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.

Sexually Transmitted Infections

Title Behavioral Counseling to Prevent Sexually Transmitted Infections
Population All sexually active adolescents Adults at increased risk for STIs Non-sexually-active adolescents and adults not at increased risk for STIs
Recommendation Offer high-intensity counseling
Grade: B
Offer high-intensity counseling
Grade: B
No recommendation
Grade: I (Insufficient Evidence)
Risk Assessment All sexually active adolescents are at increased risk for STIs and should be offered counseling.

Adults should be considered at increased risk and offered counseling if they have:

  • Current STIs or have had an STI within the past year.
  • Multiple sexual partners.
In communities or populations with high rates of STIs, all sexually active patients in non-monogamous relationships may be considered at increased risk.
Interventions Characteristics of successful high-intensity counseling interventions:
  • Multiple sessions of counseling.
  • Frequently delivered in group settings.
Suggestions for Practice High-intensity counseling may be delivered in primary care settings, or in other sectors of the health system and community settings after referral.

Delivery of this service may be greatly improved by strong linkages between the primary care setting and community.
Evidence is limited regarding counseling for adolescents who are not sexually active. Intensive counseling for all adolescents in order to reach those who are at risk but have not been appropriately identified is not supported by current evidence. Evidence is lacking regarding the effectiveness of counseling for adults not at increased risk for STIs.
Other Relevant USPSTF Recommendations USPSTF recommendations on screening for chlamydial infection, gonorrhea, genital herpes, hepatitis B, hepatitis C, HIV, and syphilis, and on counseling for HIV, can be found at http://www.uspreventiveservicestaskforce.org.

Abbreviation: STI = Sexually Transmitted Infection

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/.

Skin Cancer (Counseling)

Title Behavioral Counseling to Prevent Skin Cancer
Population Children, adolescents, and young adults aged 10 to 24 years with fair skin Adults older than age 24 years
Recommendation Provide counseling about minimizing exposure to ultraviolet radiation to reduce risk for skin cancer.
Grade: B
No recommendation.
Grade: I
(Insufficient Evidence)
Risk Assessment Individuals with a fair skin type are at greatly increased risk for skin cancer. Fair skin type can be defined by eye and hair color; freckling; and historical factors, such as usual reaction to sun exposure (always or usually burning or infrequently tanning).
Behavioral Counseling Effective counseling interventions were generally of low intensity and almost entirely accomplished within the primary care visit.

Successful counseling interventions used cancer prevention or appearance-focused messages (such as stressing the aging effect of ultraviolet radiation on the skin) to reach specific audiences.

Interventions Behavior change interventions are aimed at reducing ultraviolet radiation exposure. Sun-protective behaviors include the use of a broad-spectrum sunscreen with a sun protection factor ≥15, wearing hats or other shade-protective clothing, avoiding the outdoors during midday hours (10 a.m. to 3 p.m.), and avoiding the use of indoor tanning.
Balance of Harms and Benefits For children, adolescents, and young adults aged 10 to 24 years with fair skin, primary care counseling interventions can increase the use of sun-protective behaviors by a moderate amount, with no appreciable harms. For adults older than 24 years, there is inadequate evidence to determine the effect of counseling on the use of sun-protective behaviors.
Other Relevant USPSTF Recommendations The USPSTF has made recommendations on screening for skin 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/.

Skin Cancer (Screening)

Title Screening for Skin Cancer
Population Adult general population1
Recommendation No recommendation
Grade: I (Insufficient Evidence)
Risk Assessment Skin cancer risks: family history of skin cancer, considerable history of sun exposure and sunburn.

Groups at increased risk for melanoma:

  • Fair-skinned men and women over the age of 65 years.
  • Patients with atypical moles.
  • Patients with more than 50 moles.
Screening Tests There is insufficient evidence to assess the balance of benefits and harms of whole body skin examination by a clinician or patient skin self-examination for the early detection of skin cancer.
Screening Intervals Not applicable.
Suggestions for Practice Clinicians should remain alert for skin lesions with malignant features that are noted while performing physical examinations for other purposes. Features associated with increased risk for malignancy include: asymmetry, border irregularity, color variability, diameter >6mm ("A," "B," "C," "D"), or rapidly changing lesions. Suspicious lesions should be biopsied.
Other Relevant Recommendations from the USPSTF and the Community Preventive Services Task Force The USPSTF has reviewed the evidence for counseling to prevent skin cancer. The recommendation statement and supporting documents can be accessed at http://www.uspreventiveservicestaskforce.org.

The Community Preventive Services Task Force has reviewed the evidence on public health interventions to reduce skin cancer. The recommendations can be accessed at http://www.thecommunityguide.org.

