Discussion: Women’s and Men’s Health, Infectious Disease, and Hematologic Disorders

Title

Screening for Abdominal Aortic Aneurysm

Population

Men ages 65 to 75 years who have ever smoked

Men ages 65 to 75 years who have never smoked

Women ages 65 to 75 years

Recommendation

Screen once for abdominal aortic aneurysm with ultrasonography. Grade: B

No recommendation for or against screening. Grade: C

Do not screen for abdominal aortic aneurysm. Grade: D

Risk Assessment

The major risk factors for abdominal aortic aneurysm include male sex, a history of ever smoking (defined as 100 cigarettes in a person's lifetime), and age of 65 years or older.

Screening Tests

Screening abdominal ultrasonography is an accurate test when performed in a setting with adequate quality assurance (i.e., in an accredited facility with credentialed technologists). Abdominal palpation has poor accuracy and is not an adequate screening test.

Timing of Screening

One-time screening to detect an abdominal aortic aneurysm using ultrasonography is sufficient. There is negligible health benefit in re-screening those who have normal aortic diameter on initial screening.

Interventions

Open surgical repair of an aneurysm of at least 5.5 cm leads to decreased abdominal aortic aneurysm-related mortality in the long term; however, there are major harms associated with this procedure.

Balance of Benefits and Harms

In men ages 65 to 75 years who have ever smoked, the benefits of screening for abdominal aortic aneurysm outweigh the harms.

In men ages 65 to 75 years who have never smoked, the balance between the benefits and harms of screening for abdominal aortic aneurysm is too close to make a general recommendation for this population.

The potential overall benefit of screening for abdominal aortic aneurysm among women ages 65 to 75 years is low because of the small number of abdominal aortic aneurysm-related deaths in this population and the harms associated with surgical repair.

Other Relevant USPSTF Recommendations

The USPSTF has made recommendations on screening for carotid artery stenosis, coronary heart disease, high blood pressure, lipid disorders, and peripheral arterial disease. These recommendations are available at http://www.uspreventiveservicestaskforce.org .

Title

Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse

Population

Adults aged 18 years or older

Adolescents

Recommendation

Screen for alcohol misuse and provide brief behavioral counseling interventions to persons engaged in risky or hazardous drinking. Grade: B

No recommendation. Grade: I statement

Screening Tests

Numerous screening instruments can detect alcohol misuse in adults with acceptable sensitivity and specificity. The USPSTF prefers the following tools for alcohol misuse screening in the primary care setting:

1. AUDIT

2. Abbreviated AUDIT-C

3. Single-question screening, such as asking, “How many times in the past year have you had 5 (for men) or 4 (for women and all adults older than 65 years) or more drinks in a day?”

Behavioral Counseling Interventions

Counseling interventions in the primary care setting can improve unhealthy alcohol consumption behaviors in adults engaging in risky or hazardous drinking. Behavioral counseling interventions for alcohol misuse vary in their specific components, administration, length, and number of interactions. Brief multicontact behavioral counseling seems to have the best evidence of effectiveness; very brief behavioral counseling has limited effect.

Balance of Benefits and Harms

There is a moderate net benefit to alcohol misuse screening and brief behavioral counseling interventions in the primary care setting for adults aged 18 years or older.

The evidence on alcohol misuse screening and brief behavioral counseling interventions in the primary care setting for adolescents is insufficient, and the balance of benefits and harms cannot be determined.

Other Relevant USPSTF Recommendations

The USPSTF has made recommendations on screening for illicit drug use and counseling and interventions to prevent tobacco use. These recommendations are available at http://www.uspreventiveservicestaskforce.org .

Title

Aspirin for the Prevention of Cardiovascular Disease

Population

Men age 45-79 years

Women age 55-79 years

Men age <45 years

Women age <55 years

Men & Women age ≥80 years

Recommendation

Encourage aspirin use when potential CVD benefit (MIs prevented) outweighs potential harm of GI hemorrhage.

Encourage aspirin use when potential CVD benefit (strokes prevented) outweighs potential harm of GI hemorrhage.

Do not encourage aspirin use for MI prevention.

Do not encourage aspirin use for stroke prevention.

No Recommendation

Grade: A

Grade: D

Grade: I (Insufficient Evidence)

How to Use This Recommendation

Shared decision making is strongly encouraged with individuals whose risk is close to (either above or below) the estimates of 10-year risk levels indicated below. As the potential CVD benefit increases above harms, the recommendation to take aspirin should become stronger.

To determine whether the potential benefit of MIs prevented (men) and strokes prevented (women) outweighs the potential harm of increased GI hemorrhage, both 10-year CVD risk and age must be considered.

Risk level at which CVD events prevented (benefit) exceeds GI harms

The table above applies to adults who are not taking NSAIDs and who do not have upper GI pain or a history of GI ulcers.

