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Since the last Practice Alert update on the United States Preventive Services Task Force in May of 2016,1 the Task Force has released 19 recommendations on 13 topics that include: the use of aspirin and statins for the prevention of cardiovascular disease (CVD); support for breastfeeding; use of folic acid during pregnancy; and screening for syphilis, latent tuberculosis (TB), herpes, chronic obstructive pulmonary disease (COPD), colorectal cancer (CRC), obstructive sleep apnea (OSA), celiac disease, and skin cancer. The Task Force also released a draft recommendation regarding prostate cancer screening in asymptomatic men (see “A change for prostate cancer screening?”) and addressed screening pelvic examinations in asymptomatic women, the subject of this month’s audiocast. (To listen, go to: http://bit.ly/2nIVoD5.)
Recommendations to implement
Recommendations from the past year that family physicians should put into practice are detailed below and in TABLE 1.2-8
CRC: Screen all individuals ages 50 to 75, but 76 to 85 selectively. The Task Force reaffirmed its 2008 finding that screening for CRC in adults ages 50 to 75 years is substantially beneficial.2 In contrast to the previous recommendation, however, the new one does not state which screening tests are preferred. The tests considered were 3 stool tests (fecal immunochemical test [FIT], FIT-tumor DNA testing [FIT-DNA], and guaiac-based fecal occult blood test [gFOBT]), as well as 3 direct visualization tests (colonoscopy, sigmoidoscopy, and CT colonoscopy). The Task Force assessed various testing frequencies of each test and some test combinations. While the Task Force does not recommend any one screening strategy, there are still significant unknowns about FIT-DNA and CT colonoscopy. The American Academy of Family Physicians does not recommend using these 2 tests for screening purposes at this time.9
CRC screening for adults ages 76 to 85 was given a “C” recommendation, which means the value of the service to the population overall is small, but that certain individuals may benefit from it. The Task Force advises selectively offering a “C” service to individuals based on professional judgment and patient preferences. Regarding CRC screening in individuals 76 years or older, the ones most likely to benefit are those who have never been screened and those without significant comorbidities that could limit life expectancy. All “C” recommendations from the past year are listed in TABLE 2.2-4
CVD prevention: When aspirin or a statin is indicated. The Task Force released 2 recommendations for the prevention of CVD this past year. One pertained to the use of low-dose aspirin3 (which also helps to prevent CRC), and the other addressed the use of low- to moderate-dose statins.4 Each recommendation is fairly complicated and nuanced in terms of age and risk for CVD. A decision to use low-dose aspirin must also consider the risk of bleeding.
To calculate a patient’s risk for CVD, the Task Force recommends using the risk calculator developed by the American College of Cardiology and the American Heart Association (http://www.cvriskcalculator.com/).
Adults for whom low-dose aspirin and low- to moderate-dose statins are recommended are described in TABLE 1.2-8 Patients for whom individual decision making is advised, rather than a generalized recommendation, are reviewed in TABLE 2.2-4 There is insufficient evidence to make a recommendation for the use of aspirin before age 50 or at age 70 and older,3 and for the use of statins in adults age 76 and older who do not have a history of CVD4 (TABLE 33,4,10-14). The use of low-dose aspirin and low-to-moderate dose statins have been the subject of JFP audiocasts in May 2016 and January 2017. (See http://bit.ly/2oiun8d and http://bit.ly/2oqkohR.)
2 pregnancy-related recommendations. To prevent neural tube defects in newborns, the Task Force now recommends daily folic acid, 0.4 to 0.8 mg (400 to 800 mcg), for all women who are planning on or are capable of becoming pregnant.5 This is an update of a 2009 recommendation that was worded slightly differently, recommending the supplement for all women of childbearing age.
A new recommendation on breastfeeding recognizes its benefits for both mother and baby and finds that interventions to encourage breastfeeding increase the prevalence of this practice and its duration.6 Interventions—provided to individuals or groups by professionals or peers or through formal education—include promoting the benefits of breastfeeding, giving practical advice and direct support on how to breastfeed, and offering psychological support.
