Section 2. Recommendations for Adults

Guide to Clinical Preventive Services, 2014

All clinical summaries in this Guide are abridged recommendations. To see the full recommendation statements and recommendations published after March 2014, go to http://www.uspreventiveservicestaskforce.org.

Abdominal Aortic Aneurysm

Title Screening for Abdominal Aortic Aneurysm
Population Men ages 65 to 75 years who have ever smoked Men ages 65 to 75 years who have never smoked Women ages 65 to 75 years
Recommendation Screen once for abdominal aortic aneurysm with ultrasonography.
Grade: B
No recommendation for or against screening.
Grade: C
Do not screen for abdominal aortic aneurysm.
Grade: D
Risk Assessment The major risk factors for abdominal aortic aneurysm include male sex, a history of ever smoking (defined as 100 cigarettes in a person's lifetime), and age of 65 years or older.
Screening Tests Screening abdominal ultrasonography is an accurate test when performed in a setting with adequate quality assurance (i.e., in an accredited facility with credentialed technologists). Abdominal palpation has poor accuracy and is not an adequate screening test.
Timing of Screening One-time screening to detect an abdominal aortic aneurysm using ultrasonography is sufficient. There is negligible health benefit in re-screening those who have normal aortic diameter on initial screening.
Interventions Open surgical repair of an aneurysm of at least 5.5 cm leads to decreased abdominal aortic aneurysm-related mortality in the long term; however, there are major harms associated with this procedure.
Balance of Benefits and Harms In men ages 65 to 75 years who have ever smoked, the benefits of screening for abdominal aortic aneurysm outweigh the harms. In men ages 65 to 75 years who have never smoked, the balance between the benefits and harms of screening for abdominal aortic aneurysm is too close to make a general recommendation for this population. The potential overall benefit of screening for abdominal aortic aneurysm among women ages 65 to 75 years is low because of the small number of abdominal aortic aneurysm-related deaths in this population and the harms associated with surgical repair.
Other Relevant USPSTF Recommendations The USPSTF has made recommendations on screening for carotid artery stenosis, coronary heart disease, high blood pressure, lipid disorders, and peripheral arterial disease. These recommendations are available at http://www.uspreventiveservicestaskforce.org.

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org/.

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Alcohol Misuse

Title Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse
Population Adults aged 18 years or older Adolescents
Recommendation Screen for alcohol misuse and provide brief behavioral counseling interventions to persons engaged in risky or hazardous drinking.
Grade: B
No recommendation.
Grade: I statement
Screening Tests Numerous screening instruments can detect alcohol misuse in adults with acceptable sensitivity and specificity. The USPSTF prefers the following tools for alcohol misuse screening in the primary care setting:
  1. AUDIT
  2. Abbreviated AUDIT-C
  3. Single-question screening, such as asking, “How many times in the past year have you had 5 (for men) or 4 (for women and all adults older than 65 years) or more drinks in a day?”
Behavioral Counseling Interventions Counseling interventions in the primary care setting can improve unhealthy alcohol consumption behaviors in adults engaging in risky or hazardous drinking. Behavioral counseling interventions for alcohol misuse vary in their specific components, administration, length, and number of interactions. Brief multicontact behavioral counseling seems to have the best evidence of effectiveness; very brief behavioral counseling has limited effect.
Balance of Benefits and Harms There is a moderate net benefit to alcohol misuse screening and brief behavioral counseling interventions in the primary care setting for adults aged 18 years or older. The evidence on alcohol misuse screening and brief behavioral counseling interventions in the primary care setting for adolescents is insufficient, and the balance of benefits and harms cannot be determined.
Other Relevant USPSTF Recommendations The USPSTF has made recommendations on screening for illicit drug use and counseling and interventions to prevent tobacco use. These recommendations are available at http://www.uspreventiveservicestaskforce.org.

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org/.

