Clinical Breast Examination
The USPSTF could not determine the benefits of clinical breast examination (CBE) alone or the incremental benefit of adding CBE to mammography (grade I recommendation). No screening trial has examined the benefits of CBE alone (without accompanying mammography). Four of the eight trials of screening used mammography alone, and four used mammog-raphy plus CBE. In the trials that used both methods, CBE detected 40% to 69% of breast cancers. It is not clear from the trials whether CBE contributed to the reduction in breast cancer mortality observed in some of the trials.
Breast Self-examination
A randomized trial from China failed to show a reduction in breast cancer mortality or an improvement in tumor stage at presentation in women receiving instruction in breast self-exam-ination.27 Results from a Russian trial were similar.28 In both trials, women who had been instructed in breast self-examination were more likely to seek medical advice for benign breast lesions.
Genetic Risk Assessment
In women whose family history suggests an increased risk of deleterious BRCA1 or BRCA2 mutations, the USPSTF recommends referral for genetic counseling and evaluation for BRCA testing (grade B recommendation). However, the USPSTF recommends against routine testing for breast cancer susceptibility genes (i.e., BRCA1 or BRCA2) or routine referral for genetic counseling in women whose family history does not suggest an increased risk of deleterious mutations in these genes (grade D recommendation). Such screening and counseling have few or no benefits and could have important adverse ethical, legal, social, and medical consequences.
Cancer Screening Measures That Are Not Recommended
The USPSTF recommended against screening for bladder, ovarian, pancreatic, and testicular cancers. In each case, the deciding factor was that screening and treatment caused serious, immediate harms, whereas evidence of a benefit was inconclusive. As with mammography for breast cancer, screening for these cancers is aimed at detection of early invasive disease, and treatment has substantial morbidity. This degree of morbidity is in contrast to that associated with screening for colonic polyps or cervical dysplasia, for which treatment is relatively safe and is aimed at preserving, rather than removing, the involved organ.
Table 9 Recommended and Strongly Recommended Measures for Cancer Prevention*
|
Service |
Recommendation Grade |
Candidates |
Comment |
|
Cervical cancer screening |
A |
Women who have been sexually active and have a cervix; begin screening within 3 yr of onset of sexual activity or at age 21 (whichever comes first) and screen at least every 3 yr, stopping at age 65 |
Reduces the risk of invasive cervical cancer and mortality from cervical cancer |
|
Colorectal cancer screening |
A |
Adults 50 yr and older (earlier in patients with a strong family history) |
Reduces the risk of invasive colon cancer and mortality from colon cancer |
|
Breast cancer screening |
B |
Women 40 yr and older |
Reduces mortality from breast cancer |
|
Breast cancer chemoprophylaxis |
B |
Women at high risk for developing breast cancer |
Reduces the incidence of invasive breast cancer |
*As per the United States Preventive Services Task Force [see Table 6].
Table 10 Recommended Preventive Noncancer Screening*
|
Condition |
Screening Measure |
Comments |
|
Abdominal aortic aneurysm |
Abdominal palpation, ultrasonography |
Men 65 to 70 yr of age who have ever smoked should be screened one time by ultrasonography |
|
Depression |
Standardized questionnaire |
In most trials, screening alone had nonsignificant effects on treatment rates and on clinical outcome; however, larger benefits were observed in studies in which the communication of screening results was coordinated with effective follow-up and treatment; in such settings, 110 patients would need to be screened to produce one additional remission after 6 mo of treatment |
|
Obesity |
Measurement of body mass index (BMI) |
Screening can identify obesity (BMI > 30 kg/m2); programs that combined diet and physical activity produced modest weight loss (6.4 lb on average for 1 yr or more); most trials did not report the proportion of subjects who lost weight |
|
Osteoporosis |
Dual-energy x-ray absorptiometry |
Women older than 65 yr and high-risk women 50 yr of age and older should be screened; alen-dronate reduces the risk of fracture over 3-5 yr, but the longer-term benefit of treatment is unclear |
*"B" recommendations, United States Preventive Services Task Force.
Prostate Cancer Screening
The USPSTF concluded that evidence was insufficient to recommend for or against prostate cancer screening. This conclusion was based on the following considerations: (1) there are no completed randomized, controlled trials of screening, although studies are ongoing in the United States29 and in Europe30; (2) although prostate cancer is a major cause of cancer death in men, many cases are clinically indolent (in autopsy studies, the prevalence of histologic prostate cancer in men older than 50 years is about 30%, but only 3% of men die of prostate cancer)31; (3) the value of treatment for the localized cancers targeted by screening is unknown; the one randomized, controlled trial of radical prostatectomy, which found no improvement in the 15-year survival rates of patients undergoing surgery, has been criticized for methodological problems32 (another randomized, controlled trial comparing expectant management with radical prostatectomy for the treatment of localized cancer is under way)33; (4) aggressive treatments for localized disease are associated with significant morbidity; and (5) mortality from prostate cancer has not declined in the United States despite 15 years of widespread use of PSA testing.