Latent TB: Advantages of newer testing method. The recommendation on screening for latent tuberculosis (TB) is an update from the one made in 1996.7 At that time, screening for latent infection was performed using a tuberculin skin test (TST). Now a TST or interferon-gamma release assay (IGRA) can be used. Testing with IGRA may be the best option for those who have received a bacille Calmette–Guérin vaccination (because it can cause a false-positive TST) or for those who are not likely to return to have their TST read.
Those at high risk for latent TB include people who were born or have resided in countries with a high TB prevalence, those who have lived in a correctional institution or homeless shelter, and anyone in a high-risk group based on local epidemiology of the disease. (Read more on TB in this month’s Case Report.) Others at high risk are those who are immune suppressed because of infection or medications, and those who work in health care or correctional facilities. Screening of these groups is usually conducted as part of occupational health or is considered part of routine health care.
Syphilis: Screen high-risk individuals in 2 steps. The recommendation on syphilis screening basically reaffirms the one from 2004.8 Those at high risk for syphilis include men who have sex with men (who now account for 90% of new cases), those who are HIV positive, and those who engage in commercial sex work. Other racial and demographic groups can be at high risk depending on the local epidemiology of the disease. In a separate recommendation, the Task Force advises screening all pregnant women for syphilis.
Screening for syphilis infection involves 2 steps: first, a nontreponemal test (Venereal Disease Research Laboratory [VDRL] or rapid plasma reagin [RPR] test); second, a confirmatory treponemal antibody detection test (fluorescent treponemal antibody absorption [FTA-ABS] or Treponema pallidum particle agglutination [TPPA] test). Treatment for syphilis remains benzathine penicillin with the number of injections depending on the stage of infection. The Centers for Disease Control and Prevention is the best source for current recommendations for treatment of all sexually transmitted infections.15
Screening tests to avoid
TABLE 416,17 lists screening tests the Task Force recommends against. While chronic obstructive pulmonary disease afflicts 14% of US adults ages 40 to 79 years and is the third leading cause of death in the country, the Task Force found that early detection in asymptomatic adults does not affect the course of the illness and is of no benefit.16
Genital herpes, also prevalent, infects an estimated one out of 6 individuals, ages 14 to 49. It causes little mortality, except in neonates, but those infected can have recurrent flares and suffer psychological harms from stigmatization. Most genital herpes is caused by herpes simplex virus-2, and there is a serological test to detect it. However, the Task Force recommends against using the test to screen asymptomatic adults and adolescents, including those who are pregnant. This recommendation is based on the test’s high false-positive rate, which can cause emotional harm, and on the lack of evidence that detection through screening improves outcomes.17
The evidence is lacking for these practices
The Task Force is one of only a few organizations that will not make a recommendation if evidence is lacking on benefits and harms. In addition to the ‘I’ statements regarding CVD and CRC mentioned earlier, the Task Force found insufficient evidence to recommend screening for lipid disorders in individuals ages 20 years or younger,10 performing a visual skin exam as a screening tool for skin cancer,11 screening for celiac disease,12 performing a periodic pelvic examination in asymptomatic women,13 and screening for obstructive sleep apnea using screening questionnaires14 (TABLE 33,4,10-14).
SIDEBAR
A change for prostate cancer screening?The USPSTF recently issued new draft recommendations regarding prostate cancer screening in asymptomatic men (available at: https://screeningforprostatecancer.org/).
The draft now divides men into 2 age groups, stating that the decision to screen for prostate cancer using a prostate specific antigen (PSA) test should be individualized for men ages 55 to 69 years (a C recommendation, meaning that there is at least moderate certainty that the net benefit is small), and that men ages 70 and older (lowered from age 75 in the previous 2012 recommendation1) should not be screened (a D recommendation, meaning that there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits).
The USPSTF believes that clinicians should explain to men ages 55 to 69 years that screening offers a small potential benefit of reducing the chance of dying from prostate cancer, but also comes with potential harms, including false-positive results requiring additional testing/procedures, overdiagnosis and overtreatment, and treatment complications such as incontinence and impotence. In this way, each man has the chance to incorporate his values and preferences into the decision.
For men ages 70 and older, the potential benefits simply do not outweigh the potential harms, according to the USPSTF.
