Section 2. Recommendations for Adults (continued)

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 Carotid Artery Stenosis

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

Population	Adult general population¹
Recommendation	Do not screen with ultrasound or other screening tests. Grade: D
Risk Assessment	The major risk factors for carotid artery stenosis (CAS) include: older age, male gender, hypertension, smoking, hypercholesterolemia, and heart disease. However, accurate, reliable risk assessment tools are not available.
Balance of Benefits and Harms	Harms outweigh benefits. In the general population, screening with carotid duplex ultrasound would result in more false-positive results than true positive results. This would lead either to surgeries that are not indicated or to confirmatory angiography. As the result of these procedures, some people would suffer serious harms (death, stroke, and myocardial infarction) that outweigh the potential benefit surgical treatment may have in preventing stroke.
Other Relevant Recommendations from the USPSTF	Adults should be screened for hypertension, hyperlipidemia, and smoking. Clinicians should discuss aspirin chemoprevention with patients at increased risk for cardiovascular disease. These recommendations and related evidence are available at http://www.uspreventiveservicestaskforce.org.

¹ This recommendation applies to adults without neurological symptoms and without a history of transient ischemic attacks (TIA) or stroke. If otherwise eligible, an individual who has a carotid area TIA should be evaluated promptly for consideration of carotid endarterectomy.

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 Cervical Cancer

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

Population	Women ages 21 to 65	Women ages 30 to 65	Women younger than age 21	Women older than age 65 who have had adequate prior screening and are not high risk	Women after hysterectomy with removal of the cervix and with no history of high-grade precancer or cervical cancer	Women younger than age 30
Recommendation	Screen with cytology (Pap smear) every 3 years. Grade: A	Screen with cytology every 3 years or co-testing (cytology/HPV testing) every 5 years. Grade: A	Do not screen. Grade: D	Do not screen. Grade: D	Do not screen. Grade: D	Do not screen with HPV testing (alone or with cytology) Grade: D
Risk Assessment	Human papillomavirus (HPV) infection is associated with nearly all cases of cervical cancer. Other factors that put a woman at increased risk of cervical cancer include HIV infection, a compromised immune system, in utero exposure to diethylstilbestrol, and previous treatment of a high-grade precancerous lesion or cervical cancer.
Screening Tests and Interval	Screening women ages 21 to 65 years every 3 years with cytology provides a reasonable balance between benefits and harms. Screening with cytology more often than every 3 years confers little additional benefit, with large increases in harms. HPV testing combined with cytology (co-testing) every 5 years in women ages 30 to 65 years offers a comparable balance of benefits and harms, and is therefore a reasonable alternative for women in this age group who would prefer to extend the screening interval.
Timing of Screening	Screening earlier than age 21 years, regardless of sexual history, leads to more harms than benefits. Clinicians and patients should base the decision to end screening on whether the patient meets the criteria for adequate prior testing and appropriate follow-up, per established guidelines.
Interventions	Screening aims to identify high-grade precancerous cervical lesions to prevent development of cervical cancer and early-stage asymptomatic invasive cervical cancer. High-grade lesions may be treated with ablative and excisional therapies, including cryotherapy, laser ablation, loop excision, and cold knife conization. Early-stage cervical cancer may be treated with surgery (hysterectomy) or chemoradiation.
Balance of Benefits and Harms	The benefits of screening with cytology every 3 years substantially outweigh the harms.	The benefits of screening with co-testing (cytology/HPV testing) every 5 years outweigh the harms.	The harms of screening earlier than age 21 years outweigh the benefits.	The benefits of screening after age 65 years do not outweigh the potential harms.	The harms of screening after hysterectomy outweigh the benefits.	The potential harms of screening with HPV testing (alone or with cytology) outweigh the potential benefits.
Other Relevant USPSTF Recommendations	The USPSTF has made recommendations on screening for breast cancer and ovarian cancer, as well as genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility. These recommendations are available at http://www.uspreventiveservicestaskforce.org/.