Lung Cancer Screening
The USPSTF concluded that evidence was insufficient to recommend for or against screening asymptomatic patients for lung cancer with low-dose CT, chest x-ray, sputum cytology, or a combination of these tests. Although there is fair evidence that screening with these measures can result in detection of lung cancer at an earlier stage, there is poor evidence that any screening strategy for lung cancer decreases mortality. Moreover, the invasive nature of diagnostic testing and the possibility of a high number of false positive tests in certain populations raises the potential for significant harms from screening.
Noncancer Screening
Selected screening tests for diseases other than cancer are recommended for all adults, or for groups defined by age and sex. These diseases include abdominal aortic aneurysm in older men, depression, obesity, and osteoporosis [see Table 10].
Behavioral-Counseling Interventions
Unhealthy behaviors have a huge impact on mortality and morbidity. Tobacco use remains the leading preventable cause of death in the United States, contributing to more than 440,000 deaths each year. Misuse of alcohol is responsible for 100,000 more deaths. Although tobacco use has decreased, alcohol abuse, obesity, and diabetes have increased in recent years, bringing new attention to the need to eat, drink, and exercise sensibly.
The evidence base supporting brief counseling by primary care physicians has grown substantially in the past 10 years. To date, however, efficacy has been proved only for counseling on tobacco cessation and alcohol use [see Table 11]. Evidence to support counseling on diet, exercise, and other behaviors (e.g., use of sunscreens, seat-belt use) is limited. In many instances, follow-up in the available studies was too short to confirm that behavior change is sustained long enough to reduce the risk of developing disease or injury.
Table 11 Selected Recommendations for Counseling and Patient Education
|
Counseling Topic |
USPSTF Grade* |
|
Tobacco use |
B |
|
Alcohol use/driving after drinking |
B |
|
Healthy diet |
I |
|
Physical activity |
I |
|
Seat-belt use |
I |
|
Regular dental care |
I |
|
Avoidance of sun exposure/use of protective clothing |
I |
|
Adequate calcium intake (women) |
I |
|
Use of sunscreens |
I |
Smoking cessation
There is strong evidence that smoking bans, increasing the price of tobacco products, and public-information campaigns can discourage people from starting to smoke and encourage them to stop. Smoking cessation rapidly decreases the risk of stroke and heart disease and slowly decreases the risk of lung cancer [see CE:III Reducing Risk of Injury and Disease]. In patients with peripheral vascular disease, smoking cessation reduces the risk of limb amputation and recurrent stroke.
Brief counseling by clinicians can help smokers take action. Counseling by physicians becomes increasingly important as more patients become motivated to quit. Because many patients have tried and failed before, brief messages should emphasize that repeated efforts often bring success.
Alcohol use
Screening and counseling of alcohol use in primary care is aimed at drinkers who are at risk for harm from alcohol consumption that exceeds daily, weekly, or per-occasion norms (i.e., risky or hazardous drinking) [see 13:III Alcohol Abuse and Dependency]. Unlike harmful drinking and alcohol abuse or dependence, risky drinking behavior has not yet resulted in physical, social, or psychological harm to the drinker, and such drinkers do not meet diagnostic criteria for alcohol dependence.34 In contrast to persons who engage in risky drinking, alcohol-abusing and alcohol-dependent drinkers may require intense addiction treatment and are unlikely to respond to brief advice from a physician.
Self-administered questionnaires or brief interviews can be used to assess average quantity or frequency and binge use. In the United States, about 8% to 18% of patients screen positive for binge drinking. CAGE is a four-item screening questionnaire to detect alcohol abuse and dependence. Its name derives from the topics of the four questions: Have you ever felt you ought to Cut down on drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink in the morning to steady your nerves or get rid of a hangover (Eye-opener)? In contrast, the Alcohol Use Disorders Identification Test (AUDIT), a 10-item instrument, is designed to identify risky and harmful use. In several controlled trials conducted in primary care settings, it was found that brief, multicontact behavioral-counseling interventions reduced risky and harmful alcohol use. About one in 10 risky drinkers reduced their alcohol use to sensible levels for up to 1 year.35
Reminder Systems
The USPSTF has created patient pocket guides that are based on its guidelines and that clinicians can use as reminder systems to promote patients’ involvement in their own preventive care. These pocket guides are available on the Internet. There is one for all adults (http://www.ahrq.gov/ppip/adguide), one for adults older than 50 years (http://www.ahrq.gov/ppip/50plus/ index.html), and one for women (http://www.ahrq.gov/ppip/ healthywom.htm).