1. USPSTF. Final recommendation statement. Prostate cancer: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/prostate-cancer-screening#Pod1. Accessed April 11, 2017.
1. Campos-Outcalt D. Eight USPSTF recommendations FPs need to know about. J Fam Pract. 2016;65:338-341.
2. USPSTF. Colorectal cancer: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/colorectal-cancer-screening2. Accessed March 22, 2017.
3. USPSTF. Aspirin use to prevent cardiovascular disease and colorectal cancer: preventive medications. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/aspirin-to-prevent-cardiovascular-disease-and-cancer. Accessed March 22, 2017.
4. USPSTF. Statin use for the prevention of cardiovascular disease in adults: preventive medication. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/statin-use-in-adults-preventive-medication1. Accessed March 22, 2017.
5. USPSTF. Folic acid for the prevention of neural tube defects: preventive medication. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/folic-acid-for-the-prevention-of-neural-tube-defects-preventive-medication. Accessed March 22, 2017.
6. USPSTF. Breastfeeding: primary care interventions. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breastfeeding-primary-care-interventions. Accessed March 22, 2017.
7. USPSTF. Latent tuberculosis infection: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/latent-tuberculosis-infection-screening. Accessed March 22, 2017.
8. USPSTF. Syphilis infection in nonpregnant adults and adolescents: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/syphilis-infection-in-nonpregnant-adults-and-adolescents. Accessed March 22, 2017.
9. AAFP. Colorectal cancer screening, adults. Available at: http://www.aafp.org/patient-care/clinical-recommendations/all/colorectal-cancer.html. Accessed March 22, 2017.
10. USPSTF. Lipid disorders in children and adolescents: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/lipid-disorders-in-children-screening1. Accessed March 22, 2017.
11. USPSTF. Skin cancer: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/skin-cancer-screening2. Accessed March 22, 2017.
12. USPSTF. Celiac disease: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/celiac-disease-screening. Accessed March 22, 2017.
13. USPSTF. Gynecological conditions: periodic screening with the pelvic examination. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/gynecological-conditions-screening-with-the-pelvic-examination. Accessed March 22, 2017.
14. USPSTF. Obstructive sleep apnea in adults: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/obstructive-sleep-apnea-in-adults-screening. Accessed March 22, 2017.
15. CDC. 2015 sexually transmitted diseases treatment guidelines. Available at: https://www.cdc.gov/std/tg2015/default.htm. Accessed March 22, 2017.
16. USPSTF. Chronic obstructive pulmonary disease: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/chronic-obstructive-pulmonary-disease-screening. Accessed March 22, 2017.
17. USPSTF. Genital herpes infection: serologic screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/genital-herpes-screening1. Accessed March 22, 2017.
Since the last Practice Alert update on the United States Preventive Services Task Force in May of 2016,1 the Task Force has released 19 recommendations on 13 topics that include: the use of aspirin and statins for the prevention of cardiovascular disease (CVD); support for breastfeeding; use of folic acid during pregnancy; and screening for syphilis, latent tuberculosis (TB), herpes, chronic obstructive pulmonary disease (COPD), colorectal cancer (CRC), obstructive sleep apnea (OSA), celiac disease, and skin cancer. The Task Force also released a draft recommendation regarding prostate cancer screening in asymptomatic men (see “A change for prostate cancer screening?”) and addressed screening pelvic examinations in asymptomatic women, the subject of this month’s audiocast. (To listen, go to: http://bit.ly/2nIVoD5.)
