Preventive Medicine Section
Evidenced-based Clinical Preventive Services Helena Karnani, MD
Abstract: Preventive medicine recommendations are constantly being
updated and it is important for physicians to keep current and offer appropriate clinical preventive services to their patients. This article will review the latest recommendations for clinical preventive services and immunizations from the United States Preventive Services Task Force, the American Cancer Society and the Centers for Disease Control. It will also discuss the evidence, rationale and controversies surrounding some of these recommendations.
Introduction Physicians play an important role in maintaining patients’ health and wellness and avoiding preventable diseases, yet, we could be doing a better job. A 2010 report from the Commonwealth Fund1 found that the US ranks last on measures of healthy living when compared to six other industrialized countries such as Canada, Australia and Germany. Statistics reviewed included infant mortality rates and preventable deaths before the age of 75. The US is second to last on measures of healthy life expectancy at age 60. Florida ranks 34th out of all 50 states regarding the health of its citizens, and Duval County has significantly worse statistics than the State average in areas including rates of obesity, diabetes and breast cancer.2 Many factors influence public health but, as health care professionals, we can do our part to make a difference in the health of our community and our patients. This article will focus on recent evidence-based guidelines for disease prevention for leading health issues in adults from the United States Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS). It will also update recent changes for immunization recommendations in adults and children. The USPSTF is a panel of independent scientists who review scientific evidence related to clinical preventive services and make recommendation statements that weigh the effectiveness, benefits and harms of preventive interventions. These statements are published online as a guide to clinical preventive services.3 You may also download a USPSTF electronic preventative services selector (ePSS) to your PDA, mobile or tablet device which will list recommendations for patients of a specific age and sex. (Table 1)4, 5 Guidelines from the American Cancer Society may be accessed online at the Cancer Journal for Clinicians.6 Address correspondence to: Helena Karnani hkarnani@jaxhealth. com or to St Vincent’s Family Medicine Center, 2627, Riverside Ave, Jacksonville, Fl 32204 12 Vol. 64, No. 2 2013 Northeast Florida Medicine
Overview of Latest Recommendations for Leading Health Issues Cervical Cancer Screening:
Both the USPSTF and ACS updated their recommendations for cervical cancer screening in 2012. Both organizations recommend that screening with liquid based technology should start at age 21 regardless of the age of first intercourse and be performed at an interval of every three years. After the age of 30 the screening interval may be extended to every five years using a combination of cytology and HPV testing. Testing may stop at age 65 years if there are three consecutive normal PAPs and no PAPs of CIN2 (cervical intraepithelial neoplasia with moderate dysplasia) or greater in the past 20 years. PAP smears are not required after hysterectomy if there is no cervix and the woman does not have a history of CIN2 or worse in the past 20 years.7
Breast Cancer Screening:
The ACS last updated its breast screening guidelines in 20038 and recommends annual mammograms starting at age 40 and should continue annually for as long as a woman is in good health and would be a reasonably good candidate for treatment. ACS states the decision to stop screening after a certain age should be an individual decision taking into account estimated longevity and ability to be treated, as well as risks, benefits and the patient’s wishes. In 2007, the ACS recommended annual MRI screening in addition to mammograms starting at age 30 in women with life time risk of breast cancer is greater than 20-25 percent (as determined by the Gail9 or BRCA PRO10 scores). This recommendation includes women with BRCA mutations, a history of chest radiation and other high risk syndromes. The USPSTF updated its recommendations in 2009. It recommends biennial screening mammograms for women aged 50 to 74 years and notes there is insufficient evidence to assess the benefits and harms of screening after age 74. The USPSTF states that regular screening younger than the age of 50 should be an individual patient decision after discussing the specific benefits and harms. This latter recommendation caused great debate when it was first published since most physicians recommend mammograms for women in their 40’s and these women expect to have them. So, why the controversy? Even with new technology, mammography has a sensitivity (true positive rate) of 77-95 percent, and is less sensitive in younger women. It is necessary to screen 1,904 women aged 40-49 to prevent one breast cancer death. At the www . DCMS online . org