Section 2. Recommendations for Adults (continued)

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.

Illicit Drug Use

Title Screening for Illicit Drug Use
Population Adolescents1, adults, and pregnant women not previously identified as users of illicit drugs
Recommendation No 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 Harms The 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 Practice Clinicians should be alert to the signs and symptoms of illicit drug use in patients.
Treatment More 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.

1For adolescents, see also Illicit and Prescription Drug Use in Children and Adolescents, Counseling.

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/.

 Impaired Visual Acuity in Older Adults1

Title Screening for Impaired Visual Acuity in Older Adults1
Population Adults age 65 and older
Recommendation No 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 Tests Visual 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 Harms There 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 Recommendations Recommendations 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/.

Intimate Partner Violence and Elderly Abuse

Title Screening for Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults
Population Asymptomatic women of childbearing age Elderly or vulnerable adults
Recommendation Screen women for intimate partner violence (IPV), and provide or refer women who screen positive to intervention services.
Grade: B
No recommendation.
Grade: I
Risk Assessment While all women are at potential risk for abuse, factors that elevate risk include young age, substance abuse, marital difficulties, and economic hardships.
Interventions Adequate evidence from randomized trials support a variety of interventions for women of childbearing age that can be delivered or referred by primary care, including counseling, home visits, information cards, referrals to community services, and mentoring support. Depending on the type of intervention, these services may be provided by clinicians, nurses, social workers, nonclinician mentors, or community workers.
Balance of Benefits and Harms Screening and interventions for IPV in women of childbearing age are associated with moderate health improvements through the reduction of exposure to abuse, physical and mental harms, and mortality. The associated harms are deemed no greater than small. Therefore, the overall net benefit is moderate. The USPSTF was not able to estimate the magnitude of net benefit for screening all elderly or vulnerable adults (i.e., adults who are physically or mentally dysfunctional) for abuse and neglect because there were no studies on the accuracy, effectiveness, or harms of screening in this population.
Other Relevant USPSTF Recommendations The USPSTF has made recommendations on screening for depression in adults and screening and counseling to reduce alcohol misuse in adults. 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/.

Lipid Disorders in Adults

Title Screening for Lipid Disorders in Adults
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
Recommendation Screen for lipid disorders.
Grade: A
Screen for lipid disorders.
Grade: B
No recommendation for or against screening
Grade: C
Risk Assessment Consideration 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 Tests The 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.

Interventions Drug 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 Harms The 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 harms The 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 Recommendations The 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/.

Lung Cancer

Title Screening for Lung Cancer
Population Asymptomatic adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit smoking within the past 15 years.
Recommendation Screen annually for lung cancer with low-dose computed tomography.
Discontinue screening when the patient has not smoked for 15 years.
Grade: B
Risk Assessment Age, total cumulative exposure to tobacco smoke, and years since quitting smoking are the most important risk factors for lung cancer. Other risk factors include specific occupational exposures, radon exposure, family history, and history of pulmonary fibrosis or chronic obstructive lung disease.
Screening Tests Low-dose computed tomography has high sensitivity and acceptable specificity for detecting lung cancer in high-risk persons and is the only currently recommended screening test for lung cancer.
Treatment Non–small cell lung cancer is treated with surgical resection when possible and also with radiation and chemotherapy.
Balance of Benefits and Harms Annual screening for lung cancer with low-dose computed tomography is of moderate net benefit in asymptomatic persons who are at high risk for lung cancer based on age, total cumulative exposure to tobacco smoke, and years since quitting smoking.
Other Relevant USPSTF Recommendations The USPSTF has made recommendations on counseling and interventions to prevent tobacco use and tobacco-caused 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/.

