Clarifying the US Preventive Services Task Force’s 2005 recommendations

The United States Preventive Services Task Force (USPSTF) is the most evidence-based and authoritative organization making recommendations on preventive services in the US. During 2005, 20 recommendations were made on a total of 10 conditions. TABLE 1 lists the recommendations made in 2005. TABLE 2 describes the criteria for the recommendations coming from the task force.

Several of these recommendations deserve elaboration.

TABLE 1
USPSTF recommendations made in 2005

TABLE 2
Meaning of recommendations by the USPSTF

Sexually transmitted infections

Among the conditions studied in 2005 were gonorrhea, herpes simplex virus (HSV), and human immunodefeciency virus (HIV). The recommendations were different for each. The task force strongly recommends (A recommendation) screening all pregnant women and all high-risk adolescents and adults for HIV. No recommendation is made regarding HIV screening in adolescents and adults who are not at high risk.

The task force recommends (B recommendation) screening high-risk women for gonorrhea, including those who are pregnant.

It recommends against (D recommendation) screening for gonorrhea in men and women at low risk and believes there is insufficient evidence (I recommendation) to advocate for or against screening men at high risk and pregnant women at low risk. It recommends against screening for HSV during pregnancy and among asymptomatic adolescents and adults.

The Task Force defines high risk a little differently for gonorrhea and HIV. These definitions are listed in TABLE 3.

What the C and I recommendations do and do not mean. Keep several points in mind regarding these recommendations. When no recommendation is made for or against (C recommendation), it signifies there is evidence of some benefit but not clear enough to outweigh harms. An I recommendation means that there is not enough quality evidence to make a recommendation. These 2 recommendations are often misinterpreted as a recommendation against the service, which they are not.

Don’t confuse screening with diagnosis. Screening, by definition, means looking for a condition among asymptomatic persons. Diagnostic tests performed to clarify the cause of symptoms or to improve clinical care are not screening tests. Screening recommendations therefore do not apply in these latter instances. In addition, the task force recognizes that screening recommendations need to be interpreted in light of local epidemiology. In areas of high STD prevalence, more widespread screening might well be justified.

TABLE 3
USPSTF definitions of risk for HIV and gonorrhea

Abdominal aortic aneurysms

The rationale behind these recommendations was discussed in a previous Practice Alert.¹ The take-home message for physicians is that any male who has ever smoked can possibly benefit from a one-time abdominal ultrasound.

Women’s health conditions

Two sets of recommendations pertain to hormone replacement therapy (HRT) and screening for breast and ovarian cancer.

When to avoid HRT. The task force recommends against using combined estrogen and progestin in postmenopausal women, and against using estrogen to prevent chronic health conditions in postmenopausal women who have had a hysterectomy.

Estrogen and progestin combinations reduce the risk for fractures and colorectal cancer but have no beneficial effect on (and may increase the risk of) coronary heart disease. Other documented harms include increased risk for breast cancer, venous thromboembolism, stroke, cholecystitis, dementia, and lower global cognitive function. Unopposed estrogen reduces the risk for fractures but increases risk for venous thromboembolism, stroke, dementia, and lower global cognitive functioning, and it has no beneficial effect on coronary heart disease.

When to investigate possible BRCA1 or BRCA2 gene mutations. For women with family histories suggestive of mutations of BRCA1 or BRCA2 genes—which place women at markedly higher lifetime risk of breast and ovarian cancer—the task force recommends referral for counseling and possible genetic testing. While the task force acknowledges the unresolved ethical, social, and legal issues, as well as the unknown benefits of chemoprevention and intensive screening, they believe the potential of prophylactic surgery to prevent breast and ovarian cancer is sufficient to make the recommendation.

Note that the recommendation is for referral for genetic counseling in which genetic testing may be considered. It is not a recommendation for testing by itself.