Recommendations to implement
Recommendations from the past year that family physicians should put into practice are detailed below and in TABLE 1.2-8
CRC: Screen all individuals ages 50 to 75, but 76 to 85 selectively. The Task Force reaffirmed its 2008 finding that screening for CRC in adults ages 50 to 75 years is substantially beneficial.2 In contrast to the previous recommendation, however, the new one does not state which screening tests are preferred. The tests considered were 3 stool tests (fecal immunochemical test [FIT], FIT-tumor DNA testing [FIT-DNA], and guaiac-based fecal occult blood test [gFOBT]), as well as 3 direct visualization tests (colonoscopy, sigmoidoscopy, and CT colonoscopy). The Task Force assessed various testing frequencies of each test and some test combinations. While the Task Force does not recommend any one screening strategy, there are still significant unknowns about FIT-DNA and CT colonoscopy. The American Academy of Family Physicians does not recommend using these 2 tests for screening purposes at this time.9
CRC screening for adults ages 76 to 85 was given a “C” recommendation, which means the value of the service to the population overall is small, but that certain individuals may benefit from it. The Task Force advises selectively offering a “C” service to individuals based on professional judgment and patient preferences. Regarding CRC screening in individuals 76 years or older, the ones most likely to benefit are those who have never been screened and those without significant comorbidities that could limit life expectancy. All “C” recommendations from the past year are listed in TABLE 2.2-4
CVD prevention: When aspirin or a statin is indicated. The Task Force released 2 recommendations for the prevention of CVD this past year. One pertained to the use of low-dose aspirin3 (which also helps to prevent CRC), and the other addressed the use of low- to moderate-dose statins.4 Each recommendation is fairly complicated and nuanced in terms of age and risk for CVD. A decision to use low-dose aspirin must also consider the risk of bleeding.
To calculate a patient’s risk for CVD, the Task Force recommends using the risk calculator developed by the American College of Cardiology and the American Heart Association (http://www.cvriskcalculator.com/).
Adults for whom low-dose aspirin and low- to moderate-dose statins are recommended are described in TABLE 1.2-8 Patients for whom individual decision making is advised, rather than a generalized recommendation, are reviewed in TABLE 2.2-4 There is insufficient evidence to make a recommendation for the use of aspirin before age 50 or at age 70 and older,3 and for the use of statins in adults age 76 and older who do not have a history of CVD4 (TABLE 33,4,10-14). The use of low-dose aspirin and low-to-moderate dose statins have been the subject of JFP audiocasts in May 2016 and January 2017. (See http://bit.ly/2oiun8d and http://bit.ly/2oqkohR.)
2 pregnancy-related recommendations. To prevent neural tube defects in newborns, the Task Force now recommends daily folic acid, 0.4 to 0.8 mg (400 to 800 mcg), for all women who are planning on or are capable of becoming pregnant.5 This is an update of a 2009 recommendation that was worded slightly differently, recommending the supplement for all women of childbearing age.
A new recommendation on breastfeeding recognizes its benefits for both mother and baby and finds that interventions to encourage breastfeeding increase the prevalence of this practice and its duration.6 Interventions—provided to individuals or groups by professionals or peers or through formal education—include promoting the benefits of breastfeeding, giving practical advice and direct support on how to breastfeed, and offering psychological support.
Latent TB: Advantages of newer testing method. The recommendation on screening for latent tuberculosis (TB) is an update from the one made in 1996.7 At that time, screening for latent infection was performed using a tuberculin skin test (TST). Now a TST or interferon-gamma release assay (IGRA) can be used. Testing with IGRA may be the best option for those who have received a bacille Calmette–Guérin vaccination (because it can cause a false-positive TST) or for those who are not likely to return to have their TST read.
Those at high risk for latent TB include people who were born or have resided in countries with a high TB prevalence, those who have lived in a correctional institution or homeless shelter, and anyone in a high-risk group based on local epidemiology of the disease. (Read more on TB in this month’s Case Report.) Others at high risk are those who are immune suppressed because of infection or medications, and those who work in health care or correctional facilities. Screening of these groups is usually conducted as part of occupational health or is considered part of routine health care.
Syphilis: Screen high-risk individuals in 2 steps. The recommendation on syphilis screening basically reaffirms the one from 2004.8 Those at high risk for syphilis include men who have sex with men (who now account for 90% of new cases), those who are HIV positive, and those who engage in commercial sex work. Other racial and demographic groups can be at high risk depending on the local epidemiology of the disease. In a separate recommendation, the Task Force advises screening all pregnant women for syphilis.
