance of digital rectal
examination (DRE). If clinicians choose to offer screening to
individual patients, they should target men with a life
expectancy of at least 10 years, explain the potential risks and
benefits of screening and treatment, and let patients decide
whether or not to undergo screening.
- Prostate cancer causes 40,000 deaths a year in the United
States. There is not yet conclusive evidence that early
detection can reduce prostate cancer mortality, an issue
being studied in an ongoing trial sponsored by the
National Cancer Institute. At the same time, the
potential adverse consequences of widespread screening
are important, especially in men over age 70: frequent
false-positive results, unnecessary prostate biopsies,
and harms from aggressive treatments for indolent cancers
that may never have caused symptoms in a patients
lifetime.
Task Force Background
The Task Force included specialists in family medicine,
internal medicine, obstetrics and gynecology, pediatrics, and
preventive medicine. More than 100 outside experts in medicine,
nursing, public health epidemiology, and health promotion and
education also contributed to the project.
The Task Force assessed more than 6,000 studies of 200
interventions for 70 diseases and conditions. These included 53
screening tests (for cardiovascular disease, cancer, metabolic
and nutritional diseases, infectious diseases, vision and hearing
disorders, prenatal disorders, congenital disorders,
musculoskeletal disorders, mental disorders, and substance
abuse). In addition, the Task Force assessed 11 counseling topics
(ranging from preventing household injuries to preventing tobacco
use), immunizations against 12 common childhood and adult
diseases, and the use of aspirin and postmenopausal hormones to
prevent disease.
The Task Force is a pioneer in rigorously evaluating
scientific evidence to decide the merits of prevention measures.
Since publication of the 1989 Guide, the evidence-based
method has become the standard for developing guidelines for
medical and nursing practice. Based on this method, the Task
Force recommends only those preventive services with demonstrated
effectiveness in preventing disease, disability, or death.
The Task Force was first convened by the U.S. Public Health
Service. The Office of Disease Prevention and Health Promotion
supported the first two editions of the Guide. Future operations
of the Task Force will be supported by the Agency for Health Care
Policy and Research.
For More Information
More information about the U.S. Preventive Services Task Force
can be obtained from David Atkins, M.D., M.P.H., 540 Gaither Road, Suite 6000,
Rockville, MD 20850,
telephone: (301) 427-1608.
Members of the U.S. Preventive Services Task Force
Donald M. Berwick, M.D., M.P.P. (Task Force Vice-Chairman); Department
of Pediatrics; Harvard Medical School; Boston, MA
Alfred O. Berg, M.D., M.P.H.; Department of Family Medicine;
University of Washington; Seattle, WA
Paul S. Frame, M.D.; Tri-County Family Medicine; Cohocton, NY
Dennis G. Fryback, PhD; Department of Preventive Medicine;
University of Wisconsin, Madison; Madison, WI
David A. Grimes, M.D.; Department of Obstetrics, Gynecology, and
Reproductive Sciences; University of California at San Francisco;
San Francisco General Hospital; San Francisco, CA
Robert S. Lawrence, M.D.; School of Hygiene and Public Health; The
Johns Hopkins University; Baltimore, MD
Robert B. Wallace, M.D., M.Sc.; Department of Preventive Medicine;
University of Iowa; Iowa City, IA
A. Eugene Washington, M.D., M.Sc.; Department of Obstetrics,
Gynecology, and Reproductive Sciences; University of California
at San Francisco; Mount Zion Medical Center; San Francisco, CA
Modena E.H. Wilson, M.D., M.P.H.; Department of Pediatrics; Johns
Hopkins Hospital; Baltimore, MD
AHCPR Publication No. 97-R004
Current as of July 1998
540 Gaither Road Rockville, MD 20850 