Transcript Alisa Holland, PGY-2 1/11/11

Alisa Holland, PGY-2
1/11/11
USPSTF Grade Definitions
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A – Strongly Recommended
 Benefits outweigh harms. Good evidence of improvement
in health outcomes.
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B – Recommended
 Benefits outweigh harms. Fair evidence of improvement
in health outcomes.

C – No Recommendation
 Fair evidence of improvement in health outcomes.
Benefits and harms are too close to recommend
intervention.
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D – Not Recommended
 Risks outweigh harms or fair evidence to suggest that
intervention is ineffective.

I – Insufficient Evidence to Recommend
 Cannot determine balance of benefits and harms.
Cancer
Breast
 Cervical
 Colorectal
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Breast Cancer Recommendations
(USPSTF)
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Last Update: December 2009
Screening mammogram every other year from
ages 50 to 74 (Grade B)
Recommends against teaching breast selfexam (Grade D)
Insufficient evidence to recommend
performing clinical breast exam after age 40 if
patient receives a screening mammogram
Insufficient evidence to assess benefits and
harms of digital mammogram and breast MRI
Breast Cancer Recommendations
(USPSTF)
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Refer women with family history of BRCA1
and BRCA2 mutations for genetic counseling
and BRCA testing (Grade B).
Recommends against referring women for
BRCA testing who have no family history of
BRCA mutations (Grade D)
Recommends against routine use of tamoxifen
or raloxifene for chemoprevention in low or
average risk patients (Grade D)
Discuss chemoprevention with patients at high
risk for breast cancer and low risk for therapy
side effects (Grade B).
USPSTF Evidence

Screening every other year on average has
81% of the benefit of annual screening.
 50% fewer false positive results
Screening annually reduces mortality from
breast cancer by additional 3%.
 SBE and CBE are shown not to reduce
mortality and result in increase of benign
biopsy results.
 Chemoprevention with tamoxifen in high
risk women showed a significant reduction
in invasive and non-invasive breast
cancers (BCPT trial).
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Breast Cancer Recommendation
(ACS)
Screening mammogram every year starting
at age 40 and continuing as long as the
patient is in good health.
 SBE is an option for women starting in their
20s.
 CBE should be performed every 3 years
between ages 20-39. Annual CBEs
starting at age 40 years.
 Women with high risk of breast cancer
should have mammogram and MRI every
year.
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Cervical Cancer Recommendations
(USPSTF)
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Released: January 2003
Screen patients who are sexually active and who
have a cervix (Grade A).
Recommends against screening women over age 65
who have a history of normal pap smears (10 years
per ACS guidelines) and are not high risk (Grade D)
Recommends against routine pap smears in patients
who have had a total hysterectomy for benign
reasons (Grade D)
Insufficient evidence to recommend computerized
screening and HPV testing as primary screening
tests.
Cervical Cancer Recommendations
(ACS)
Begin screening within three years of
onset of sexual activity or age 21 and
screen at least every three years.
 Lengthen screening interval starting no
sooner than age 30 if patient has had 23 consecutive normal results. Continue
annual screening if patient has risk
factors such as cervical neoplasia, HPV,
STDs, or high risk sexual behavior.

Colorectal Cancer Recommendations
(USPSTF)
Released: October 2008
Screen using FOBT, sigmoidoscopy, or
colonoscopy between ages 50 and 75
(Grade A).
 Recommends against screening between
ages 76 and 85 (Grade C)
 Recommends against screening after age
85 (Grade D)
 Insufficient evidence to assess benefits
and harms of CT colonography or fecal
DNA testing for screening purposes
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Colorectal Cancer Recommendations
(USPSTF)
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Recommended screening intervals:
 FOBT annually
 Sigmoidoscopy every 5 years with FOBT
every 3 years
 Screening colonoscopy every 10 years
Colorectal Cancer Recommendations
(ACS)
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Options for screening include:
 Flexible sigmoidoscopy every 5 years
 Colonoscopy every 10 years
 Double-contrast barium enema every 5
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years
CT colonography every 5 years
FOBT annually
Fecal immunochemical test (FIT) annually
Stool DNA (sDNA) test, unknown interval
USPSTF No Screen List
Bladder cancer
 Lung cancer
 Oral cancers
 Ovarian cancer
 Pancreatic cancer
 Testicular cancer
 Prostate cancer*
 Skin cancer