Screening for syphilis infection involves 2 steps: first, a nontreponemal test (Venereal Disease Research Laboratory [VDRL] or rapid plasma reagin [RPR] test); second, a confirmatory treponemal antibody detection test (fluorescent treponemal antibody absorption [FTA-ABS] or Treponema pallidum particle agglutination [TPPA] test). Treatment for syphilis remains benzathine penicillin with the number of injections depending on the stage of infection. The Centers for Disease Control and Prevention is the best source for current recommendations for treatment of all sexually transmitted infections.15
Screening tests to avoid
TABLE 416,17 lists screening tests the Task Force recommends against. While chronic obstructive pulmonary disease afflicts 14% of US adults ages 40 to 79 years and is the third leading cause of death in the country, the Task Force found that early detection in asymptomatic adults does not affect the course of the illness and is of no benefit.16
Genital herpes, also prevalent, infects an estimated one out of 6 individuals, ages 14 to 49. It causes little mortality, except in neonates, but those infected can have recurrent flares and suffer psychological harms from stigmatization. Most genital herpes is caused by herpes simplex virus-2, and there is a serological test to detect it. However, the Task Force recommends against using the test to screen asymptomatic adults and adolescents, including those who are pregnant. This recommendation is based on the test’s high false-positive rate, which can cause emotional harm, and on the lack of evidence that detection through screening improves outcomes.17
The evidence is lacking for these practices
The Task Force is one of only a few organizations that will not make a recommendation if evidence is lacking on benefits and harms. In addition to the ‘I’ statements regarding CVD and CRC mentioned earlier, the Task Force found insufficient evidence to recommend screening for lipid disorders in individuals ages 20 years or younger,10 performing a visual skin exam as a screening tool for skin cancer,11 screening for celiac disease,12 performing a periodic pelvic examination in asymptomatic women,13 and screening for obstructive sleep apnea using screening questionnaires14 (TABLE 33,4,10-14).
SIDEBAR
A change for prostate cancer screening?The USPSTF recently issued new draft recommendations regarding prostate cancer screening in asymptomatic men (available at: https://screeningforprostatecancer.org/).
The draft now divides men into 2 age groups, stating that the decision to screen for prostate cancer using a prostate specific antigen (PSA) test should be individualized for men ages 55 to 69 years (a C recommendation, meaning that there is at least moderate certainty that the net benefit is small), and that men ages 70 and older (lowered from age 75 in the previous 2012 recommendation1) should not be screened (a D recommendation, meaning that there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits).
The USPSTF believes that clinicians should explain to men ages 55 to 69 years that screening offers a small potential benefit of reducing the chance of dying from prostate cancer, but also comes with potential harms, including false-positive results requiring additional testing/procedures, overdiagnosis and overtreatment, and treatment complications such as incontinence and impotence. In this way, each man has the chance to incorporate his values and preferences into the decision.
For men ages 70 and older, the potential benefits simply do not outweigh the potential harms, according to the USPSTF.
1. USPSTF. Final recommendation statement. Prostate cancer: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/prostate-cancer-screening#Pod1. Accessed April 11, 2017.
Since the last Practice Alert update on the United States Preventive Services Task Force in May of 2016,1 the Task Force has released 19 recommendations on 13 topics that include: the use of aspirin and statins for the prevention of cardiovascular disease (CVD); support for breastfeeding; use of folic acid during pregnancy; and screening for syphilis, latent tuberculosis (TB), herpes, chronic obstructive pulmonary disease (COPD), colorectal cancer (CRC), obstructive sleep apnea (OSA), celiac disease, and skin cancer. The Task Force also released a draft recommendation regarding prostate cancer screening in asymptomatic men (see “A change for prostate cancer screening?”) and addressed screening pelvic examinations in asymptomatic women, the subject of this month’s audiocast. (To listen, go to: http://bit.ly/2nIVoD5.)
