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 Illicit Drug Use

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

PopulationAdolescents, adults, and pregnant women not previously identified as users of illicit drugs
RecommendationNo recommendation.
Grade: I (Insufficient Evidence).
Screening Tests

Toxicologic tests of blood or urine can provide objective evidence of drug use, but do not distinguish occasional users from impaired drug users.

Valid and reliable standardized questionnaires are available to screen adolescents and adults for drug use or misuse.

There is insufficient evidence to evaluate the clinical utility of these instruments when widely applied in primary care settings.

Balance of Benefits and HarmsThe USPSTF concludes that for adolescents, adults, and pregnant women, the evidence is insufficient to determine the benefits and harms of screening for illicit drug use
Suggestions for PracticeClinicians should be alert to the signs and symptoms of illicit drug use in patients.
TreatmentMore evidence is needed on the effectiveness of primary care office-based treatments for illicit drug use/dependence.
Other Relevant USPSTF
Recommendations
The USPSTF recommendation for screening and counseling interventions to reduce alcohol misuse by adults and pregnant women can be found at http://www.uspreventiveservicestaskforce.org/uspstf/uspsdrin.htm.

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/.

 

Screening for Impaired Visual Acuity in Older Adults1

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

PopulationAdults age 65 and older
RecommendationNo recommendation.
Grade: I (Insufficient Evidence)
Risk Assessment

Older age is an important risk factor for most types of visual impairment.

Additional risk factors include:

  • Smoking, alcohol use, exposure to ultraviolet light, diabetes, corticosteroids, and black race (for cataracts).
  • Smoking, family history, and white race (for age-related macular degeneration).
Screening TestsVisual acuity testing (for example, the Snellen eye chart) is the usual method for screening for impairment of visual acuity in the primary care setting.

Screening questions are not as accurate as a visual acuity test.
Balance of Benefits and HarmsThere is no direct evidence that screening for vision impairment in older adults in primary care settings is associated with improved clinical outcomes.

There is evidence that early treatment of refractive error, cataracts, and age-related macular degeneration may lead to harms that are small.

The magnitude of net benefit for screening cannot be calculated because of a lack of evidence.
Other Relevant USPSTF RecommendationsRecommendations on screening for glaucoma and on screening for hearing loss in older adults can be accessed at http://www.uspreventiveservicestaskforce.org.

1 This recommendation does not cover screening for glaucoma.

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/.

 

Screening for Lipid Disorders in Adults

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

Population
  • Men age 35 years and older
  • Women age 45 years and older who are at increased risk for coronary heart disease (CHD)
  • Men ages 20 to 35 years who are at increased risk for CHD
  • Women ages 20 to 45 years who are at increased risk for CHD
  • Men ages 20 to 35 years
  • Women age 20 years and older who are not at increased risk for CHD
RecommendationScreen for lipid disorders.
Grade: A
Screen for lipid disorders.
Grade: B
No recommendation for or against screening
Grade: C
Risk AssessmentConsideration of lipid levels along with other risk factors allows for an accurate estimation of CHD risk. Risk factors for CHD include diabetes, history of previous CHD or atherosclerosis, family history of cardiovascular disease, tobacco use, hypertension, and obesity (body mass index ≥30 kg/m2).
Screening TestsThe preferred screening tests for dyslipidemia are measuring serum lipid (total cholesterol, high-density and low-density lipoprotein cholesterol) levels in non-fasting or fasting samples. Abnormal screening results should be confirmed by a repeated sample on a separate occasion, and the average of both results should be used for risk assessment.
Timing of Screening

The optimal interval for screening is uncertain. Reasonable options include every 5 years, shorter intervals for people who have lipid levels close to those warranting therapy, and longer intervals for those not at increased risk who have had repeatedly normal lipid levels.

An age at which to stop screening has not been established. Screening may be appropriate in older people who have never been screened; repeated screening is less important in older people because lipid levels are less likely to increase after age 65 years.