Menopausal Hormone Therapy

Title Menopausal Hormone Therapy for the Primary Prevention of Chronic Conditions
Population Postmenopausal women Postmenopausal women who have had a hysterectomy
Recommendation Do not prescribe combined estrogen and progestin for the prevention of chronic conditions.
Grade: D
Do not prescribe estrogen for the prevention of chronic conditions.
Grade: D
Risk Assessment This recommendation applies to the average-risk population. Risk factors for a specific chronic disease or individual characteristics that affect the likelihood of a specific therapy-associated adverse event may cause a woman's net balance of benefits and harms to differ from that of the average population.
Preventive Medications Although combined estrogen and progestin therapy (specifically, oral conjugated equine estrogen, 0.625 mg/d, plus medroxyprogesterone acetate, 2.5 mg/d) decreases the risk for fractures in postmenopausal women, there is an accompanying increased risk for serious adverse events, such as stroke, invasive breast cancer, dementia, gallbladder disease, deep venous thrombosis, and pulmonary embolism.

Estrogen therapy (specifically, oral conjugated equine estrogen, 0.625 mg/d) decreases the risk for fractures and has a small effect on the risk for invasive breast cancer, but it is also associated with important harms, such as an increased likelihood of stroke, deep venous thrombosis, and gallbladder disease.

Neither combined estrogen and progestin therapy nor estrogen alone reduces the risk for coronary heart disease in postmenopausal women.

Balance of Benefits and Harms The chronic disease prevention benefits of combined estrogen and progestin do not outweigh the harms in most postmenopausal women. The chronic disease prevention benefits of estrogen are unlikely to outweigh the harms in most postmenopausal women who have had a hysterectomy.
Other Relevant USPSTF Recommendations The USPSTF has made recommendations on screening for osteoporosis and the use of preventive medications for breast cancer, as well as other relevant interventions for the primary or secondary prevention of chronic diseases in women, such as medications for cardiovascular disease and screening for coronary heart disease, high blood pressure, lipid disorders, colorectal cancer, breast cancer, and dementia. 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/.

Motor Vehicle Occupant Restraints

Title Primary Care Counseling for Proper Use of Motor Vehicle Occupant Restraints
Population General primary care population
Recommendation No recommendation.
Grade I (Insufficient Evidence)
Interventions There 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 Practice Current 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 Services The 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/.

Obesity in Adults

Title Screening for and Management Of Obesity In Adults
Population Adults aged 18 years or older
Recommendation Screen for obesity. Patients with a body mass index (BMI) of 30 kg/m2 or higher should be offered or referred to intensive, multicomponent behavioral interventions.
Grade: B
Screening Tests Body mass index is calculated from the measured weight and height of an individual. Recent evidence suggests that waist circumference may be an acceptable alternative to BMI measurement in some patient subpopulations.
Timing of Screening No evidence was found about appropriate intervals for screening.
Interventions Intensive, multicomponent behavioral interventions for obese adults include the following components:
  • Behavioral management activities, such as setting weight-loss goals
  • Improving diet or nutrition and increasing physical activity
  • Addressing barriers to change
  • Self-monitoring
  • Strategizing how to maintain lifestyle changes
Balance of Harms and Benefits Adequate evidence indicates that intensive, multicomponent behavioral interventions for obese adults can lead to weight loss, as well as improved glucose tolerance and other physiologic risk factors for cardiovascular disease.

Inadequate evidence was found about the effectiveness of these interventions on long-term health outcomes (for example, mortality, cardiovascular disease, and hospitalizations).

Adequate evidence indicates that the harms of screening and behavioral interventions for obesity are small. Possible harms of behavioral weight-loss interventions include decreased bone mineral density and increased fracture risk, serious injuries resulting from increased physical activity, and increased risk for eating disorders.

Other Relevant USPSTF Recommendations Recommendations on screening for obesity in children and adolescents can be found 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/.

Oral Cancer

Title Screening for Oral Cancer
Population Asymptomatic adults
Recommendation No 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 Tests Direct 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.
Interventions Patients 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 Recommendations The 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/.

