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.

 

Behavioral Counseling to Prevent Sexually Transmitted Infections

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

PopulationAll sexually active adolescentsAdults at increased risk for STIsNon-sexually-active adolescents and adults not at increased risk for STIs
RecommendationOffer 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.
InterventionsCharacteristics of successful high-intensity counseling interventions:
  • Multiple sessions of counseling.
  • Frequently delivered in group settings.
Suggestions for PracticeHigh-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 RecommendationsUSPSTF 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/.

 

Screening for Skin Cancer1

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

PopulationAdult general population1
RecommendationNo 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 TestsThere 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 IntervalsNot applicable.
Suggestions for PracticeClinicians 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/.

 

Screening for Suicide Risk

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

PopulationGeneral population
RecommendationNo recommendation
Grade: I (Insufficient Evidence)
Risk AssessmentThe 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 TestsThere 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.
InterventionsThere 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 RecommendationsThe 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/.

 

Screening for Syphilis Infection

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

PopulationPersons at increased risk for syphilis infectionAsymptomatic persons who are not at increased risk for syphilis infection
RecommendationScreen for syphilis infection.
Grade: A
Do not screen for syphilis infection.
Grade: D
Risk AssessmentPopulations at increased risk for syphilis infection include men who have sex with men and engage in high-risk sexual behavior, commercial sex workers, persons who exchange sex for drugs, and those in adult correctional facilities. Persons diagnosed with other sexually transmitted diseases may be more likely than others to engage in high-risk behavior, placing them at increased risk.
Screening TestsScreening for syphilis infection is a two-step process that involves an initial nontreponemal test (Venereal Disease Research Laboratory or Rapid Plasma Reagin), followed by a confirmatory treponemal test (fluorescent treponemal antibody absorbed or T. pallidum particle agglutination).
Timing of ScreeningThe optimal screening interval in average- and high-risk persons has not been determined.
InterventionsPreferred treatment consists of antibiotic therapy with parenterally administered penicillin G.
Balance of Benefits and HarmsScreening may result in potential harms (such as false-positive results, unnecessary anxiety to the patient, and harms of antibiotic use). However, the benefits of screening persons at increased risk for syphilis infection substantially outweigh the potential harms.Given the low incidence of infection in the general population and the consequent low yield of such screening, the potential harms of screening (i.e., opportunity costs, false-positive tests, and labeling) in a low-incident population outweigh the benefits.
Other Relevant USPSTF RecommendationsThe USPSTF has made other recommendations on screening for sexually transmitted infections, including screening for syphilis infection in 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/.

 

Screening for Syphilis Infection in Pregnancy

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

PopulationAll pregnant women
RecommendationScreen 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 ScreeningTest 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 RecommendationsRecommendations on screening for other STDs, and on counseling for STDs, can be found at http://www.uspreventiveservicestaskforce.org.

 

Screening for Testicular Cancer

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

PopulationAdolescent and adult males
RecommendationDo not screen
Grade: D
Screening TestsThere 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.
InterventionsManagement 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 RecommendationsRecommendations 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/.

 

Screening for Thyroid Disease

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

PopulationAsymptomatic adults
RecommendationNo recommendation
Grade: I (Insufficient Evidence)
Risk AssessmentPeople at higher risk for thyroid dysfunction include the elderly, postpartum women, persons with high levels of radiation exposure (>20 mGy), and patients with Down syndrome.
Screening TestsScreening for thyroid dysfunction can be performed using the medical history, physical examination, or any of several serum thyroid function tests. Thyroid stimulating hormone (TSH) is usually recommended because it can detect abnormalities before other tests become abnormal.
InterventionsA potential benefit of treating subclinical thyroid disease is to prevent the spontaneous development of overt hypothyroidism or hyperthyroidism, but this potential benefit has not been well studied in clinical trials as of 2004.
Balance of Benefits and Harms

There is fair evidence that the TSH test can detect subclinical thyroid disease in persons without symptoms of thyroid dysfunction, but poor evidence that treatment improves clinically important outcomes in adults with screen-detected thyroid disease. There is the potential for harm caused by false-positive screening tests; however, the magnitude of harm is not known. There is good evidence that overtreatment with levothyroxine occurs in a substantial proportion of patients, but the long-term harmful effects of overtreatment are not known.

As a result, the USPSTF could not determine the balance of benefits and harms of screening asymptomatic adults for thyroid disease.

Other Relevant USPSTF RecommendationsThe USPSTF has also made recommendations on screening for diabetes, hemochromatosis, iron deficiency anemia, and obesity. 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/.

 

Counseling and Interventions to Prevent Tobacco Use and Tobacco-Caused Disease in Adults and Pregnant Women

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

PopulationAdults age ≥ 18 yearsPregnant women of any age
RecommendationAsk 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.

PharmacotherapyCombination 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 RecommendationsRecommendations 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/.

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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/guide2012/section2d.html