The following elements of a family history place a woman at risk:

• 2 first-degree relatives with breast cancer, 1 of whom received the diagnosis at age 50 years or younger
• A combination of 3 or more first- or second-degree relatives with breast cancer regardless of age at diagnosis
• A combination of both breast and ovarian cancer among first- and second-degree relatives
• A first-degree relative with bilateral breast cancer
• A combination of 2 or more first-or second-degree relatives with ovarian cancer regardless of age at diagnosis
• A first- or second-degree relative with both breast and ovarian cancer at any age
• A history of breast cancer in a male relative.

For Ashkenazi Jewish women, an increased-risk family history includes any first-degree relative (or 2 second-degree relatives on the same side of the family) with breast or ovarian cancer.

For women without a high-risk family history, the task force believes that counseling or routine testing will lead to more harms than benefits and they recommend against it.

Overweight in children and adolescents

The task force acknowledges the increasing prevalence of overweight and obesity in children and adolescents and the consequent adverse health outcomes caused by this condition. As with many unhealthy conditions or habits, however, it is not known whether screening and counseling in the primary care setting reduce child and adolescent obesity.

Remember that the task force is not recommending for or against measuring height, weight, and body-mass index in the office or talking to young patients about their weight. They are simply summarizing the state of the science, which is unclear about whether such efforts by physicians have any effect.

Resources

The complete set of current USPSTF recommendations along with clinical considerations and links to evidence reports can be found on the USPSTF web site, www.ahrq.gov/clinic/uspstfix.htm.

CORRESPONDENCE
Doug Campos-Outcalt, MD,MPA, 4001North Third Street #415, Phoenix, AZ 85012. E-mail: [email protected]

The United States Preventive Services Task Force (USPSTF) is the most evidence-based and authoritative organization making recommendations on preventive services in the US. During 2005, 20 recommendations were made on a total of 10 conditions. TABLE 1 lists the recommendations made in 2005. TABLE 2 describes the criteria for the recommendations coming from the task force.

Several of these recommendations deserve elaboration.

TABLE 1
USPSTF recommendations made in 2005

TABLE 2
Meaning of recommendations by the USPSTF

Sexually transmitted infections

Among the conditions studied in 2005 were gonorrhea, herpes simplex virus (HSV), and human immunodefeciency virus (HIV). The recommendations were different for each. The task force strongly recommends (A recommendation) screening all pregnant women and all high-risk adolescents and adults for HIV. No recommendation is made regarding HIV screening in adolescents and adults who are not at high risk.

The task force recommends (B recommendation) screening high-risk women for gonorrhea, including those who are pregnant.

It recommends against (D recommendation) screening for gonorrhea in men and women at low risk and believes there is insufficient evidence (I recommendation) to advocate for or against screening men at high risk and pregnant women at low risk. It recommends against screening for HSV during pregnancy and among asymptomatic adolescents and adults.

The Task Force defines high risk a little differently for gonorrhea and HIV. These definitions are listed in TABLE 3.

What the C and I recommendations do and do not mean. Keep several points in mind regarding these recommendations. When no recommendation is made for or against (C recommendation), it signifies there is evidence of some benefit but not clear enough to outweigh harms. An I recommendation means that there is not enough quality evidence to make a recommendation. These 2 recommendations are often misinterpreted as a recommendation against the service, which they are not.

Don’t confuse screening with diagnosis. Screening, by definition, means looking for a condition among asymptomatic persons. Diagnostic tests performed to clarify the cause of symptoms or to improve clinical care are not screening tests. Screening recommendations therefore do not apply in these latter instances. In addition, the task force recognizes that screening recommendations need to be interpreted in light of local epidemiology. In areas of high STD prevalence, more widespread screening might well be justified.

TABLE 3
USPSTF definitions of risk for HIV and gonorrhea

Abdominal aortic aneurysms

The rationale behind these recommendations was discussed in a previous Practice Alert.¹ The take-home message for physicians is that any male who has ever smoked can possibly benefit from a one-time abdominal ultrasound.

Women’s health conditions

Two sets of recommendations pertain to hormone replacement therapy (HRT) and screening for breast and ovarian cancer.

When to avoid HRT. The task force recommends against using combined estrogen and progestin in postmenopausal women, and against using estrogen to prevent chronic health conditions in postmenopausal women who have had a hysterectomy.