Osteoporosis

Title Screening for Osteoporosis
Population Women age ≥65 years without previous known fractures or secondary causes of osteoporosis Women 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 factors Men without previous known fractures or secondary causes of osteoporosis
Recommendation Screen for osteoporosis.
Grade: B
No recommendation
Grade: I
(insufficient evidence)
Risk Assessment As 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 Tests Current diagnostic and treatment criteria rely on dual-energy x-ray absorptiometry of the hip and lumbar spine.
Timing of Screening Evidence is lacking about optimal intervals for repeated screening.
Intervention In 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/.

 Ovarian Cancer

Title Screening for Ovarian Cancer
Population Asymptomatic women without known genetic mutations that increase risk for ovarian cancer
Recommendation Do 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 Tests Transvaginal ultrasonography and serum cancer antigen (CA)–125 testing are the most commonly suggested screening modalities.
Treatments Treatment 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 Recommendations The 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/.

Peripheral Artery Disease

Title Screening for Peripheral Artery Disease and Cardiovascular Disease Risk Assessment with the Ankle Brachial Index in Adults
Population Asymptomatic adults without a known diagnosis of peripheral artery disease (PAD), cardiovascular disease, severe chronic kidney disease, or diabetes
Recommendation No recommendation.
Grade: I statement
Risk Assessment Important risk factors for PAD include older age, diabetes, smoking, hypertension, high cholesterol level, obesity, and physical inactivity. Peripheral artery disease is more common in men than women and occurs at an earlier age in men.
Screening Tests Resting ankle–brachial index (ABI) is the most commonly used test in screening for and detection of PAD in clinical settings. It is calculated as the systolic blood pressure obtained at the ankle divided by the systolic blood pressure obtained at the brachial artery while the patient is lying down. Physical examination has low sensitivity for detecting mild PAD in asymptomatic persons.
Balance of Benefits and Harms Evidence on screening for PAD with the ABI in asymptomatic adults with no known diagnosis of cardiovascular disease or diabetes is insufficient; therefore, the balance of benefits and harms cannot be determined.
Other Relevant USPSTF Recommendations The USPSTF has made recommendations on using nontraditional risk factors, including the ABI, in screening for coronary heart 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/.

Prostate Cancer

Title Screening for Prostate Cancer
Population Adult males
Recommendation Do not use prostate-specific antigen (PSA)-based screening for prostate cancer.
Grade: D
Screening Tests Contemporary recommendations for prostate cancer screening all incorporate the measurement of serum PSA levels; other methods of detection, such as digital rectal examination or ultrasonography, may be included.

There is convincing evidence that PSA-based screening programs result in the detection of many cases of asymptomatic prostate cancer, and that a substantial percentage of men who have asymptomatic cancer detected by PSA screening have a tumor that either will not progress or will progress so slowly that it would have remained asymptomatic for the man's lifetime (i.e., PSA-based screening results in considerable overdiagnosis).

Interventions Management strategies for localized prostate cancer include watchful waiting, active surveillance, surgery, and radiation therapy.

There is no consensus regarding optimal treatment.

Balance of harms and benefits The reduction in prostate cancer mortality 10 to 14 years after PSA-based screening is, at most, very small, even for men in the optimal age range of 55 to 69 years.

The harms of screening include pain, fever, bleeding, infection, and transient urinary difficulties associated with prostate biopsy, psychological harm of false-positive test results, and overdiagnosis.

Harms of treatment include erectile dysfunction, urinary incontinence, bowel dysfunction, and a small risk for premature death.

Because of the current inability to reliably distinguish tumors that will remain indolent from those destined to be lethal, many men are being subjected to the harms of treatment for prostate cancer that will never become symptomatic.

The benefits of PSA-based screening for prostate cancer do not outweigh the harms.

Relevant USPSTF Recommendations Recommendations on screening for other types of cancer can be found at http://www.uspreventiveservicestaskforce.org.

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Page last reviewed June 2014
Internet Citation: Section 2. Recommendations for Adults (continued): 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/section2c.html