Recommendations to implement
Recommendations from the past year that family physicians should put into practice are detailed below and in TABLE 1.2-8
CRC: Screen all individuals ages 50 to 75, but 76 to 85 selectively. The Task Force reaffirmed its 2008 finding that screening for CRC in adults ages 50 to 75 years is substantially beneficial.2 In contrast to the previous recommendation, however, the new one does not state which screening tests are preferred. The tests considered were 3 stool tests (fecal immunochemical test [FIT], FIT-tumor DNA testing [FIT-DNA], and guaiac-based fecal occult blood test [gFOBT]), as well as 3 direct visualization tests (colonoscopy, sigmoidoscopy, and CT colonoscopy). The Task Force assessed various testing frequencies of each test and some test combinations. While the Task Force does not recommend any one screening strategy, there are still significant unknowns about FIT-DNA and CT colonoscopy. The American Academy of Family Physicians does not recommend using these 2 tests for screening purposes at this time.9
CRC screening for adults ages 76 to 85 was given a “C” recommendation, which means the value of the service to the population overall is small, but that certain individuals may benefit from it. The Task Force advises selectively offering a “C” service to individuals based on professional judgment and patient preferences. Regarding CRC screening in individuals 76 years or older, the ones most likely to benefit are those who have never been screened and those without significant comorbidities that could limit life expectancy. All “C” recommendations from the past year are listed in TABLE 2.2-4
CVD prevention: When aspirin or a statin is indicated. The Task Force released 2 recommendations for the prevention of CVD this past year. One pertained to the use of low-dose aspirin3 (which also helps to prevent CRC), and the other addressed the use of low- to moderate-dose statins.4 Each recommendation is fairly complicated and nuanced in terms of age and risk for CVD. A decision to use low-dose aspirin must also consider the risk of bleeding.
To calculate a patient’s risk for CVD, the Task Force recommends using the risk calculator developed by the American College of Cardiology and the American Heart Association (http://www.cvriskcalculator.com/).
Adults for whom low-dose aspirin and low- to moderate-dose statins are recommended are described in TABLE 1.2-8 Patients for whom individual decision making is advised, rather than a generalized recommendation, are reviewed in TABLE 2.2-4 There is insufficient evidence to make a recommendation for the use of aspirin before age 50 or at age 70 and older,3 and for the use of statins in adults age 76 and older who do not have a history of CVD4 (TABLE 33,4,10-14). The use of low-dose aspirin and low-to-moderate dose statins have been the subject of JFP audiocasts in May 2016 and January 2017. (See http://bit.ly/2oiun8d and http://bit.ly/2oqkohR.)
2 pregnancy-related recommendations. To prevent neural tube defects in newborns, the Task Force now recommends daily folic acid, 0.4 to 0.8 mg (400 to 800 mcg), for all women who are planning on or are capable of becoming pregnant.5 This is an update of a 2009 recommendation that was worded slightly differently, recommending the supplement for all women of childbearing age.
A new recommendation on breastfeeding recognizes its benefits for both mother and baby and finds that interventions to encourage breastfeeding increase the prevalence of this practice and its duration.6 Interventions—provided to individuals or groups by professionals or peers or through formal education—include promoting the benefits of breastfeeding, giving practical advice and direct support on how to breastfeed, and offering psychological support.
Latent TB: Advantages of newer testing method. The recommendation on screening for latent tuberculosis (TB) is an update from the one made in 1996.7 At that time, screening for latent infection was performed using a tuberculin skin test (TST). Now a TST or interferon-gamma release assay (IGRA) can be used. Testing with IGRA may be the best option for those who have received a bacille Calmette–Guérin vaccination (because it can cause a false-positive TST) or for those who are not likely to return to have their TST read.
Those at high risk for latent TB include people who were born or have resided in countries with a high TB prevalence, those who have lived in a correctional institution or homeless shelter, and anyone in a high-risk group based on local epidemiology of the disease. (Read more on TB in this month’s Case Report.) Others at high risk are those who are immune suppressed because of infection or medications, and those who work in health care or correctional facilities. Screening of these groups is usually conducted as part of occupational health or is considered part of routine health care.
Syphilis: Screen high-risk individuals in 2 steps. The recommendation on syphilis screening basically reaffirms the one from 2004.8 Those at high risk for syphilis include men who have sex with men (who now account for 90% of new cases), those who are HIV positive, and those who engage in commercial sex work. Other racial and demographic groups can be at high risk depending on the local epidemiology of the disease. In a separate recommendation, the Task Force advises screening all pregnant women for syphilis.
