Section 2. Recommendations for Adults

Guide to Clinical Preventive Services, 2012

All clinical summaries in this Guide are abridged recommendations. To see the full recommendation statements and recommendations published after March 2012, go to http://www.uspreventiveservicestaskforce.org.

Screening for Abdominal Aortic Aneurysm

Clinical Summary of U.S. Preventive Services Task Force Recommendation

PopulationMen ages 65 to 75 years who have ever smokedMen ages 65 to 75 years who have never smokedWomen ages 65 to 75 years
RecommendationScreen 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 AssessmentThe 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 TestsScreening 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 ScreeningOne-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.
InterventionsOpen 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 HarmsIn 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 RecommendationsThe 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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Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse

Clinical Summary of U.S. Preventive Services Task Force Recommendation

PopulationAdults, including pregnant womenAdolescents
RecommendationScreen and provide behavioral counseling interventions to reduce alcohol misuse.
Grade: B
No recommendation.
Grade: I (Insufficient Evidence)
Risk AssessmentRisky” or “hazardous” drinking has been defined in the United States as more than 7 drinks per week or more than 3 drinks per occasion for women, and more than 14 drinks per week or more than 4 drinks per occasion for men. “Harmful drinking” describes persons who are currently experiencing physical, social, or psychological harm from alcohol use but do not meet criteria for dependence. Alcohol abuse and dependence are defined by specific criteria in the DSM-IV.
Screening TestsThe Alcohol Use Disorders Identification Test (AUDIT) is the most studied screening tool for detecting the full spectrum of alcohol-related problems in primary care settings. The 4-item CAGE is the most popular screening test for detecting alcohol abuse or dependence.

TWEAK, a 5-item scale, and the T-ACE are designed to screen pregnant women for alcohol misuse. They detect lower levels of alcohol consumption that may pose risks during pregnancy.

Clinicians may choose screening strategies that are appropriate for their clinical population and setting.

Timing of ScreeningOne-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.
InterventionsThe optimal interval for screening and intervention is unknown. Patients with past alcohol problems, young adults, and other high-risk groups (e.g., smokers) may benefit most from frequent screening.
Balance of Benefits and HarmsScreening in primary care settings can accurately identify patients whose alcohol consumption does not meet criteria for alcohol dependence, but places them at risk for increased morbidity and mortality. Brief behavioral counseling interventions with followup produce small to moderate reductions in alcohol consumption that are sustained over 6 to 12 months or longer.The evidence is insufficient to assess the potential benefits and harms of screening and behavioral counseling interventions in this population
Other Relevant USPSTF RecommendationsThe USPSTF has also made recommendations on screening for illicit drug use and counseling for tobacco cessation in adolescents, adults, and pregnant women. 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

Clinical Summary of U.S. Preventive Services Task Force Recommendation

PopulationMen
age 45-79 years
Women
age 55-79 years
Men
age <45 years
Women
age <55 years
Men & Women
age ≥80 years
RecommendationEncourage 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: AGrade: DGrade: 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

MenWomen
10-year CHD risk10-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 RecommendationsThe 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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Routine Aspirin or Nonsteroidal Anti-Inflammatory Drug (NSAID) for the Primary Prevention of Colorectal Cancer

Clinical Summary of U.S. Preventive Services Task Force Recommendation

PopulationAsymptomatic adults at average risk for colorectal cancer
RecommendationDo not use aspirin or NSAIDs for the prevention of colorectal cancer.
Grade: D
Risk AssessmentThe 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 RecommendationsThe 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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Screening for Bacterial Vaginosis in Pregnancy to Prevent Preterm Delivery

Clinical Summary of U.S. Preventive Services Task Force Recommendation

PopulationAsymptomatic pregnant women without risk factors for preterm deliveryAsymptomatic pregnant women with risk factors for preterm delivery
RecommendationDo 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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Screening for Asymptomatic Bacteriuria in Adults

Clinical Summary of U.S. Preventive Services Task Force Recommendation

PopulationAll pregnant womenMen and nonpregnant women
RecommendationScreen 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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Screening for Bladder Cancer

Clinical Summary of U.S. Preventive Services Task Force Recommendation

PopulationAsymptomatic adults
Recommendation

No recommendation.
Grade: I (Insufficient Evidence)

Risk AssessmentRisk 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 TestsScreening tests for bladder cancer include:
  • Microscopic urinalysis for hematuria
  • Urine cytology
  • Urine biomarkers
InterventionsThe 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 HarmsThere 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 PracticeIn 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 RecommendationsRecommendations 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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Genetic Risk Assessment and Breast Cancer Susceptibility Gene (BRCA) Mutation Testing for Breast and Ovarian Cancer Susceptibility

Clinical Summary of U.S. Preventive Services Task Force Recommendation

PopulationWomen whose family history is not associated with an increased risk for deleterious mutations in the BRCA1 or BRCA2 geneWomen whose family history is associated with an increased risk for deleterious mutations in the BRCA1 or BRCA2 gene
RecommendationDo not refer patients for genetic counseling or BRCA testing.
Grade: D
Refer patients for genetic counseling and evaluation for BRCA testing.
Grade: B
Risk Assessment

An increased-risk family history is defined as follows:

For non-Ashkenazi Jewish women: 2 first-degree relatives with breast cancer, 1 of whom received the diagnosis at age 50 years or younger; a combination of 3 or more first- or second-degree relatives with breast cancer, regardless of age at diagnosis; a combination of both breast and ovarian cancer among first- and second-degree relatives; a first-degree relative with bilateral breast cancer; a combination of 2 or more first- or second-degree relatives with ovarian cancer, regardless of age at diagnosis; a first- or second-degree relative with both breast and ovarian cancer at any age; or a history of breast cancer in a male relative.