1 The USPSTF does not examine outcomes related to surveillance of patients with familial syndromes, such as familial atypical mole and melanoma (FAM-M) syndrome.

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/.

Suicide Risk

Title Screening for Suicide Risk
Population General population
Recommendation No recommendation
Grade: I (Insufficient Evidence)
Risk Assessment The strongest risk factors for attempted suicide include mood disorders or other mental disorders, comorbid substance abuse disorders, history of deliberate self-harm, and a history of suicide attempts. Deliberate self-harm refers to intentionally initiated acts of self-harm with a nonfatal outcome (including self-poisoning and self-injury). Suicide risk is assessed along a continuum ranging from suicidal ideation alone (relatively less severe) to suicidal ideation with a plan (more severe). Suicidal ideation with a specific plan of action is associated with a significant risk for attempted suicide.
Screening Tests There is limited evidence on the accuracy of screening tools to identify suicide risk in the primary care setting, including tools to identify those at high risk. The characteristics of the most commonly used screening instruments (Scale for Suicide Ideation, Scale for Suicide Ideation–Worst, and the Suicidal Ideation Questionnaire) have not been validated to assess suicide risk in primary care settings.
Interventions There is insufficient evidence to determine if treatment of persons at high risk for suicide reduces suicide attempts or mortality.
Balance of Benefits and Harms There is no evidence that screening for suicide risk reduces suicide attempts or mortality. There is insufficient evidence to determine if treatment of persons at high risk reduces suicide attempts or mortality. There are no studies that directly address the harms of screening and treatment for suicide risk.

As a result, the USPSTF could not determine the balance of benefits and harms of screening for suicide risk in the primary care setting.

Other Relevant USPSTF Recommendations The USPSTF has also made recommendations on screening for alcohol misuse, depression, and illicit drug use. These recommendations are available at http://www.uspreventiveservicestaskforce.org.

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

Syphilis (Pregnant Women)

Title Screening for Syphilis Infection in Pregnancy
Population All pregnant women
Recommendation Screen for syphilis infection.
Grade: A
Screening Tests Nontreponemal tests commonly used for initial screening include:
  • Venereal Disease Research Laboratory (VDRL)
  • Rapid Plasma Reagin (RPR)

Confirmatory tests include:

  • Fluorescent treponemal antibody absorbed (FTA-ABS)
  • Treponema pallidum particle agglutination (TPPA)
Timing of Screening Test all pregnant women at the first prenatal visit.
Other Clinical Considerations Most organizations recommend testing high-risk women again during the third trimester and at delivery. Groups at increased risk include:
  • Uninsured women
  • Women living in poverty
  • Sex workers
  • Illicit drug users
  • Those diagnosed with other sexually transmitted diseases (STDs)
  • Other women living in communities with high syphilis morbidity

Prevalence is higher in southern U.S. and in metropolitan areas and in Hispanic and African American populations.

Interventions The Centers for Disease Control and Prevention (CDC) recommends treatment with parenteral benzathine penicillin G. Women with penicillin allergies should be desensitized and treated with penicillin.

Consult the CDC for the most up-to-date recommendations: http://www.cdc.gov/std/treatment/

Other Relevant USPSTF Recommendations Recommendations on screening for other STDs, and on counseling for STDs, 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/.

 Testicular Cancer

Title Screening for Testicular Cancer
Population Adolescent and adult males
Recommendation Do not screen
Grade: D
Screening Tests There is inadequate evidence that screening asymptomatic patients by means of self-examination or clinician examination has greater yield or accuracy for detecting testicular cancer at more curable stages.
Interventions Management of testicular cancer consists of orchiectomy and may include other surgery, radiation therapy, or chemotherapy, depending on stage and tumor type. Regardless of disease stage, over 90% of all newly diagnosed cases of testicular cancer will be cured.
Balance of Benefits and Harms Screening by self-examination or clinician examination is unlikely to offer meaningful health benefits, given the very low incidence and high cure rate of even advanced testicular cancer.

Potential harms include false-positive results, anxiety, and harms from diagnostic tests or procedures.

Other Relevant USPSTF Recommendations Recommendations on screening for other types of cancer 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/.

Tobacco Use in Adults

Title Counseling and Interventions to Prevent Tobacco Use and Tobacco-Caused Disease in Adults and Pregnant Women
Population Adults age ≥ 18 years Pregnant women of any age
Recommendation Ask about tobacco use. Provide tobacco cessation interventions to those who use tobacco products.
Grade: A
Ask about tobacco use. Provide augmented pregnancy-tailored counseling for women who smoke.
Grade: A
Counseling The “5-A” framework provides a useful counseling strategy:
  1. Ask about tobacco use.
  2. Advise to quit through clear personalized messages.
  3. Assess willingness to quit.
  4. Assist to quit.
  5. Arrange follow-up and support.