Heart and Vascular Disease
AAA
 Aspirin use
 Hypertension
 Lipids
 Tobacco use

Abdominal Aortic Aneurysm
(USPSTF)
Released: February 2005
 One time screening using abdominal
ultrasound for men between the ages of
65 and 75 with a history of tobacco use
(Grade B)
 Recommends against routine screening
in women (Grade D)
 Abdominal palpation not recommended
for screening given poor accuracy
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Aspirin Use
(USPSTF)
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Released: March 2009
Use in men aged 45 to 79 if benefit from
reduction of MI outweighs potential harm of GI
hemorrhage (Grade A).
Use in women 55 to 79 if benefit from
reduction in ischemic strokes outweighs
potential harm of GI hemorrhage (Grade A).
Insufficient evidence to recommend use in
patients aged 80 years and over.
Recommends against routine use for MI
prevention in men under age 45 and for stroke
prevention in women under age 55 (Grade D).
Hypertension and Hyperlipidemia
(USPSTF)
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Released: December 2007 (HTN) and June
2008 (HLD)
Screen for HTN in patients aged 18 and older
(Grade A).
Screen men age 35 and older for HLD (Grade
A).
Screen men aged 20 to 35 for HLD if they are
at increased risk for CHD (Grade B).
Screen women age 45 and older for HLD if
they are at increased risk for CHD (Grade A).
Screen women aged 20 to 45 if they are at
increased risk for CHD (Grade B).
Tobacco Use Recommendations
(USPSTF)
Released: April 2009
 Ask all adults about tobacco use and
provide cessation interventions (Grade
A).
 Ask all pregnant women about tobacco
use and provide tailored cessation
counseling (Grade A).
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Tobacco Use Counseling Guidelines

“5-A” framework:
 Ask about tobacco use
 Advise to quit with a clear personalized
message
 Assess willingness to quit
 Assist in quitting
 Arrange for follow-up and support