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Screening for Chlamydial Infection

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

Population	Non-pregnant women			Pregnant women			Men
	24 years and younger	25 years and older		24 years and younger	25 years and older
	Includes adolescents	Not at increased risk	At increased risk	Includes adolescents	Not at increased risk	At increased risk
Recommendation	Screen if sexually active Grade A	Do not automatically screen. Grade: C	Screen. Grade: A	Screen. Grade: B	Do not automatically screen. Grade: C	Screen. Grade: B	No recommendation. Grade: I (Insufficient Evidence¹)
Risk Assessment	Age: Women and men aged 24 years and younger are at greatest risk. History of: Previous Chlamydial infection or other sexually transmitted infections, new or multiple sexual partners, inconsistent condom use, sex work. Demographics: African-Americans and Hispanic women and men have higher prevalence rates than the general population in many communities.
Screening Tests	Nucleic acid amplification tests (NAATs) can identify chlamydial infection in asymptomatic women (non-pregnant and pregnant) and asymptomatic men. NAATs have high specificity and sensitivity and can be used with urine and vaginal swabs.
Screening Intervals	Non-Pregnant Women The optimal interval for screening is not known. The CDC recommends that women at increased risk be screened at least annually.²			Pregnant Women For women 24 years and younger and older women at increased risk: Screen at the first prenatal visit. For patients at continuing risk, or who are newly at risk: Screen in the 3rd trimester.			Not applicable
Treatment	The Centers for Disease Control and Prevention has outlined appropriate treatment at: http://www.cdc.gov/STD/treatment. Test and/or treat partners of patients treated for Chlamydial infection.

¹ Chlamydial infection results in few sequelae in men. Therefore, the major benefit of screening men would be to reduce the likelihood that infected and untreated men would pass the infection to sexual partners. There is no evidence that screening men reduces the long-term consequences of chlamydial infection in women. Because of this lack of evidence, the USPSTF was not able to assess the balance of benefits and harms, and concluded that the evidence is insufficient to recommend for or against routinely screening men.
² Centers for Disease Control and Prevention, Sexually transmitted diseases treatment guidelines, 2006. MMWR 2006. 55(No. RR-11).

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Screening for Chronic Obstructive Pulmonary Disease Using Spirometry

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

Population	Adult general population
Recommendation	Do not screen for chronic obstructive pulmonary disease using spirometry Grade: D
Additional Population Information	This screening recommendation applies to healthy adults who do not recognize or report respiratory symptoms to a clinician. It does not apply to individuals with a family history of alpha-1 antitrypsin deficiency.
Risk Assessment	Risk factors for COPD include: Current or past tobacco use. Exposure to occupational and environmental pollutants. Age 40 or older.
Screening Tests¹	Spirometry can be performed in a primary care physician's office or a pulmonary testing laboratory. The USPSTF did not review evidence comparing the accuracy of spirometry performed in primary care versus referral settings. For individuals who present to clinicians complaining of chronic cough, increased sputum production, wheezing, or dyspnea, spirometry would be indicated as a diagnostic test for COPD, asthma, and other pulmonary diseases.
Other Approaches to the Prevention of Pulmonary Illnesses	These services should be offered to patients regardless of COPD status: All current smokers should receive smoking cessation counseling and be offered pharmacologic therapies demonstrated to increase cessation rates. All patients 50 years of age or older should be offered influenza immunization annually. All patients 65 years of age or older should be offered one-time pneumococcal immunization.
Other Relevant USPSTF Recommendations	Clinicians should screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products. The USPSTF tobacco cessation counseling recommendation and supporting evidence are available at http://www.uspreventiveservicestaskforce.org/uspstf/uspstbac2.htm.

¹ The potential benefit of spirometry-based screening for COPD is prevention of one or more exacerbations by treating patients found to have an airflow obstruction previously undetected. However, even in groups with the greatest prevalence of airflow obstruction, hundreds of patients would need to be screened with spirometry to defer one exacerbation.