Intensity of counseling matters: brief one-time counseling works; however, longer sessions or multiple sessions are more effective.

Telephone counseling “quit lines” also improve cessation rates.

Pharmacotherapy Combination therapy with counseling and medications is more effective than either component alone. FDA-approved pharmacotherapy includes nicotine replacement therapy, sustained-release bupropion, and varenicline. The USPSTF found inadequate evidence to evaluate the safety or efficacy of pharmacotherapy during pregnancy
Implementation Successful implementation strategies for primary care practice include:
  • Instituting a tobacco user identification system.
  • Promoting clinician intervention through education, resources, and feedback.
  • Dedicating staff to provide treatment, and assessing the delivery of treatment in staff performance evaluations.
Other Relevant USPSTF Recommendations Recommendations on other behavioral counseling topics are available at http://www.uspreventiveservicestaskforce.org/

Abbreviations: FDA = U.S. Food and Drug Administration; USPSTF = U.S. Preventive Services Task Force

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/.

Vitamin D and Calcium Supplementation to Prevent Fractures

Title Vitamin D and Calcium Supplementation to Prevent Fractures in Adults
Population Men or premenopausal women Community-dwelling postmenopausal women at doses of >400 IU of vitamin D3 and >1,000 mg of calcium Community-dwelling postmenopausal women at doses of ≤400 IU of vitamin D3 and ≤1,000 mg of calcium
Recommendation No recommendation. Grade: I statement No recommendation.
Grade: I statement
Do not supplement.
Grade: D recommendation
Preventive Medications Appropriate intake of vitamin D and calcium are essential to overall health. However, there is inadequate evidence to determine the effect of combined vitamin D and calcium supplementation on the incidence of fractures in men or premenopausal women.

There is adequate evidence that daily supplementation with 400 IU of vitamin D3 and 1,000 mg of calcium has no effect on the incidence of fractures in postmenopausal women.

There is inadequate evidence regarding the effect of higher doses of combined vitamin D and calcium supplementation on fracture incidence in community-dwelling postmenopausal women.

Balance of Benefits and Harms Evidence is lacking regarding the benefit of daily vitamin D and calcium supplementation for the primary prevention of fractures, and the balance of benefits and harms cannot be determined. Evidence is lacking regarding the benefit of daily supplementation with >400 IU of vitamin D3 and >1,000 mg of calcium for the primary prevention of fractures in postmenopausal women, and the balance of benefits and harms cannot be determined. Daily supplementation with ≤400 IU of vitamin D3 and ≤1,000 mg of calcium has no net benefit for the primary prevention of fractures.
Other Relevant USPSTF Recommendations 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/.

Vitamin Supplementation to Prevent Cardiovascular Disease and Cancer

Title Vitamin, Mineral, and Multivitamin Supplements for the Primary Prevention of Cardiovascular Disease and Cancer
Population Healthy adults without special nutritional needs. This recommendation does not apply to children, women who are pregnant or may become pregnant, or persons who are chronically ill or hospitalized or have a known nutritional deficiency.
Recommendation Multivitamins:
No recommendation.
Grade: I statement
Single- or paired-nutrient supplements:
No recommendation.
Grade: I statement
β-carotene or vitamin E:
Do not recommend.
Grade: D
Preventive Medications Evidence on supplementation with multivitamins to reduce the risk for cardiovascular disease or cancer is inadequate, as is the evidence on supplementation with individual vitamins, minerals, or functional pairs.

Supplementation with β-carotene or vitamin E does not reduce the risk for cardiovascular disease or cancer.

Balance of Benefits and Harms The evidence is insufficient to determine the balance of benefits and harms of supplementation with multivitamins for the prevention of cardiovascular disease or cancer. The evidence is insufficient to determine the balance of benefits and harms of supplementation with single or paired nutrients for the prevention of cardiovascular disease or cancer. There is no net benefit of supplementation with vitamin E or β-carotene for the prevention of cardiovascular disease or cancer.
Other Relevant USPSTF Recommendations The USPSTF has made several recommendations on the prevention of cardiovascular disease and cancer, including recommendations for smoking cessation; screening for lipid disorders, hypertension, diabetes, and cancer; obesity screening and counseling; and aspirin use. These recommendations are available at http://www.uspreventiveservicestaskforce.org.

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

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Current as of 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/section2d.html