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Aspirin for the Prevention of Cardiovascular Disease

Title Aspirin for the Prevention of Cardiovascular Disease
Population Men
age 45-79 years
Women
age 55-79 years
Men
age <45 years
Women
age <55 years
Men & Women
age ≥80 years
Recommendation Encourage aspirin use when potential CVD benefit (MIs prevented) outweighs potential harm of GI hemorrhage. Encourage aspirin use when potential CVD benefit (strokes prevented) outweighs potential harm of GI hemorrhage. Do not encourage aspirin use for MI prevention. Do not encourage aspirin use for stroke prevention. No Recommendation
Grade: A Grade: D Grade: I
(Insufficient Evidence)
How to Use This Recommendation Shared decision making is strongly encouraged with individuals whose risk is close to (either above or below) the estimates of 10-year risk levels indicated below. As the potential CVD benefit increases above harms, the recommendation to take aspirin should become stronger.

To determine whether the potential benefit of MIs prevented (men) and strokes prevented (women) outweighs the potential harm of increased GI hemorrhage, both 10-year CVD risk and age must be considered.

Risk level at which CVD events prevented (benefit) exceeds GI harms

Men Women
10-year CHD risk 10-year stroke risk
Age 45-59 years ≥4% Age 55-59 years ≥3%
Age 60-69 years ≥9% Age 60-69 years ≥8%
Age 70-79 years ≥12% Age 70-79 years ≥11%

The table above applies to adults who are not taking NSAIDs and who do not have upper GI pain or a history of GI ulcers.

NSAID use and history of GI ulcers raise the risk of serious GI bleeding considerably and should be considered in determining the balance of benefits and harms. NSAID use combined with aspirin use approximately quadruples the risk of serious GI bleeding compared to the risk with aspirin use alone. The rate of serious bleeding in aspirin users is approximately 2-3 times higher in patients with a history of GI ulcers.

Risk Assessment For men: Risk factors for CHD include age, diabetes, total cholesterol level, HDL level, blood pressure, and smoking.
CHD risk estimation tool: http://hp2010.nhlbihin.net/atpiii/calculator.asp

For women: Risk factors for ischemic stroke include age, high blood pressure, diabetes, smoking, history of CVD, atrial fibrillation, and left ventricular hypertrophy.
Stroke risk estimation tool: http://www.westernstroke.org/index.php?header_name=stroke_tools.gif&main=stroke_tools.php

Other Relevant USPSTF Recommendations The USPSTF has made recommendations on screening for abdominal aortic aneurysm, carotid artery stenosis, coronary heart disease, high blood pressure, lipid disorders, and peripheral arterial disease. These recommendations are available at http://www.uspreventiveservicestaskforce.org.

Abbreviations: CHD = coronary heart disease, CVD = cardiovascular disease, GI = gastrointestinal, HDL = high-density lipoprotein, MI = myocardial infarction, NSAIDs = nonsteroidal anti-inflammatory drugs.

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org/.

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Aspirin or NSAIDs for Prevention of Colorectal Cancer

Title Routine Aspirin or Nonsteroidal Anti-Inflammatory Drug (NSAID) for the Primary Prevention of Colorectal Cancer
Population Asymptomatic adults at average risk for colorectal cancer
Recommendation Do not use aspirin or NSAIDs for the prevention of colorectal cancer.
Grade: D
Risk Assessment The major risk factors for colorectal cancer are older age (older than age 50 years), family history (having two or more first or second-degree relatives with colorectal cancer), and African American race.
Balance of Benefits and Harms Aspirin and NSAIDs, taken in higher doses for longer periods, reduce the incidence of adenomatous polyps. However, there is poor evidence that aspirin and NSAID use leads to a reduction in colorectal cancer-associated mortality.

Aspirin increases the incidence of gastrointestinal bleeding and hemorrhagic stroke; NSAIDs increase the incidence of gastrointestinal bleeding and renal impairment, especially in the elderly.

The USPSTF concluded that the harms outweigh the benefits of aspirin and NSAID use for the prevention of colorectal cancer

Other Relevant USPSTF Recommendations The USPSTF has made recommendations on screening for colorectal cancer and aspirin use for the prevention of cardiovascular disease. These recommendations are available at http://www.uspreventiveservicestaskforce.org.

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org/.