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Screening for Colorectal Cancer

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

Population	Adults age 50 to 75¹	Adults age 76 to 85 years¹	Adults older than 85¹
Recommendation	Screen with high sensitivity fecal occult blood testing (FOBT), sigmoidoscopy, or colonoscopy. Grade: A	Do not screen routinely Grade: C	Do not screen Grade: D
Recommendation	For all populations, evidence is insufficient to assess the benefits and harms of screening with computerized tomography colonography (CTC) and fecal DNA testing. Grade: I (insufficient evidence)

Screening Tests	High sensitivity FOBT, sigmoidoscopy with FOBT, and colonoscopy are effective in decreasing colorectal cancer mortality. The risks and benefits of these screening methods vary. Colonoscopy and flexible sigmoidoscopy (to a lesser degree) entail possible serious complications.
Screening Test Intervals	Intervals for recommended screening strategies: Annual screening with high-sensitivity fecal occult blood testing Sigmoidoscopy every 5 years, with high-sensitivity fecal occult blood testing every 3 years Screening colonoscopy every 10 years
Balance of Benefits and Harms	The benefits of screening outweigh the potential harms for 50- to 75-year-olds.	The likelihood that detection and early intervention will yield a mortality benefit declines after age 75 because of the long average time between adenoma development and cancer diagnosis.
Implementation	Focus on strategies that maximize the number of individuals who get screened. Practice shared decisionmaking; discussions with patients should incorporate information on test quality and availability. Individuals with a personal history of cancer or adenomatous polyps are followed by a surveillance regimen, and screening guidelines are not applicable.
Other Relevant USPSTF Recommendations	The USPSTF recommends against the use of aspirin or nonsteroidal anti-inflammatory drugs for the primary prevention of colorectal cancer. This recommendation is available at http://www.uspreventiveservicestaskforce.org.

¹ These recommendations do not apply to individuals with specific inherited syndromes (Lynch Syndrome or Familial Adenomatous Polyposis) or those with inflammatory bowel disease.

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Using Nontraditional Risk Factors In Coronary Heart Disease Risk Assessment

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

Population	Asymptomatic men and women with no history of coronary heart disease (CHD), diabetes, or any CHD risk equivalent
Recommendation	No recommendation. Grade: I (Insufficient Evidence)
Risk Assessment	This recommendation applies to adult men and women classified at intermediate 10-year risk for CHD (10% to 20%) by traditional risk factors.
Importance	Coronary heart disease (CHD) is the most common cause of death in adults in the United States. Treatment to prevent CHD events by modifying risk factors is currently based on the Framingham risk model. If the classification of individuals at intermediate risk could be improved by using additional risk factors, treatment to prevent CHD might be targeted more effectively. Risk factors not currently part of the Framingham model (nontraditional risk factors) include high sensitivity C-reactive protein (hs-CRP), ankle-brachial index (ABI), leukocyte count. fasting blood glucose level, periodontal disease, carotid intima-media thickness,; electron beam computed tomography,; homocysteine level, and lipoprotein(a) level.
Balance of Benefits and Harms	There is insufficient evidence to determine the percentage of intermediate-risk individuals who would be reclassified by screening with nontraditional risk factors, other than hs-CRP and ABI. For individuals reclassified as high-risk on the basis of hs-CRP or ABI scores, data are not available to determine whether they benefit from additional treatments. Little evidence is available to determine the harms of using nontraditional risk factors in screening. Potential harms include lifelong use of medications without proven benefit and psychological and other harms from being misclassified in a higher risk category.
Suggestions for Practice	Clinicians should continue to use the Framingham model to assess CHD risk and guide risk-based preventive therapy. Adding nontraditional risk factors to CHD assessment would require additional patient and clinical staff time and effort. Routinely screening with nontraditional risk factors could result in lost opportunities to provide other important health services of proven benefit.
Other Relevant USPSTF Recommendations	USPSTF recommendations on risk assessment for CHD, the use of aspirin to prevent cardiovascular disease, and screening for high blood pressure can be accessed at http://www.uspreventiveservicestaskforce.org.

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Screening for Depression in Adults