Estrogen and progestin combinations reduce the risk for fractures and colorectal cancer but have no beneficial effect on (and may increase the risk of) coronary heart disease. Other documented harms include increased risk for breast cancer, venous thromboembolism, stroke, cholecystitis, dementia, and lower global cognitive function. Unopposed estrogen reduces the risk for fractures but increases risk for venous thromboembolism, stroke, dementia, and lower global cognitive functioning, and it has no beneficial effect on coronary heart disease.

When to investigate possible BRCA1 or BRCA2 gene mutations. For women with family histories suggestive of mutations of BRCA1 or BRCA2 genes—which place women at markedly higher lifetime risk of breast and ovarian cancer—the task force recommends referral for counseling and possible genetic testing. While the task force acknowledges the unresolved ethical, social, and legal issues, as well as the unknown benefits of chemoprevention and intensive screening, they believe the potential of prophylactic surgery to prevent breast and ovarian cancer is sufficient to make the recommendation.

Note that the recommendation is for referral for genetic counseling in which genetic testing may be considered. It is not a recommendation for testing by itself.

The following elements of a family history place a woman at risk:

• 2 first-degree relatives with breast cancer, 1 of whom received the diagnosis at age 50 years or younger
• A combination of 3 or more first- or second-degree relatives with breast cancer regardless of age at diagnosis
• A combination of both breast and ovarian cancer among first- and second-degree relatives
• A first-degree relative with bilateral breast cancer
• A combination of 2 or more first-or second-degree relatives with ovarian cancer regardless of age at diagnosis
• A first- or second-degree relative with both breast and ovarian cancer at any age
• A history of breast cancer in a male relative.

For Ashkenazi Jewish women, an increased-risk family history includes any first-degree relative (or 2 second-degree relatives on the same side of the family) with breast or ovarian cancer.

For women without a high-risk family history, the task force believes that counseling or routine testing will lead to more harms than benefits and they recommend against it.

Overweight in children and adolescents

The task force acknowledges the increasing prevalence of overweight and obesity in children and adolescents and the consequent adverse health outcomes caused by this condition. As with many unhealthy conditions or habits, however, it is not known whether screening and counseling in the primary care setting reduce child and adolescent obesity.

Remember that the task force is not recommending for or against measuring height, weight, and body-mass index in the office or talking to young patients about their weight. They are simply summarizing the state of the science, which is unclear about whether such efforts by physicians have any effect.

Resources

The complete set of current USPSTF recommendations along with clinical considerations and links to evidence reports can be found on the USPSTF web site, www.ahrq.gov/clinic/uspstfix.htm.

CORRESPONDENCE
Doug Campos-Outcalt, MD,MPA, 4001North Third Street #415, Phoenix, AZ 85012. E-mail: [email protected]

The United States Preventive Services Task Force (USPSTF) is the most evidence-based and authoritative organization making recommendations on preventive services in the US. During 2005, 20 recommendations were made on a total of 10 conditions. TABLE 1 lists the recommendations made in 2005. TABLE 2 describes the criteria for the recommendations coming from the task force.

Several of these recommendations deserve elaboration.

TABLE 1
USPSTF recommendations made in 2005

TABLE 2
Meaning of recommendations by the USPSTF

Sexually transmitted infections

Among the conditions studied in 2005 were gonorrhea, herpes simplex virus (HSV), and human immunodefeciency virus (HIV). The recommendations were different for each. The task force strongly recommends (A recommendation) screening all pregnant women and all high-risk adolescents and adults for HIV. No recommendation is made regarding HIV screening in adolescents and adults who are not at high risk.

The task force recommends (B recommendation) screening high-risk women for gonorrhea, including those who are pregnant.

It recommends against (D recommendation) screening for gonorrhea in men and women at low risk and believes there is insufficient evidence (I recommendation) to advocate for or against screening men at high risk and pregnant women at low risk. It recommends against screening for HSV during pregnancy and among asymptomatic adolescents and adults.

The Task Force defines high risk a little differently for gonorrhea and HIV. These definitions are listed in TABLE 3.