Use multiple counseling sessions and
telephone quit lines (1-877-YES-QUIT).
USPSTF No Screen List
Coronary Artery Stenosis
 Coronary Heart Disease*
 Peripheral Artery Disease*
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Infectious Disease
Chlamydia
 Gonorrhea
 Hepatitis B
 HIV
 STD counseling
 Syphilis
 TB
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Chlamydia Recommendations
(USPSTF)
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Released: June 2007
Screen all sexually active women age 24 and
younger and women over age of 24 if they are
at increased risk (Grade A).
Screen all pregnant women under age 24 and
pregnant women over age 24 if they are at
increased risk (Grade B).
Recommends against screening women age
25 or older if they are not at increased risk
(Grade D)
Insufficient evidence to recommend screening
men
Chlamydia Recommendations
(CDC)
Screen all sexually active women under
age 25.
 Screen older women with risk factors.
 Consider screening sexually active
young men in populations with high
incidences of infection.
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Gonorrhea Recommendations
(USPSTF/CDC)
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Released: May 2005
Screen all sexually active women at
increased risk (Grade B).
Recommends against screening women
and men at low risk for infection (Grade D)
Insufficient evidence to recommend
screening men at increased risk for
infection
Insufficient evidence to recommend
screening pregnant women at low risk
Hepatitis B Recommendations
(USPSTF)
Released: February 2004
 Screen pregnant women at their first
prenatal visit (Grade A).
 Recommends against screening
asymptomatic patients routinely (Grade
D)
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Hepatitis B Recommendations
(CDC)
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Populations recommended for testing:
 Patients born in Eastern Europe, Asia,
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Africa, Middle East, and Pacific Islands
MSM
IVDU
Patients receiving cytotoxic or
immunosuppressive therapy
Patients with persistently elevated AST/ALT
Hemodialysis patients
Pregnant women
HIV Recommendations
(USPSTF)
Released: July 2005
 Screen all adults at increased risk for
infection (Grade A).
 Screen all pregnant women (Grade A).
 No recommendation for screening adults
not at increased risk (Grade C)
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HIV Recommendations
(CDC)
Screen all patients aged 13 to 64.
 Screen patients at high risk for infection
annually.
 Screen all pregnant women at their first
prenatal visit. Re-screen in third
trimester in areas with high rates of HIV.
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STD Counseling Recommendations
(USPSTF/CDC)
Released: October 2008
 Use high-intensity counseling to prevent
STDs for all adults at increased risk for
STDs (Grade B).
 Insufficient evidence to recommend
counseling to adults not sexually active
or at low risk for infection
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Syphilis Recommendations
(USPSTF/CDC)
Released: July 2004
 Screen patients at increased risk for
infection (Grade A).
 Screen all pregnant women (Grade A).
 Recommends against screening
patients not at increased risk for
infection (Grade D).
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TB Recommendations
USPSTF Recs Released: 1996 – defers
to CDC for screening recommendations.
 CDC Recommends testing patients who:
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 Have been in contact with a person with
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known or suspected TB
Are immunosuppressed
Are from Latin America, Caribbean, Africa,
Asia, Eastern Europe, or Russia
Live in an area of high TB prevalence
IVDU
USPSTF No Screen List
Bacteriuria*
 Hepatitis C
 HSV
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Mental Health and Substance Abuse
Recommendations
(USPSTF)
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Depression
 Released: December 2009
 Screen when support is in place to assure diagnosis,
treatment, and follow-up (Grade B).
 Recommends against screening when support is not
in place (Grade C)
 2 Question mood assessment: mood and anhedonia
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Alcohol Abuse
 Released: April 2004
 Screen and counsel adults and pregnant women to
reduce alcohol misuse (Grade B).
 CAGE
Tobacco/Alcohol/Drug Use Tool
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5 “R”s
 Relevance
 Risks
 Rewards
 Roadblocks
 Repeat
USPSTF No Screen List
Dementia
 Illegal drug use
 Suicidality
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Metabolic, Nutritional, and
Endocrinology
Diabetes Mellitus
 Diet
 Obesity
 Physical Activity
 Iron Deficiency Anemia
 Osteoporosis
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Diabetes Mellitus Recommendations
(USPSTF)
Released: June 2008
 Screen adults with blood pressure
greater than 135/80 mmHg (Grade B).
 Insufficient evidence to recommend
screening in patients with BPs less than
135/80 mmHg
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Diabetes Mellitus Recommendations
(ADA)
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Screen patients of any age every three years if they
are overweight and who have at least one risk factor
for DM.
Screen patients without risk factors starting at age 45
and repeat every three years.
Risk factors:
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Physical inactivity
Family history (first degree)
High-risk race
Women delivering babies > 9 lbs. or diagnosed with GDM
HTN
HLD
PCOS
Nutrition Recommendations
(USPSTF)
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Diet
 Released: January 2003
 Counsel patients with HLD and other risk factors
for heart disease or other diet related disease
(Grade B).
 Insufficient evidence to recommend routine diet
counseling
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Obesity
 Released: December 2003
 Screen all patients and counsel to promote
sustained weight loss
Physical Activity (AHA)
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Aerobic activity
 Moderate: 30 minutes per day for five days
per week
 Vigorous: 20 minutes per day for three days
per week
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Muscle strengthening exercises
 2 days per week
Iron Deficiency Anemia Recommendations
(USPSTF)
Released: May 2006
 Screen pregnant women (Grade B).
 Insufficient evidence to recommend use
of iron supplementation in non-anemic
pregnant women.
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Osteoporosis Recommendations
(USPSTF)
Released: September 2002
 Screen women aged 65 and older
routinely or starting at age 60 with
increased risk factors for fractures
(Grade B).
 No recommendation for or against
postmenopausal women under age 60
(Grade C).
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Osteoporosis Recommendations
Use older age and non hormone use
after menopause to help determine
screening population.
 Screen women over 65 every 2 years.
 Screen women under 65 every 5 years.