NSAID use and history of GI ulcers raise the risk of serious GI bleeding considerably and should be considered in determining the balance of benefits and harms. NSAID use combined with aspirin use approximately quadruples the risk of serious GI bleeding compared to the risk with aspirin use alone. The rate of serious bleeding in aspirin users is approximately 2-3 times higher in patients with a history of GI ulcers.

Risk Assessment

For men: Risk factors for CHD include age, diabetes, total cholesterol level, HDL level, blood pressure, and smoking. CHD risk estimation tool: http://hp2010.nhlbihin.net/atpiii/calculator.asp 

For women: Risk factors for ischemic stroke include age, high blood pressure, diabetes, smoking, history of CVD, atrial fibrillation, and left ventricular hypertrophy. Stroke risk estimation tool: http://www.westernstroke.org/index.php?header_name=stroke_tools.gif&main=stroke_tools.php 

Other Relevant USPSTF Recommendations

The USPSTF has made recommendations on screening for abdominal aortic aneurysm, carotid artery stenosis, coronary heart disease, high blood pressure, lipid disorders, and peripheral arterial disease. These recommendations are available at http://www.uspreventiveservicestaskforce.org .

Title

Routine Aspirin or Nonsteroidal Anti-Inflammatory Drug (NSAID) for the Primary Prevention of Colorectal Cancer

Population

Asymptomatic adults at average risk for colorectal cancer

Recommendation

Do not use aspirin or NSAIDs for the prevention of colorectal cancer. Grade: D

Risk Assessment

The major risk factors for colorectal cancer are older age (older than age 50 years), family history (having two or more first or second-degree relatives with colorectal cancer), and African American race.

Balance of Benefits and Harms

Aspirin and NSAIDs, taken in higher doses for longer periods, reduce the incidence of adenomatous polyps. However, there is poor evidence that aspirin and NSAID use leads to a reduction in colorectal cancer-associated mortality.

Aspirin increases the incidence of gastrointestinal bleeding and hemorrhagic stroke; NSAIDs increase the incidence of gastrointestinal bleeding and renal impairment, especially in the elderly.

The USPSTF concluded that the harms outweigh the benefits of aspirin and NSAID use for the prevention of colorectal cancer

Other Relevant USPSTF Recommendations

The USPSTF has made recommendations on screening for colorectal cancer and aspirin use for the prevention of cardiovascular disease. These recommendations are available at http://www.uspreventiveservicestaskforce.org .

Title

Screening for Bacterial Vaginosis in Pregnancy to Prevent Preterm Delivery

Population

Asymptomatic pregnant women without risk factors for preterm delivery

Asymptomatic pregnant women with risk factors for preterm delivery

Recommendation

Do not screen. Grade: D

No recommendation. Grade: I (Insufficient Evidence)

Risk Assessment

Risk factors of preterm delivery include:

· African-American women.

· Pelvic infection.

· Previous preterm delivery.

Bacterial vaginosis is more common among African-American women, women of low socioeconomic status, and women who have previously delivered low-birth-weight infants.

Screening Tests

Bacterial vaginosis is diagnosed using Amsel's clinical criteria or Gram stain.

When using Amsel's criteria, 3 out of 4 criteria must be met to make a clinical diagnosis:

1. Vaginal pH >4.7.

2. The presence of clue cells on wet mount.

3. Thin homogeneous discharge.

4. Amine 'fishy odor' when potassium hydroxide is added to the discharge.

Screening Intervals

Not applicable.

Treatment

Treatment is appropriate for pregnant women with symptomatic bacterial vaginosis infection.

Oral metronidazole and oral clindamycin, as well as vaginal metronidazole gel or clindamycin cream, are used to treat bacterial vaginosis.

The optimal treatment regimen is unclear.1

Title

Screening for Asymptomatic Bacteriuria in Adults

Population

All pregnant women

Men and nonpregnant women

Recommendation

Screen with urine culture Grade: A

Do not screen. Grade: D

Detection and Screening Tests

Asymptomatic bacteriuria can be reliably detected through urine culture.

The presence of at least 105 colony-forming units per mL of urine, of a single uropathogen, and in a midstream clean-catch specimen is considered a positive test result.

Screening Intervals

A clean-catch urine specimen should be collected for screening culture at 12-16 weeks' gestation or at the first prenatal visit, if later.

The optimal frequency of subsequent urine testing during pregnancy is uncertain.

Do not screen.

Benefits of Detection and Early Treatment

The detection and treatment of asymptomatic bacteriuria with antibiotics significantly reduces the incidence of symptomatic maternal urinary tract infections and low birthweight.

Screening men and nonpregnant women for asymptomatic bacteriuria is ineffective in improving clinical outcomes.