What the C and I recommendations do and do not mean. Keep several points in mind regarding these recommendations. When no recommendation is made for or against (C recommendation), it signifies there is evidence of some benefit but not clear enough to outweigh harms. An I recommendation means that there is not enough quality evidence to make a recommendation. These 2 recommendations are often misinterpreted as a recommendation against the service, which they are not.

Don’t confuse screening with diagnosis. Screening, by definition, means looking for a condition among asymptomatic persons. Diagnostic tests performed to clarify the cause of symptoms or to improve clinical care are not screening tests. Screening recommendations therefore do not apply in these latter instances. In addition, the task force recognizes that screening recommendations need to be interpreted in light of local epidemiology. In areas of high STD prevalence, more widespread screening might well be justified.

TABLE 3
USPSTF definitions of risk for HIV and gonorrhea

Abdominal aortic aneurysms

The rationale behind these recommendations was discussed in a previous Practice Alert.¹ The take-home message for physicians is that any male who has ever smoked can possibly benefit from a one-time abdominal ultrasound.

Women’s health conditions

Two sets of recommendations pertain to hormone replacement therapy (HRT) and screening for breast and ovarian cancer.

When to avoid HRT. The task force recommends against using combined estrogen and progestin in postmenopausal women, and against using estrogen to prevent chronic health conditions in postmenopausal women who have had a hysterectomy.

Estrogen and progestin combinations reduce the risk for fractures and colorectal cancer but have no beneficial effect on (and may increase the risk of) coronary heart disease. Other documented harms include increased risk for breast cancer, venous thromboembolism, stroke, cholecystitis, dementia, and lower global cognitive function. Unopposed estrogen reduces the risk for fractures but increases risk for venous thromboembolism, stroke, dementia, and lower global cognitive functioning, and it has no beneficial effect on coronary heart disease.

When to investigate possible BRCA1 or BRCA2 gene mutations. For women with family histories suggestive of mutations of BRCA1 or BRCA2 genes—which place women at markedly higher lifetime risk of breast and ovarian cancer—the task force recommends referral for counseling and possible genetic testing. While the task force acknowledges the unresolved ethical, social, and legal issues, as well as the unknown benefits of chemoprevention and intensive screening, they believe the potential of prophylactic surgery to prevent breast and ovarian cancer is sufficient to make the recommendation.

Note that the recommendation is for referral for genetic counseling in which genetic testing may be considered. It is not a recommendation for testing by itself.

The following elements of a family history place a woman at risk:

• 2 first-degree relatives with breast cancer, 1 of whom received the diagnosis at age 50 years or younger
• A combination of 3 or more first- or second-degree relatives with breast cancer regardless of age at diagnosis
• A combination of both breast and ovarian cancer among first- and second-degree relatives
• A first-degree relative with bilateral breast cancer
• A combination of 2 or more first-or second-degree relatives with ovarian cancer regardless of age at diagnosis
• A first- or second-degree relative with both breast and ovarian cancer at any age
• A history of breast cancer in a male relative.

For Ashkenazi Jewish women, an increased-risk family history includes any first-degree relative (or 2 second-degree relatives on the same side of the family) with breast or ovarian cancer.

For women without a high-risk family history, the task force believes that counseling or routine testing will lead to more harms than benefits and they recommend against it.

Overweight in children and adolescents

The task force acknowledges the increasing prevalence of overweight and obesity in children and adolescents and the consequent adverse health outcomes caused by this condition. As with many unhealthy conditions or habits, however, it is not known whether screening and counseling in the primary care setting reduce child and adolescent obesity.

Remember that the task force is not recommending for or against measuring height, weight, and body-mass index in the office or talking to young patients about their weight. They are simply summarizing the state of the science, which is unclear about whether such efforts by physicians have any effect.

Resources

The complete set of current USPSTF recommendations along with clinical considerations and links to evidence reports can be found on the USPSTF web site, www.ahrq.gov/clinic/uspstfix.htm.

CORRESPONDENCE
Doug Campos-Outcalt, MD,MPA, 4001North Third Street #415, Phoenix, AZ 85012. E-mail: [email protected]