Screening for syphilis infection involves 2 steps: first, a nontreponemal test (Venereal Disease Research Laboratory [VDRL] or rapid plasma reagin [RPR] test); second, a confirmatory treponemal antibody detection test (fluorescent treponemal antibody absorption [FTA-ABS] or Treponema pallidum particle agglutination [TPPA] test). Treatment for syphilis remains benzathine penicillin with the number of injections depending on the stage of infection. The Centers for Disease Control and Prevention is the best source for current recommendations for treatment of all sexually transmitted infections.15
Screening tests to avoid
TABLE 416,17 lists screening tests the Task Force recommends against. While chronic obstructive pulmonary disease afflicts 14% of US adults ages 40 to 79 years and is the third leading cause of death in the country, the Task Force found that early detection in asymptomatic adults does not affect the course of the illness and is of no benefit.16
Genital herpes, also prevalent, infects an estimated one out of 6 individuals, ages 14 to 49. It causes little mortality, except in neonates, but those infected can have recurrent flares and suffer psychological harms from stigmatization. Most genital herpes is caused by herpes simplex virus-2, and there is a serological test to detect it. However, the Task Force recommends against using the test to screen asymptomatic adults and adolescents, including those who are pregnant. This recommendation is based on the test’s high false-positive rate, which can cause emotional harm, and on the lack of evidence that detection through screening improves outcomes.17
The evidence is lacking for these practices
The Task Force is one of only a few organizations that will not make a recommendation if evidence is lacking on benefits and harms. In addition to the ‘I’ statements regarding CVD and CRC mentioned earlier, the Task Force found insufficient evidence to recommend screening for lipid disorders in individuals ages 20 years or younger,10 performing a visual skin exam as a screening tool for skin cancer,11 screening for celiac disease,12 performing a periodic pelvic examination in asymptomatic women,13 and screening for obstructive sleep apnea using screening questionnaires14 (TABLE 33,4,10-14).
SIDEBAR
A change for prostate cancer screening?The USPSTF recently issued new draft recommendations regarding prostate cancer screening in asymptomatic men (available at: https://screeningforprostatecancer.org/).
The draft now divides men into 2 age groups, stating that the decision to screen for prostate cancer using a prostate specific antigen (PSA) test should be individualized for men ages 55 to 69 years (a C recommendation, meaning that there is at least moderate certainty that the net benefit is small), and that men ages 70 and older (lowered from age 75 in the previous 2012 recommendation1) should not be screened (a D recommendation, meaning that there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits).
The USPSTF believes that clinicians should explain to men ages 55 to 69 years that screening offers a small potential benefit of reducing the chance of dying from prostate cancer, but also comes with potential harms, including false-positive results requiring additional testing/procedures, overdiagnosis and overtreatment, and treatment complications such as incontinence and impotence. In this way, each man has the chance to incorporate his values and preferences into the decision.
For men ages 70 and older, the potential benefits simply do not outweigh the potential harms, according to the USPSTF.
1. USPSTF. Final recommendation statement. Prostate cancer: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/prostate-cancer-screening#Pod1. Accessed April 11, 2017.
1. Campos-Outcalt D. Eight USPSTF recommendations FPs need to know about. J Fam Pract. 2016;65:338-341.
2. USPSTF. Colorectal cancer: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/colorectal-cancer-screening2. Accessed March 22, 2017.
3. USPSTF. Aspirin use to prevent cardiovascular disease and colorectal cancer: preventive medications. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/aspirin-to-prevent-cardiovascular-disease-and-cancer. Accessed March 22, 2017.
4. USPSTF. Statin use for the prevention of cardiovascular disease in adults: preventive medication. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/statin-use-in-adults-preventive-medication1. Accessed March 22, 2017.
5. USPSTF. Folic acid for the prevention of neural tube defects: preventive medication. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/folic-acid-for-the-prevention-of-neural-tube-defects-preventive-medication. Accessed March 22, 2017.
6. USPSTF. Breastfeeding: primary care interventions. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breastfeeding-primary-care-interventions. Accessed March 22, 2017.