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USPSTF No Screen List
Hemochromatosis
 Thyroid Disease
 Glaucoma
 COPD
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Immunizations
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Influenza
Pneumococcal
Td/Tdap
Hepatitis B
Hepatitis A
HPV
MMR
Varicella
Meningococcal
Zoster
Influenza Vaccine Recommendations
(CDC)
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Updated: 2010
IM vaccine contains killed virus
Nasal spray vaccine contains live attenuated
virus
 Use in healthy patients ages 2-49
 Not for use in pregnant patients
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Give to all patients over 6 months of age
annually starting in September.
Patients over age 65 can receive standard
dose vaccine or Fluzone High-Dose (higher
percentage of antigen per virus strain).
Do not give to patients allergic to eggs.
Pneumococcal (PPSV23) Vaccine
Recommendations
(CDC)
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Indications for administration to patients under
65:
Chronic heart dz
Immunodeficiency
Multiple myeloma
Chronic lung dz
HIV
Asthma
Diabetes Mellitus
Chronic renal failure
Emphysema
CSF leaks
Nephrotic syndrome
Organ transplantation
Cochlear implants
Leukemia
Immunosuppressant use
Alcoholism
Lymphoma
Splenic dysfunction
Chronic liver dz
Hodgkin disease
Sickle Cell disease
Cigarette smoking
Malignancy
Revaccinate once after five years or at age 65
Vaccinate all patients at age 65 years.
Tetanus/Tetanus, Diptheria, and Pertussis
(Tdap) Recommendations
(CDC)
Update tetanus vaccine status every 10
years.
 Revaccinate if patient has major or dirty
wound and five years have elapsed since
last vaccine.
 Replace tetanus booster with Tdap for one
occurrence to lower burden of pertussis
among adults and decrease exposure to
infants.
 Vaccinate healthcare professionals with
Tdap as soon as 2 years after previous Td
booster for additional pertussis protection.
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Hepatitis B Vaccine Recommendations
(CDC)
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In areas of high HBV incidence,
vaccinate all patients with Hepatitis B
vaccine who have not had complete
series
 3 IM doses of Hep B vaccine at 0, 1, and 6
months
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Combined Hep A-Hep B vaccine
(Twinrix) available for any adult with risk
factors for both viruses.
Hepatitis A Vaccine Recommendations
(CDC)
Hepatitis A administered as two series
schedule at 0 and 6 months.
 Indications for Hepatitis A vaccination:
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 Patients traveling to areas with high or
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intermediate endemicity of Hepatitis A
MSM
Chronic liver disease
Drug use (IV and non-IV)
Occupational exposure
Patients with clotting factor disorders
HPV Vaccine Recommendations
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Recommended for girls aged 11 or 12
years but can be given to women up to age
26
Can also be administered to males aged 9
to 26 years to prevent condyloma
acuminatum (10/09)
Given in 3 shot series at 0, 1-2, and 6
months
HPV4: 6, 11, 16, 18
HPV2 (released October 2009): 16, 18
MMR Vaccine Recommendations
(CDC)
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Schedule: 2 doses, given at 0 and 4 weeks
Vaccinate adults with one dose unless they have
evidence of immunity, have previously been
vaccinated, or have had documented measles.
Vaccinate women of childbearing age who do not
have laboratory evidence of immunity or
documentation of previous vaccination.
 Contraindicated during pregnancy
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Give additional dose if patient was recently exposed
to an outbreak, are in college, work in a healthcare
facility, or are travelling internationally.
Do not give to individuals allergic to gelatin or
neomycin.
Varicella Vaccine Recommendations
(CDC)
Schedule: 2 doses at 0 and 4 weeks
 Test pregnant women for immunity and
vaccinate if indicated starting after
delivery.
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 Contraindicated during pregnancy
Vaccinate all non-immune adults.
 Do not give to individuals allergic to
gelatin or neomycin.
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Meningococcal Vaccine Recommendations
(CDC)
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Vaccinate following populations:
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Sickle Cell Disease
Splenic dysfunction
Complement deficiencies
College students living in dorms
Microbiologists routinely exposed to N. meningitidis
Military recruits
Residents of or visitors to countries with high prevalence
of meningococcal disease
MCV4 for patients 55 and under
 Better immunologic response
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MPSV for patients 56 and older
Revaccinate after five years with MCV4 if risk still
exists
Zoster Vaccine Recommendations
(CDC)
Vaccinate all patients aged 60 and older
with single dose.
 Most effective in patients aged 60 to 69
(64% risk reduction). Risk reduction
decreases with increasing age (18% risk
reduction for 80 year old patient).
 Patients with chronic medical conditions
may be vaccinated prior to age 60.
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 Contraindications: pregnancy, HIV with CD4
count < 200, immunocompromising conditions
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Decreases incidence of postherpetic
neuralgia and shortens duration of illness.
References
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USPreventiveServicesTaskForce.org
Cancer.org
CDC.gov
Diabetes.org
Effects of Mammography Screening Under Different Screening Schedules: Model
Estimates of Potential Benefits and Harms. Mandelblatt, et al. Ann Intern Med
2009;151:738-747.
Screening for Breast Cancer: An Update for the U.S. Preventive Services Task Force.
Nelson, et al. Ann Intern Med 2009;151:727-737
Fisher B, et al. Tamoxifen for prevention of breast cancer: report of the National
Surgical Adjuvant Breast and Bowel Project P-1 Study. J Natl Cancer Inst
1998;90:1371-88.
Smith RA, et al. American Cancer Society Guideline for the Early Detection of Cervical
Neoplasia and Cancer. CA Cancer J Clin 2002;52(1):8-22.
American College of Obstetricians and Gynecologists. Guidelines for Women's Health
Care. 2nd ed. Washington, DC: ACOG;2002: 121-134, 140-141.
Ridker PM, et al. A randomized trial of low-dose aspirin in the primary prevention of
cardiovascular disease in women. N Engl J Med 2005;352:1293-304.
Berger JS, et al. Aspirin for the primary prevention of cardiovascular events in women
and men: a sex-specific meta-analysis of randomized controlled trials. JAMA 2006;
295:306-13.
Recommendations for Identification and Public Health Management of Persons with
Chronic Hepatitis B Virus Infection, CDC.gov, MMWR 2008;57(RR-8).
Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant
Women in Health-Care Settings, CDC.gov, MMWR 2006; 55(RR14);1-17
Centers for Disease Control and Prevention. Recommended adult immunization
schedule—United States, 2010. MMWR 2010;59(1).