InterventionsDrug therapy is usually more effective than diet alone in improving lipid profiles, but choice of treatment should consider overall risk, costs of treatment, and patient preferences. Guidelines for treating lipid disorders are available from the National Cholesterol Education Program of the National Institutes of Health (http://www.nhlbi.nih.gov/about/ncep/).
Balance of Benefits and HarmsThe benefits of screening for and treating lipid disorders in men age 35 and older and women age 45 and older at increased risk for CHD substantially outweigh the potential harmsThe benefits of screening for and treating lipid disorders in young adults at increased risk for CHD moderately outweigh the potential harms.The net benefits of screening for lipid disorders in young adults not at increased risk for CHD are not sufficient to make a general recommendation.
Other Relevant USPSTF RecommendationsThe USPSTF has made recommendations on screening for lipid disorders in children and screening for carotid artery stenosis, coronary heart disease, high blood pressure, 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/.

 

Screening for Lung Cancer

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

PopulationAsymptomatic persons
RecommendationNo recommendation.
Grade: I (Insufficient Evidence)
Risk AssessmentCigarette smoking is the major risk factor for lung cancer. Other risk factors include family history, chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, environmental radon exposure, passive smoking, asbestos exposure, and certain occupational exposures.
Screening TestsScreening with low dose computerized tomography, chest x-ray, or sputum cytology can detect lung cancer at earlier stages; however, as of 2004, there is insufficient evidence that any screening strategy for lung cancer decreases mortality.
Balance of Benefits and Harms

As of 2004, the benefit of screening for lung cancer has not been established in any group, including asymptomatic high-risk populations such as older smokers. The balance of Benefits and Harms becomes increasingly unfavorable for persons at lower risk, such as nonsmokers.

Because of the invasive nature of diagnostic testing and the possibility of a high number of false-positive results in certain populations, there is potential for significant harms from screening.

Therefore, the USPSTF could not determine the balance between the benefits and harms of screening for lung cancer.

Other Relevant USPSTF RecommendationsThe USPSTF has made recommendations on screening for many other types of 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/.

 

Primary Care Counseling for Proper Use of Motor Vehicle Occupant Restraints

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

PopulationGeneral primary care population
RecommendationNo recommendation.
Grade I (Insufficient Evidence)
InterventionsThere is good evidence that community and public health interventions, including legislation, law enforcement campaigns, car seat distribution campaigns, media campaigns, and other community-based interventions, are effective in improving the proper use of car seats, booster seats, and seat belts.
Suggestions for PracticeCurrent evidence is insufficient to assess the incremental benefit of counseling in primary care settings, beyond increases related to other interventions, in improving rates of proper use of motor vehicle occupant restraints.

Linkages between primary care and community interventions are critical for improving proper car seat, booster seat, and seat belt use.
Relevant Recommendations from the Guide to Community Preventive ServicesThe Community Preventive Services Task Force has reviewed evidence of the effectiveness of selected population-based interventions to reduce motor vehicle occupant injuries, focusing on three strategic areas:
  • Increasing the proper use of child safety seats.
  • Increasing the use of safety belts.
  • Reducing alcohol-impaired driving.
Multiple interventions in these areas have been recommended. Recommendations can be accessed at http://www.thecommunityguide.org/mvoi/

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/.

 

Screening for Oral Cancer

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

PopulationAsymptomatic adults
RecommendationNo recommendation.
Grade I (Insufficient Evidence)
Risk Assessment

Tobacco use in all forms is the biggest risk factor for oral cancer. Alcohol abuse combined with tobacco use increases risk.

Clinicians should be alert to the possibility of oral cancer when treating patients who use tobacco or alcohol.

Screening TestsDirect inspection and palpation of the oral cavity is the most commonly recommended method of screening for oral cancer, although there are little data on the sensitivity and specificity of this method. Screening techniques other than inspection and palpation are being evaluated but are still experimental.
InterventionsPatients should be encouraged to not use tobacco and to limit alcohol use in order to decrease their risk for oral cancer, as well as for heart disease, stroke, lung cancer, and cirrhosis.
Balance of Benefits and Harms

There is no good-quality evidence that screening for oral cancer leads to improved health outcomes for either high-risk adults (i.e., adults older than age 50 years who use tobacco) or average-risk adults in the general population. It is unlikely that controlled trials of screening for oral cancer will ever be conducted in the general population because of the very low incidence of oral cancer in the United States. There is also no evidence of the harms of screening.