7. USPSTF. Latent tuberculosis infection: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/latent-tuberculosis-infection-screening. Accessed March 22, 2017.
8. USPSTF. Syphilis infection in nonpregnant adults and adolescents: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/syphilis-infection-in-nonpregnant-adults-and-adolescents. Accessed March 22, 2017.
9. AAFP. Colorectal cancer screening, adults. Available at: http://www.aafp.org/patient-care/clinical-recommendations/all/colorectal-cancer.html. Accessed March 22, 2017.
10. USPSTF. Lipid disorders in children and adolescents: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/lipid-disorders-in-children-screening1. Accessed March 22, 2017.
11. USPSTF. Skin cancer: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/skin-cancer-screening2. Accessed March 22, 2017.
12. USPSTF. Celiac disease: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/celiac-disease-screening. Accessed March 22, 2017.
13. USPSTF. Gynecological conditions: periodic screening with the pelvic examination. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/gynecological-conditions-screening-with-the-pelvic-examination. Accessed March 22, 2017.
14. USPSTF. Obstructive sleep apnea in adults: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/obstructive-sleep-apnea-in-adults-screening. Accessed March 22, 2017.
15. CDC. 2015 sexually transmitted diseases treatment guidelines. Available at: https://www.cdc.gov/std/tg2015/default.htm. Accessed March 22, 2017.
16. USPSTF. Chronic obstructive pulmonary disease: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/chronic-obstructive-pulmonary-disease-screening. Accessed March 22, 2017.
17. USPSTF. Genital herpes infection: serologic screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/genital-herpes-screening1. Accessed March 22, 2017.
1. Campos-Outcalt D. Eight USPSTF recommendations FPs need to know about. J Fam Pract. 2016;65:338-341.
2. USPSTF. Colorectal cancer: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/colorectal-cancer-screening2. Accessed March 22, 2017.
3. USPSTF. Aspirin use to prevent cardiovascular disease and colorectal cancer: preventive medications. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/aspirin-to-prevent-cardiovascular-disease-and-cancer. Accessed March 22, 2017.
4. USPSTF. Statin use for the prevention of cardiovascular disease in adults: preventive medication. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/statin-use-in-adults-preventive-medication1. Accessed March 22, 2017.
5. USPSTF. Folic acid for the prevention of neural tube defects: preventive medication. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/folic-acid-for-the-prevention-of-neural-tube-defects-preventive-medication. Accessed March 22, 2017.
6. USPSTF. Breastfeeding: primary care interventions. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breastfeeding-primary-care-interventions. Accessed March 22, 2017.
7. USPSTF. Latent tuberculosis infection: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/latent-tuberculosis-infection-screening. Accessed March 22, 2017.
8. USPSTF. Syphilis infection in nonpregnant adults and adolescents: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/syphilis-infection-in-nonpregnant-adults-and-adolescents. Accessed March 22, 2017.
9. AAFP. Colorectal cancer screening, adults. Available at: http://www.aafp.org/patient-care/clinical-recommendations/all/colorectal-cancer.html. Accessed March 22, 2017.
10. USPSTF. Lipid disorders in children and adolescents: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/lipid-disorders-in-children-screening1. Accessed March 22, 2017.
11. USPSTF. Skin cancer: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/skin-cancer-screening2. Accessed March 22, 2017.
12. USPSTF. Celiac disease: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/celiac-disease-screening. Accessed March 22, 2017.
13. USPSTF. Gynecological conditions: periodic screening with the pelvic examination. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/gynecological-conditions-screening-with-the-pelvic-examination. Accessed March 22, 2017.
14. USPSTF. Obstructive sleep apnea in adults: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/obstructive-sleep-apnea-in-adults-screening. Accessed March 22, 2017.
15. CDC. 2015 sexually transmitted diseases treatment guidelines. Available at: https://www.cdc.gov/std/tg2015/default.htm. Accessed March 22, 2017.
16. USPSTF. Chronic obstructive pulmonary disease: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/chronic-obstructive-pulmonary-disease-screening. Accessed March 22, 2017.
17. USPSTF. Genital herpes infection: serologic screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/genital-herpes-screening1. Accessed March 22, 2017.