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Bacterial Vaginosis in Pregnancy

Title Screening for Bacterial Vaginosis in Pregnancy to Prevent Preterm Delivery
Population Asymptomatic pregnant women without risk factors for preterm delivery Asymptomatic pregnant women with risk factors for preterm delivery
Recommendation Do not screen.
Grade: D
No recommendation.
Grade: I (Insufficient Evidence)
Risk Assessment Risk factors of preterm delivery include:
  • African-American women.
  • Pelvic infection.
  • Previous preterm delivery.

Bacterial vaginosis is more common among African-American women, women of low socioeconomic status, and women who have previously delivered low-birth-weight infants.

Screening Tests Bacterial vaginosis is diagnosed using Amsel's clinical criteria or Gram stain.

When using Amsel's criteria, 3 out of 4 criteria must be met to make a clinical diagnosis:

  1. Vaginal pH >4.7.
  2. The presence of clue cells on wet mount.
  3. Thin homogeneous discharge.
  4. Amine 'fishy odor' when potassium hydroxide is added to the discharge.
Screening Intervals Not applicable.
Treatment Treatment is appropriate for pregnant women with symptomatic bacterial vaginosis infection.

Oral metronidazole and oral clindamycin, as well as vaginal metronidazole gel or clindamycin cream, are used to treat bacterial vaginosis.

The optimal treatment regimen is unclear.1

1 The Centers for Disease Control and Prevention (CDC) recommends 250 mg oral metronidazole 3 times a day for 7 days as the treatment for bacterial vaginosis in pregnancy.

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org/.

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Bacteriuria

Title Screening for Asymptomatic Bacteriuria in Adults
Population All pregnant women Men and nonpregnant women
Recommendation Screen with urine culture
Grade: A
Do not screen.
Grade: D
Detection and Screening Tests Asymptomatic bacteriuria can be reliably detected through urine culture.

The presence of at least 105 colony-forming units per mL of urine, of a single uropathogen, and in a midstream clean-catch specimen is considered a positive test result.

Screening Intervals A clean-catch urine specimen should be collected for screening culture at 12-16 weeks' gestation or at the first prenatal visit, if later.

The optimal frequency of subsequent urine testing during pregnancy is uncertain.

Do not screen.
Benefits of Detection and Early Treatment The detection and treatment of asymptomatic bacteriuria with antibiotics significantly reduces the incidence of symptomatic maternal urinary tract infections and low birthweight. Screening men and nonpregnant women for asymptomatic bacteriuria is ineffective in improving clinical outcomes.
Harms of Detection and Early Treatment Potential harms associated with treatment of asymptomatic bacteriuria include:
  • Adverse effects from antibiotics.
  • Development of bacterial resistance.
Other Relevant USPSTF Recommendations Additional USPSTF recommendations involving screening for infectious conditions during pregnancy can be found at www.uspreventiveservicestaskforce.org/recommendations.htm#obstetric and www.uspreventiveservicestaskforce.org/recommendations.htm#infectious.

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org/.

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Bladder Cancer

Title Screening for Bladder Cancer
Population Asymptomatic adults
Recommendation No recommendation.
Grade: I (Insufficient Evidence)
Risk Assessment Risk factors for bladder cancer include:
  • Smoking
  • Occupational exposure to carcinogens (e.g., rubber, chemical, and leather industries)
  • Male sex
  • Older age
  • White race
  • Infections caused by certain bladder parasites
  • Family or personal history of bladder cancer
Screening Tests Screening tests for bladder cancer include:
  • Microscopic urinalysis for hematuria
  • Urine cytology
  • Urine biomarkers
Interventions The principal treatment for superficial bladder cancer is transurethral resection of the bladder tumor, which may be combined with adjuvant radiation therapy, chemotherapy, biologic therapies, or photodynamic therapies.

Radical cystectomy, often with adjuvant chemotherapy, is used in cases of surgically resectable invasive bladder cancer.

Balance of Benefits and Harms There is inadequate evidence that treatment of screen-detected bladder cancer leads to improved morbidity or mortality.

There is inadequate evidence on harms of screening for bladder cancer.

