Ambulatory Screening and Prevention

In this section, we cover the following screening and prevention recommendations:

U.S. Preventive Services Task Force (USPSTF) Screening Recommendations
USPSTF Cancer Screening Recommendations

Preventive Health Care Schedule: Recommendations from the USPSTF

The USPSTF provides a convenient online tool and Prevention TaskForce (formerly ePSS) application to help clinicians identify recommended patient-specific preventive services based on a patient’s sex, age, and other factors. The American Academy of Family Physicians (AAFP) is another excellent resource for preventative health recommendations.

Search the USPSTF website for the most up-to-date screening recommendations. Currently, the USPSTF recommends that all adults aged 18 years and older should be screened for the following:

Other USPSTF screening recommendations in adults include the following:

Hepatitis B, syphilis, tuberculosis in adults at increased risk
BRCA gene risk assessment in adults with a personal or family history of BRCA-related cancer or ancestry
Chlamydia and gonorrhea in women who are sexually active and at increased risk
Intimate partner violence in women of childbearing age
Prediabetes and type 2 diabetes in obese/overweight adults starting at age 20
Cancer: cervical, colorectal, breast, lung (recommendations detailed below)
Osteoporosis in postmenopausal women older than age 65 or at elevated risk
Abdominal aortic aneurysm (AAA) in men older than age 65 at elevated risk

Cancer Screening

Screening for cancer has been controversial, and recommendations have evolved over time. In addition, cancer screening guidelines from professional specialty societies, advocacy organizations, and the USPSTF often conflict with one another. In this section, we focus on recommendations from the USPSTF, but it is worthwhile to be familiar with other groups’ recommendations that are often reported by the media and are known to patients. Recognize that screening is not without risks. False-positive results can lead to unnecessary tests and procedures that cause physical and emotional harm. Ultimately, the decision to screen is a personalized one made after discussing the risks and benefits with the patient. Patients typically need to have a life expectancy of at least 10 more years to benefit from screening.

Below, we summarize screening recommendations for the following cancers:

Colorectal Cancer
Cervical Cancer
Breast Cancer
Lung Cancer
Prostate Cancer

Colorectal Cancer

The 2021 USPSTF recommendations on screening for colorectal cancer in patients at average risk are as follows:

All patients should be screened for colorectal cancer between ages 45 and 49 years (grade B recommendation) and ages 50 and 75 years (grade A recommendation).
Screening between ages 76 and 85 should be individualized and based on each patient’s overall health (grade C recommendation). Patients in this age group who have never been screened are more likely to benefit. They should be healthy enough to undergo treatment for colorectal cancer and should not have comorbid conditions that significantly limit life expectancy.
The following screening methods are acceptable in average-risk individuals, although the estimated benefit varies. Consider patient preference; it is better to screen with a method that the patient prefers than not to screen at all.
- stool-based
  - annual high-sensitivity fecal occult-blood test (FOBT): has randomized controlled trial (RCT) evidence of mortality benefit
  - annual fecal immunochemical test (FIT): improved accuracy over FOBT
  - FIT-DNA test every 1 or 3 years: less specific than FIT but more sensitive
- direct visualization
  - CT colonography every 5 years: no sedation but still requires bowel prep
  - flexible sigmoidoscopy every 5 years: RCT evidence of mortality benefit
  - flexible sigmoidoscopy plus annual FIT every 10 years
  - colonoscopy every 10 years: prospective cohort evidence of mortality benefit

Primary prevention: In 2022, the USPSTF updated the recommendation for initiation of aspirin for primary prevention of cardiovascular disease (CVD) and changed the recommendation for the use of aspirin for primary prevention of colorectal cancer. The USPSTF states that the evidence is unclear as to whether aspirin use reduces the risk of colorectal cancer. The possible benefit may be related to aspirin’s inhibition of cyclooxygenase-2 activity, which normally stimulates oncogenesis pathways downstream (see a related NEJM article and editorial, and a NEJM Journal Watch summary). More research is needed to clarify the use of aspirin for the primary prevention of colorectal cancer.

Patients at high risk: The USPSTF did not examine evidence regarding patients with a positive family history of colorectal cancer, but guidelines are available from the U.S. Multi-Society Task Force (MSTF) on Colorectal Cancer (see table below).