Harms of Detection and Early Treatment

Potential harms associated with treatment of asymptomatic bacteriuria include:

· Adverse effects from antibiotics.

· Development of bacterial resistance.

Other Relevant USPSTF Recommendations

Additional USPSTF recommendations involving screening for infectious conditions during pregnancy can be found at www.uspreventiveservicestaskforce.org/recommendations.htm#obstetric  and www.uspreventiveservicestaskforce.org/recommendations.htm#infectious .

Title

Screening for Bladder Cancer

Population

Asymptomatic adults

Recommendation

No recommendation. Grade: I (Insufficient Evidence)

Risk Assessment

Risk factors for bladder cancer include:

· Smoking

· Occupational exposure to carcinogens (e.g., rubber, chemical, and leather industries)

· Male sex

· Older age

· White race

· Infections caused by certain bladder parasites

· Family or personal history of bladder cancer

Screening Tests

Screening tests for bladder cancer include:

· Microscopic urinalysis for hematuria

· Urine cytology

· Urine biomarkers

Interventions

The principal treatment for superficial bladder cancer is transurethral resection of the bladder tumor, which may be combined with adjuvant radiation therapy, chemotherapy, biologic therapies, or photodynamic therapies.

Radical cystectomy, often with adjuvant chemotherapy, is used in cases of surgically resectable invasive bladder cancer.

Balance of Benefits and Harms

There is inadequate evidence that treatment of screen-detected bladder cancer leads to improved morbidity or mortality.

There is inadequate evidence on harms of screening for bladder cancer.

Suggestions for Practice

In deciding whether to screen for bladder cancer, clinicians should consider the following:

· Potential preventable burden: early detection of tumors with malignant potential could have an important impact on the mortality rate of bladder cancer.

· Potential harms: false-positive results may lead to anxiety and unneeded evaluations, diagnostic-related harms from cystoscopy and biopsy, harms from labeling and unnecessary treatments, and overdiagnosis.

· Current practice: screening tests used in primary practice include microscopic urinalysis for hematuria and urine cytology; urine biomarkers are not commonly used in part because of cost. Patients with positive findings are typically referred to a urologist for further evaluation.

Other Relevant USPSTF Recommendations

Recommendations on screening for other types of cancer can be found at www.uspreventiveservicestaskforce.org. 

Title

Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer In Women

Population

Asymptomatic women who have not been diagnosed with BRCA-related cancer

Recommendation

Screen women whose family history may be associated with an increased risk for potentially harmful BRCA mutations. Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing. Grade: B

Do not routinely recommend genetic counseling or BRCA testing to women whose family history is not associated with an increased risk for potentially harmful BRCA mutations. Grade: D

Risk Assessment

Family history factors associated with increased likelihood of potentially harmful BRCA mutations include breast cancer diagnosis before age 50 years, bilateral breast cancer, family history of breast and ovarian cancer, presence of breast cancer in ≥1 male family member, multiple cases of breast cancer in the family, ≥1 or more family member with 2 primary types of BRCA-related cancer, and Ashkenazi Jewish ethnicity.

Several familial risk stratification tools are available to determine the need for in-depth genetic counseling, such as the Ontario Family History Assessment Tool, Manchester Scoring System, Referral Screening Tool, Pedigree Assessment Tool, and FHS-7.

Screening Tests

Genetic risk assessment and BRCA mutation testing are generally multistep processes involving identification of women who may be at increased risk for potentially harmful mutations, followed by genetic counseling by suitably trained health care providers and genetic testing of selected high-risk women when indicated.

Tests for BRCA mutations are highly sensitive and specific for known mutations, but interpretation of results is complex and generally requires posttest counseling.

Treatment

Interventions in women who are BRCA mutation carriers include earlier, more frequent, or intensive cancer screening; risk-reducing medications (e.g., tamoxifen or raloxifene); and risk-reducing surgery (e.g., mastectomy or salpingo-oophorectomy).

Balance of Benefits and Harms

In women whose family history is associated with an increased risk for potentially harmful BRCA mutations, the net benefit of genetic testing and early intervention is moderate.

In women whose family history is not associated with an increased risk for potentially harmful BRCA mutations, the net benefit of genetic testing and early intervention ranges from minimal to potentially harmful.

Other Relevant USPSTF Recommendations

The USPSTF has made recommendations on medications for the reduction of breast cancer risk and screening for ovarian cancer. These recommendations are available at http://www.uspreventiveservicestaskforce.org .