As a result, the USPSTF could not determine the balance between the benefits and harms of screening for oral cancer.

Relevant USPSTF RecommendationsThe USPSTF has made recommendations on screening for many other types of 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/.

 

Screening for Osteoporosis

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

PopulationWomen age ≥65 years without previous known fractures or secondary causes of osteoporosisWomen age <65 years whose 10-year fracture risk is equal to or greater than that of a 65-year-old white woman without additional risk factorsMen without previous known fractures or secondary causes of osteoporosis
RecommendationScreen for osteoporosis.
Grade: B
No recommendation
Grade: I
(insufficient evidence)
Risk AssessmentAs many as 1 in 2 postmenopausal women and 1 in 5 older men are at risk for an osteoporosis-related fracture. Osteoporosis is common in all racial groups but is most common in white persons. Rates of osteoporosis increase with age. Elderly people are particularly susceptible to fractures. According to the FRAX fracture risk assessment tool, available at http://www.shef.ac.uk/FRAX/, the 10-year fracture risk in a 65-year-old white woman without additional risk factors is 9.3%.
Screening TestsCurrent diagnostic and treatment criteria rely on dual-energy x-ray absorptiometry of the hip and lumbar spine.
Timing of ScreeningEvidence is lacking about optimal intervals for repeated screening.
InterventionIn addition to adequate calcium and vitamin D intake and weight-bearing exercise, multiple U.S. Food and Drug Administration–approved therapies reduce fracture risk in women with low bone mineral density and no previous fractures, including bisphosphonates, parathyroid hormone, raloxifene, and estrogen. The choice of treatment should take into account the patient's clinical situation and the tradeoff between benefits and harms. Clinicians should provide education about how to minimize drug side effects.
Suggestions for Practice Regarding the I Statement for Men

Clinicians should consider:

  • potential preventable burden: increasing because of the aging of the U.S. population
  • potential harms: likely to be small, mostly opportunity costs
  • current practice: routine screening of men not widespread
  • costs: additional scanners required to screen sizeable populations

Men most likely to benefit from screening have a 10-year risk for osteoporotic fracture equal to or greater than that of a 65-year-old white woman without risk factors. However, current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men.

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/.

 

Screening for Ovarian Cancer

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

PopulationAsymptomatic women without known genetic mutations that increase risk for ovarian cancer
RecommendationDo not screen for ovarian cancer.
Grade: D
Risk Assessment

Women with BRCA1 and BRCA2 genetic mutations, the Lynch syndrome (hereditary nonpolyposis colon cancer), or a family history of ovarian cancer are at increased risk for ovarian cancer.

Women with an increased-risk family history should be considered for genetic counseling to further evaluate their potential risks. “Increased-risk family history” generally means having 2 or more first- or second-degree relatives with a history of ovarian cancer or a combination of breast and ovarian cancer; for women of Ashkenazi Jewish descent, it means having a first-degree relative (or 2 second-degree relatives on the same side of the family) with breast or ovarian cancer.

Screening TestsTransvaginal ultrasonography and serum cancer antigen (CA)–125 testing are the most commonly suggested screening modalities.
TreatmentsTreatment of ovarian carcinoma includes surgical treatment (debulking) and intraperitoneal or systemic chemotherapy.
Balance of Benefits and Harms

Annual screening with transvaginal ultrasonography and serum CA-125 testing in women does not decrease ovarian cancer mortality.

Screening for ovarian cancer can lead to important harms, including major surgical interventions in women who do not have cancer.

Therefore, the harms of screening for ovarian cancer outweigh the benefits.

Relevant USPSTF RecommendationsThe USPSTF has made a recommendation on genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility. This recommendation is 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/.