Suggestions for Practice In deciding whether to screen for bladder cancer, clinicians should consider the following:
  • Potential preventable burden: early detection of tumors with malignant potential could have an important impact on the mortality rate of bladder cancer.
  • Potential harms: false-positive results may lead to anxiety and unneeded evaluations, diagnostic-related harms from cystoscopy and biopsy, harms from labeling and unnecessary treatments, and overdiagnosis.
  • Current practice: screening tests used in primary practice include microscopic urinalysis for hematuria and urine cytology; urine biomarkers are not commonly used in part because of cost. Patients with positive findings are typically referred to a urologist for further evaluation.
Other Relevant USPSTF Recommendations Recommendations on screening for other types of cancer can be found at www.uspreventiveservicestaskforce.org.

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org/.

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BRCA-Related Cancer In Women

Title Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer In Women
Population Asymptomatic women who have not been diagnosed with BRCA-related cancer
Recommendation Screen women whose family history may be associated with an increased risk for potentially harmful BRCA mutations. Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing.
Grade: B
Do not routinely recommend genetic counseling or BRCA testing to women whose family history is not associated with an increased risk for potentially harmful BRCA mutations.
Grade: D
Risk Assessment Family history factors associated with increased likelihood of potentially harmful BRCA mutations include breast cancer diagnosis before age 50 years, bilateral breast cancer, family history of breast and ovarian cancer, presence of breast cancer in ≥1 male family member, multiple cases of breast cancer in the family, ≥1 or more family member with 2 primary types of BRCA-related cancer, and Ashkenazi Jewish ethnicity.

Several familial risk stratification tools are available to determine the need for in-depth genetic counseling, such as the Ontario Family History Assessment Tool, Manchester Scoring System, Referral Screening Tool, Pedigree Assessment Tool, and FHS-7.

Screening Tests Genetic risk assessment and BRCA mutation testing are generally multistep processes involving identification of women who may be at increased risk for potentially harmful mutations, followed by genetic counseling by suitably trained health care providers and genetic testing of selected high-risk women when indicated.

Tests for BRCA mutations are highly sensitive and specific for known mutations, but interpretation of results is complex and generally requires posttest counseling.

Treatment Interventions in women who are BRCA mutation carriers include earlier, more frequent, or intensive cancer screening; risk-reducing medications (e.g., tamoxifen or raloxifene); and risk-reducing surgery (e.g., mastectomy or salpingo-oophorectomy).
Balance of Benefits and Harms In women whose family history is associated with an increased risk for potentially harmful BRCA mutations, the net benefit of genetic testing and early intervention is moderate. In women whose family history is not associated with an increased risk for potentially harmful BRCA mutations, the net benefit of genetic testing and early intervention ranges from minimal to potentially harmful.
Other Relevant USPSTF Recommendations The USPSTF has made recommendations on medications for the reduction of breast cancer risk and screening for ovarian cancer. These recommendations are available at http://www.uspreventiveservicestaskforce.org.

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org/.

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Breast Cancer (Preventive Medications)

Title Medications for Risk Reduction of Primary Breast Cancer in Women
Population Asymptomatic women aged ≥35 years without a prior diagnosis of breast cancer who are at increased risk for the disease Asymptomatic women aged ≥35 years without a prior diagnosis of breast cancer who are not at increased risk for the disease
Recommendation Engage in shared, informed decision making and offer to prescribe risk-reducing medications, if appropriate.
Grade: B
Do not prescribe risk-reducing medications.
Grade: D
Risk Assessment Important risk factors for breast cancer include patient age, race/ethnicity, age at menarche, age at first live childbirth, personal history of ductal or lobular carcinoma in situ, number of first-degree relatives with breast cancer, personal history of breast biopsy, body mass index, menopause status or age, breast density, estrogen and progestin use, smoking, alcohol use, physical activity, and diet.

Available risk assessment models can accurately predict the number of breast cancer cases that may arise in certain study populations, but their ability to accurately predict which women will develop breast cancer is modest.

Preventive Medications The selective estrogen receptor modulators tamoxifen and raloxifene have been shown to reduce the incidence of invasive breast cancer in women who are at increased risk for the disease. Tamoxifen has been approved for this use in women age 35 years or older, and raloxifene has been approved for this use in postmenopausal women. The usual daily doses for tamoxifen and raloxifene are 20 mg and 60 mg, respectively, for 5 years.
Balance of Benefits and Harms There is a moderate net benefit from use of tamoxifen and raloxifene to reduce the incidence of invasive breast cancer in women who are at increased risk for the disease. The potential harms of tamoxifen and raloxifene outweigh the potential benefits for breast cancer risk reduction in women who are not at increased risk for the disease.