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

Population	Nonpregnant adults 18 years or older
Recommendation	Screen when staff-assisted depression care supports¹ are in place to assure accurate diagnosis, effective treatment, and follow-up. Grade: B	*Do not routinely screen when staff-assisted depression care supports are not in place. Grade: C**
Risk Assessment	Persons at increased risk for depression are considered at risk throughout their lifetime. Groups at increased risk include persons with other psychiatric disorders, including substance misuse; persons with a family history of depression; persons with chronic medical diseases; and persons who are unemployed or of lower socioeconomic status. Also, women are at increased risk compared with men. However, the presence of risk factors alone cannot distinguish depressed patients from nondepressed patients.
Screening Tests	Simple screening questions may perform as well as more complex instruments. Any positive screening test result should trigger a full diagnostic interview using standard diagnostic criteria.
Timing of Screening	The optimal interval for screening is unknown. In older adults, significant depressive symptoms are associated with common life events, including medical illness, cognitive decline, bereavement, and institutional placement in residential or inpatient settings.
Balance of Benefits and Harms		Limited evidence suggests that screening for depression in the absence of staff-assisted depression care does not improve depression outcomes.
Suggestions for Practice	"Staff-assisted depression care supports" refers to clinical staff that assists the primary care clinician by providing some direct depression care and/or coordination, case management, or mental health treatment.
Relevant USPSTF Recommendations	Related USPSTF recommendations on screening for suicidality and screening children and adolescents for depression are available at http://www.uspreventiveservicestaskforce.org.

¹ Go to the Suggestions for Practice section of this figure for further explanation.

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Screening for Type 2 Diabetes Mellitus in Adults

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

Population	Asymptomatic adults with sustained blood pressure greater than 135/80 mm Hg	Asymptomatic adults with sustained blood pressure 135/80 mm Hg or lower
Recommendation	Screen for type 2 diabetes mellitus Grade: B	No recommendation Grade: I (Insufficient Evidence)
Risk Assessment	These recommendations apply to adults with no symptoms of type 2 diabetes mellitus or evidence of possible complications of diabetes. Blood pressure measurement is an important predictor of cardiovascular complications in people with type 2 diabetes mellitus. The first step in applying this recommendation should be measurement of blood pressure (BP). Adults with treated or untreated BP >135/80 mm Hg should be screened for diabetes.
Screening Tests	Three tests have been used to screen for diabetes: Fasting plasma glucose (FPG). 2-hour postload plasma. Hemoglobin A1c. The American Diabetes Association (ADA) recommends screening with FPG, defines diabetes as FPG ≥ 126 mg/dL, and recommends confirmation with a repeated screening test on a separate day.
Screening Intervals	The optimal screening interval is not known. The ADA, on the basis of expert opinion, recommends an interval of every 3 years.
Suggestions for practice regarding insufficient evidence	When BP is ≤ 135/80 mm Hg, screening may be considered on an individual basis when knowledge of diabetes status would help inform decisions about coronary heart disease (CHD) preventive strategies, including consideration of lipid-lowering agents or aspirin. To determine whether screening would be helpful on an individual basis, information about 10-year CHD risk must be considered. For example, if CHD risk without diabetes was 17% and risk with diabetes was >20%, screening for diabetes would be helpful because diabetes status would determine lipid treatment. In contrast, if risk without diabetes was 10% and risk with diabetes was 15%, screening would not affect the decision to use lipid-lowering treatment.
Other relevant information from the USPSTF and the Community Preventive Services Task Force	Evidence and USPSTF recommendations regarding blood pressure, diet, physical activity, and obesity are available at http://www.uspreventiveservicestaskforce.org. The reviews and recommendations of the Task Force on Community Preventive Services may be found at http://www.thecommunityguide.org.

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Folic Acid for the Prevention of Neural Tube Defects

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

Population	Women planning a pregnancy or capable of becoming pregnant
Recommendation	Take a daily vitamin supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid. Grade: A
Risk Assessment	Risk factors include: A personal or family history of a pregnancy affected by a neural tube defect The use of certain antiseizure medications Mutations in folate-related enzymes Maternal diabetes Maternal obesity Note: This recommendation does not apply to women who have had a previous pregnancy affected by neural tube defects or women taking certain antiseizure medicines. These women may be advised to take higher doses of folic acid.
Timing of Medication	Start supplementation at least 1 month before conception. Continue through first 2 to 3 months of pregnancy.
Recommendations of Others	ACOG, AAFP, and most other organizations recommend 4 mg/d for women with a history of a pregnancy affected by a neural tube defect.

Abbreviations: AAFP = American Academy of Family Physicians; ACOG = American College of Obstetricians and Gynecologists.

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Page last reviewed October 2011

Internet Citation: Section 2. Recommendations for Adults (continued): Guide to Clinical Preventive Services, 2012. October 2011. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide2012/section2a.html