 

Screening for Pancreatic Cancer

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

PopulationAsymptomatic adults
RecommendationDo not screen for pancreatic cancer.
Grade: D
Risk AssessmentPersons with hereditary pancreatitis may have a higher lifetime risk for developing pancreatic cancer. However, the USPSTF did not review the effectiveness of screening these patients.
Balance of Benefits and HarmsThe USPSTF found no evidence that screening for pancreatic cancer is effective in reducing mortality. There is a potential for significant harm due to the very low prevalence of pancreatic cancer, limited accuracy of available screening tests, the invasive nature of diagnostic tests, and the poor outcomes of treatment. As a result, the USPSTF concluded that the harms of screening for pancreatic cancer exceed any potential benefits.
Other Relevant USPSTF RecommendationsThe USPSTF has made recommendations on screening for many other types of 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/.

 

Screening for Peripheral Arterial Disease

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

PopulationAsymptomatic adults
RecommendationDo not screen for peripheral arterial disease (PAD).
Grade: D
Risk AssessmentRisk factors associated with PAD include older age, cigarette smoking, diabetes mellitus, hypercholesterolemia, hypertension, and possibly genetic factors.
Screening TestsAnkle brachial index (ABI) is a simple and accurate noninvasive test for the screening and diagnosis of PAD. The ABI has demonstrated better accuracy than other methods of screening, including history taking, questionnaires, and palpation of peripheral pulses. An ABI value of less than 0.90 (95% sensitive and specific for angiographic PAD) is strongly associated with limitations in lower extremity functioning and physical activity tolerance.
InterventionsSmoking cessation and physical activity training also increase maximal walking distance among men with early PAD.
Balance of Benefits and Harms

Screening for PAD in asymptomatic adults in the general population has few or no benefits, because the prevalence of PAD in this group is low and because there is little evidence that treatment of PAD at this asymptomatic stage of disease, beyond treatment based on standard cardiovascular risk assessment, improves health outcomes.

Screening asymptomatic adults with the ankle brachial index could lead to some small degree of harm, including false-positive results and unnecessary workups. Therefore, the harms of routine screening for PAD exceed the benefits for asymptomatic adults.

Other Relevant USPSTF RecommendationsThe USPSTF has made recommendations on screening for carotid artery stenosis, coronary heart disease, high blood pressure, and lipid disorders. 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/.

 

Screening for Rh (D) Incompatibility

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

PopulationPregnant women presenting at the first visit for prenatal careUnsensitized Rh (D)-negative women at 24–28 weeks' gestation
RecommendationPerform Rh (D) blood typing and antibody testing.
Grade: A
Repeat Rh (D) blood typing and antibody testing.
Grade: B

 
Screening TestsRh (D) blood typing and antibody testing prevents maternal sensitization and improves outcomes for newborns.
Timing of ScreeningRepeated antibody testing in unsensitized Rh (D)-negative women, unless the father is also known to be Rh (D)-negative, provides additional benefit over a single test at the first prenatal visit.
Interventions
  • Administration of a full (300 µg) dose of Rh (D) immunoglobulin is recommended for all unsensitized Rh (D)-negative women after repeated antibody testing at 24–28 weeks' gestation.
  • If an Rh (D)-positive or weakly Rh (D)-positive infant is delivered, a dose of Rh (D) immunoglobulin should be repeated postpartum, preferably within 72 hours after delivery.
  • Unless the biological father is known to be Rh (D)-negative, a full dose of Rh (D) immunoglobulin is recommended for all unsensitized Rh (D)-negative women after amniocentesis and after induced or spontaneous abortion; however, if the pregnancy is less than 13 weeks, a 50 µg dose is sufficient.
Balance of Benefits and HarmsThe benefits of Rh (D) blood typing and antibody testing at the first prenatal visit substantially outweigh any potential harms.The benefits of repeated testing substantially outweigh any potential harms.
Other Relevant USPSTF RecommendationsThe USPSTF has made recommendations on many types of obstetric screenings. 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/.

Return to Contents
Proceed to Next Section

Current as of 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. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/section2c.html