Potential harms include thromboembolic events, endometrial cancer, and cataracts.

Other Relevant USPSTF Recommendations The USPSTF has made recommendations on risk assessment, genetic counseling, and genetic testing for BRCA-related cancer, as well as screening for breast cancer. These recommendations are available at http://www.uspreventiveservicestaskforce.org.

For a summary of the evidence systematically reviewed in making these recommendations, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org.

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Disclaimer: Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Breast Cancer (Screening)

Title Screening for Breast Cancer Using Film Mammography
Population Women aged 40-49 years Women aged 50-74 years Women aged ≥75 years
Recommendation Individualize decision to begin biennial screening according to the patient's circumstances and values.
Grade: C
Screen every 2 years.
Grade: B
No recommendation.
Grade: I (Insufficient Evidence)
Risk Assessment This recommendation applies to women aged ≥40 years who are not at increased risk by virtue of a known genetic mutation or history of chest radiation. Increasing age is the most important risk factor for most women.  
Screening Tests Standardization of film mammography has led to improved quality. Refer patients to facilities certified under the Mammography Quality Standards Act (MQSA), listed at http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMQSA/mqsa.cfm.  
Timing of Screening Evidence indicates that biennial screening is optimal. A biennial schedule preserves most of the benefit of annual screening and cuts the harms nearly in half. A longer interval may reduce the benefit.  
Benefits of Benefits and Harms There is convincing evidence that screening with film mammography reduces breast cancer mortality, with a greater absolute reduction for women aged 50 to 74 years than for younger women.

Harms of screening include psychological harms, additional medical visits, imaging, and biopsies in women without cancer, inconvenience due to false-positive screening results, harms of unnecessary treatment, and radiation exposure. Harms seem moderate for each age group.

False-positive results are a greater concern for younger women; treatment of cancer that would not become clinically apparent during a woman's life (overdiagnosis) is an increasing problem as women age.

 
Rationale for No Recommendation (I Statement)   Among women 75 years or older, evidence of benefit is lacking
Other Relevant USPSTF Recommendations The USPSTF has made recommendations on mammography screening for breast cancer, screening for ovarian cancer, and chemoprevention of breast cancer. These recommendations can be found at www.uspreventiveservicestaskforce.org.

1 The U.S. Department of Health and Human Services, in implementing the Affordable Care Act under the standard it sets out in revised Section 2713(a)(5) of the Public Health Service Act, utilizes the 2002 recommendation on breast cancer screening of the U.S. Preventive Services Task Force. For clinical summary of 2002 Recommendation, see .

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org/.

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Breastfeeding

Title Primary Care Interventions to Promote Breastfeeding
Population Pregnant women New mothers The mother's partner, and friends Infants and young children
Recommendation Promote and support breastfeeding
Grade: B
Benefits of Breastfeeding Mothers

Less likelihood of breast and ovarian cancer

Infants

Fewer ear infections, lower-respiratory-tract infections, and gastrointestinal infections

Young children

Less likelihood of asthma, type 2 diabetes, and obesity

Interventions to Promote Breastfeeding Interventions to promote and support breastfeeding have been found to increase the rates of initiation, duration, and exclusivity of breastfeeding. Consider multiple strategies, including:
  • Formal breastfeeding education for mothers and families
  • Direct support of mothers during breastfeeding
  • Training of primary care staff about breastfeeding and techniques for breastfeeding support
  • Peer support

Interventions that include both prenatal and postnatal components may be most effective at increasing breastfeeding duration.

In rare circumstances, for example for mothers with HIV and infants with galactosemia, breastfeeding is not recommended. Interventions to promote breastfeeding should empower individuals to make informed choices supported by the best available evidence.

Implementation System-level interventions with senior leadership support may be more likely to be sustained over time.

For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to http://www.uspreventiveservicestaskforce.org/.

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Current as of June 2014
Internet Citation: Section 2. Recommendations for Adults: Guide to Clinical Preventive Services, 2014. June 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/section2.html