Title

Medications for Risk Reduction of Primary Breast Cancer in Women

Population

Asymptomatic women aged ≥35 years without a prior diagnosis of breast cancer who are at increased risk for the disease

Asymptomatic women aged ≥35 years without a prior diagnosis of breast cancer who are not at increased risk for the disease

Recommendation

Engage in shared, informed decision making and offer to prescribe risk-reducing medications, if appropriate. Grade: B

Do not prescribe risk-reducing medications. Grade: D

Risk Assessment

Important risk factors for breast cancer include patient age, race/ethnicity, age at menarche, age at first live childbirth, personal history of ductal or lobular carcinoma in situ, number of first-degree relatives with breast cancer, personal history of breast biopsy, body mass index, menopause status or age, breast density, estrogen and progestin use, smoking, alcohol use, physical activity, and diet.

Available risk assessment models can accurately predict the number of breast cancer cases that may arise in certain study populations, but their ability to accurately predict which women will develop breast cancer is modest.

Preventive Medications

The selective estrogen receptor modulators tamoxifen and raloxifene have been shown to reduce the incidence of invasive breast cancer in women who are at increased risk for the disease. Tamoxifen has been approved for this use in women age 35 years or older, and raloxifene has been approved for this use in postmenopausal women. The usual daily doses for tamoxifen and raloxifene are 20 mg and 60 mg, respectively, for 5 years.

Balance of Benefits and Harms

There is a moderate net benefit from use of tamoxifen and raloxifene to reduce the incidence of invasive breast cancer in women who are at increased risk for the disease.

The potential harms of tamoxifen and raloxifene outweigh the potential benefits for breast cancer risk reduction in women who are not at increased risk for the disease.

Potential harms include thromboembolic events, endometrial cancer, and cataracts.

Other Relevant USPSTF Recommendations

The USPSTF has made recommendations on risk assessment, genetic counseling, and genetic testing for BRCA-related cancer, as well as screening for breast cancer. These recommendations are available at http://www.uspreventiveservicestaskforce.org .

Title

Screening for Breast Cancer Using Film Mammography

Population

Women aged 40-49 years

Women aged 50-74 years

Women aged ≥75 years

Recommendation

Individualize decision to begin biennial screening according to the patient's circumstances and values. Grade: C

Screen every 2 years. Grade: B

No recommendation. Grade: I (Insufficient Evidence)

Risk Assessment

This recommendation applies to women aged ≥40 years who are not at increased risk by virtue of a known genetic mutation or history of chest radiation. Increasing age is the most important risk factor for most women.

Screening Tests

Standardization of film mammography has led to improved quality. Refer patients to facilities certified under the Mammography Quality Standards Act (MQSA), listed at http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMQSA/mqsa.cfm.

Timing of Screening

Evidence indicates that biennial screening is optimal. A biennial schedule preserves most of the benefit of annual screening and cuts the harms nearly in half. A longer interval may reduce the benefit.

Benefits of Benefits and Harms

There is convincing evidence that screening with film mammography reduces breast cancer mortality, with a greater absolute reduction for women aged 50 to 74 years than for younger women.

Harms of screening include psychological harms, additional medical visits, imaging, and biopsies in women without cancer, inconvenience due to false-positive screening results, harms of unnecessary treatment, and radiation exposure. Harms seem moderate for each age group.

False-positive results are a greater concern for younger women; treatment of cancer that would not become clinically apparent during a woman's life (overdiagnosis) is an increasing problem as women age.

Rationale for No Recommendation (I Statement)

Among women 75 years or older, evidence of benefit is lacking

Other Relevant USPSTF Recommendations

The USPSTF has made recommendations on mammography screening for breast cancer, screening for ovarian cancer, and chemoprevention of breast cancer. These recommendations can be found at www.uspreventiveservicestaskforce.org. 

Title

Primary Care Interventions to Promote Breastfeeding

Population

Pregnant women

New mothers

The mother's partner, and friends

Infants and young children

Recommendation

Promote and support breastfeeding Grade: B

Benefits of Breastfeeding

Mothers

Less likelihood of breast and ovarian cancer

Infants

Fewer ear infections, lower-respiratory-tract infections, and gastrointestinal infections

Young children

Less likelihood of asthma, type 2 diabetes, and obesity

Interventions to Promote Breastfeeding

Interventions to promote and support breastfeeding have been found to increase the rates of initiation, duration, and exclusivity of breastfeeding. Consider multiple strategies, including:

· Formal breastfeeding education for mothers and families

· Direct support of mothers during breastfeeding

· Training of primary care staff about breastfeeding and techniques for breastfeeding support

· Peer support

Interventions that include both prenatal and postnatal components may be most effective at increasing breastfeeding duration.

In rare circumstances, for example for mothers with HIV and infants with galactosemia, breastfeeding is not recommended. Interventions to promote breastfeeding should empower individuals to make informed choices supported by the best available evidence.

Implementation

System-level interventions with senior leadership support may be more likely to be sustained over time.