For women of Ashkenazi Jewish heritage: an increased-risk family history includes any first-degree relative (or 2 second-degree relatives on the same side of the family) with breast or ovarian cancer.

About 2% of adult women in the general population have an increased-risk family history as defined here. There are tools available to predict the risk for clinically important BRCA mutations, but these tools have not been verified in the general population. There is no evidence concerning the level of risk for a BRCA mutation that merits referral for genetic counseling.

Screening Tests

Genetic counseling includes elements of counseling, risk assessment, pedigree analysis, and, in some cases, recommendations for testing for BRCA mutations in affected family members, the patient, or both. A BRCA test is typically ordered by a physician. When done together with genetic counseling, the test assures the linkage of testing with appropriate management decisions.

InterventionsThe interventions that can be offered to a woman with a deleterious BRCA1 or BRCA2 mutation or other increased risk for hereditary breast cancer include intensive screening, chemoprevention, prophylactic mastectomy or oophorectomy, or a combination.
Benefits of Benefits and Harms

Women without an increased-risk family history have a low risk for developing breast or ovarian cancer associated with BRCA1 or BRCA2 mutations.

There are important adverse ethical, legal, and social consequences that can result from routine referral and testing of these women. Interventions such as prophylactic surgery, chemoprevention, or intensive screening have known harms.

The potential harms of routine referral for genetic counseling or BRCA
testing in these women outweigh the benefits.

Women with an increased-risk family history have an increased risk for developing breast or ovarian cancer associated with BRCA1 or BRCA2 mutations.

The potential benefits of referral and discussion of testing and prophylactic treatment for these women may be substantial.

The benefits of referring women with an increased-risk family history to suitably trained health care providers outweigh the harms.

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.

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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Screening for Breast Cancer Part I: Using Film Mammography 

Clinical Summary of 2009 U.S. Preventive Services Task Force Recommendation1

PopulationWomen aged 40-49 yearsWomen aged 50-74 yearsWomen aged ≥75 years
RecommendationIndividualize 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 AssessmentThis 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 ScreeningEvidence 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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Screening for Breast Cancer Part II: Using Methods Other Than Film Mammography 

Clinical Summary of 2009 U.S. Preventive Services Task Force Recommendation1

PopulationWomen aged ≥40 years
Screening MethodDigital mammographyMagnetic resonance imaging (MRI)Clinical breast examination (CBE)Breast self-examination (BSE)
Grade: D
RecommendationGrade: I (Insufficient Evidence)
Rationale for No
Recommendation or
Negative Recommendation
Evidence is lacking for benefits of digital mammography and MRI of the breast as substitutes for film mammography.Evidence of CBE's additional benefit, beyond mammography, is inadequate.Adequate evidence suggests that BSE does not reduce breast cancer mortality
Considerations for Practice
Potential Preventable Burden

For younger women and women with dense breast tissue, overall detection is somewhat better with digital mammography.

Contrast-enhanced MRI has been shown to detect more cases of cancer in very high-risk populations than does mammography.Indirect evidence suggests that when CBE is the only test available, it may detect a significant proportion of cancer case 
Potential HarmsIt is not certain whether overdiagnosis occurs more often with digital than with film mammography.

Contrast-enhanced MRI requires injection of contrast material.

MRI yields many more false-positive results and potentially more overdiagnosis than mammography.

Harms of CBE include false-positive results, which lead to anxiety, unnecessary visits, imaging, and biopsies.Harms of BSE include the same potential harms as for CBE and may be larger in magnitude.
Costs

Digital mammography is more expensive than film.

MRI is much more expensive than mammography.Costs of CBE are primarily opportunity costs to clinicians.Costs of BSE are primarily opportunity costs to clinicians.
Current PracticeSome clinical practices are now switching to digital equipment.MRI is not currently used to
screen women of average risk.
No standard approach or reporting standards are in place.The number of clinicians who teach BSE to patients is unknown; it is likely that few clinicians teach BSE to all women.

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 Appendix F.

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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Primary Care Interventions to Promote Breastfeeding

Clinical Summary of U.S. Preventive Services Task Force Recommendation

PopulationPregnant womenNew MothersThe mother's partner,
other family members,
and friends
Infants and young children
RecommendationPromote 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.

ImplementationSystem-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 October 2011
Internet Citation: Section 2. Recommendations for Adults: Guide to Clinical Preventive Services, 2012. October 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/section2.html