A strong family history, such as a first-degree relative who had colorectal cancer before age 50, should prompt consideration for referral to a specialist with expertise in hereditary syndromes, such as familial adenomatous polyposis or hereditary nonpolyposis colorectal cancer (Lynch syndrome).
Although multiple options for screening exist, the MSTF recommends colonoscopy in patients with increased risk for colorectal cancer, when possible.
Once an adenoma is detected, the patient should initiate scheduled surveillance.

MSTF Recommendations for Persons with High-Risk Family Histories Not Associated with Polyp Syndromes

Family History	Recommended Screening
Lynch syndrome	See MSTF guidelines
Familial colon cancer syndrome X	Colonoscopy every 3-5 years beginning 10 years before the age at diagnosis of the youngest affected relative
Colorectal cancer or an advanced adenoma in two first-degree relatives diagnosed at any age OR colorectal cancer or an advanced adenoma in a single first-degree relative at age <60 years	Colonoscopy every 5 years beginning 10 years before the age at diagnosis of the youngest affected first-degree relative or age 40, whichever is earlier; for those with a single first-degree relative with colorectal cancer in whom no significant neoplasia appears by age 60 years, physicians can offer expanding the interval between colonoscopies
Colorectal cancer or an advanced adenoma in a single first-degree relative diagnosed at age ≥60 years	Begin screening at age 40 years; tests and intervals are as per the average-risk screening recommendations

Cervical Cancer

As of early 2023, the USPSTF is in the process of updating cervical cancer screening recommendations. The 2018 USPSTF cervical cancer screening guideline recommends:

screening in women aged 21-65 with cytology (Pap smear) every 3 years and women aged 30-65 with combination cytology and human papillomavirus (HPV) co-testing or high-risk HPV testing alone every 5 years (grade A recommendation)
- The USPSTF recommends against:
screening with HPV testing alone or with cytology in women aged <30
screening women aged <21
screening women aged >65 who have had adequate prior screening (three consecutive negative cytology results or two consecutive negative HPV results within 10 years with most recent test in the past 5 years)
screening women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer

The recommendations do not apply to women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised, such as with HIV.

Breast Cancer

As of early 2023, the USPSTF is in the process of updating breast-cancer screening recommendations. The 2016 USPSTF breast-cancer screening guideline recommends:

Biennial screening mammography for women aged 50-74 (grade B): This recommendation is controversial and varies by specialty group.
For women aged 40-49, the decision to start screening mammography is individualized on the basis of patient risks and values; patients who place a higher value on the benefits may choose biennial screening (grade C).
Current evidence is insufficient to recommend screening mammography at age ≥75.
Although there is no recommendation for breast self-examination screening, patients should be encouraged to inform physicians of any concerning breast masses, skin changes, or nipple discharge.

Note: The 2019 USPSTF guideline on medication use to reduce risk of breast cancer is a grade B recommendation for prescribing selective estrogen-receptor modulators such as tamoxifen or raloxifene to prevent breast cancer in women at increased risk after discussing the risks and benefits. The Breast Cancer Risk Assessment Tool is one available method to help estimate risk.

Lung Cancer

The USPSTF lung cancer screening guideline was updated in 2021. The final recommendation statement expands the age range for screening and reduces pack-year history. The following are grade B recommendations:

lung cancer screening with low-dose computed tomography (CT) every year for all adults aged 50 to 80 years who have a 20-pack-year smoking history and either currently smoke or have quit within the past 15 years
discontinue screening if a patient has not smoked for 15 years or has developed a health issue that limits life expectancy or the ability/willingness to have curative lung surgery

Prostate Cancer

The 2018 USPSTF prostate cancer screening guideline recommends:

Informed discussion with men aged 55-69 about the potential harms and benefits of periodic prostate-specific antigen (PSA)-based screening (grade C): The USPSTF’s infographic to help clinicians counsel patients and estimate risks and benefits explains that for every 1000 men aged 55-69 offered screening, over 10-15 years, one to two deaths can be avoided while 60 or more men may experience serious complications, such as urinary incontinence, sexual impotence, or both, from treatment.
PSA-based screening is not recommended for men aged ≥70.
Black men and men with a family history of prostate cancer are at increased risk, but the USPSTF is unable to make any specific recommendations for these populations.