Section 3.1: Primary Care Screening Guidelines

Section 3.1: Primary Care Screening Guidelines

Clinical preventive services are a cornerstone of primary care, and family nurse practitioners must be proficient in applying evidence-based screening guidelines. The United States Preventive Services Task Force (USPSTF) provides the primary framework for these recommendations, grading them based on the strength of the evidence and net benefit (Grade A, B, C, D, or I). FNP board exams heavily test these specific age cohorts, modalities, and frequencies.

Cancer Screening Guidelines

Breast Cancer Screening

• USPSTF 2024 Update: Biennial (every 2 years) mammography for women aged 40 to 74 years (Grade B). Starting age is now 40 (lowered from 50) for average-risk women.
• Age 75+: Evidence is insufficient to recommend for or against screening (Grade I).

Cervical Cancer Screening (ASCCP & USPSTF)

• Age < 21 Years: Do not screen, regardless of sexual history (Grade D).
• Age 21–29 Years: Cytology (Pap smear) alone every 3 years (Grade A). Do not use HPV testing in this group.
• Age 30–65 Years: Three screening options (Grade A):
  1. Primary high-risk HPV (hrHPV) testing alone every 5 years.
  2. Co-testing (hrHPV + cytology) every 5 years.
  3. Cytology alone every 3 years.
• Age > 65 Years: Stop screening if adequate negative history (3 negative cytology or 2 negative co-tests in the past 10 years, most recent within 5 years) and not high risk (Grade D).
• Post-Hysterectomy: Discontinue if cervix was removed for benign indications and no history of high-grade precancer (CIN 2/3) or cervical cancer.

Colorectal Cancer Screening

• Age 45–75 Years: Screen all average-risk adults (Grade A/B). Screening starts at age 45 (recently lowered from 50).
• Age 76–85 Years: Individualize the decision based on overall health, prior screening history, and life expectancy (Grade C).
• Screening Modalities and Frequencies:
  • Colonoscopy: Every 10 years (Gold standard).
  • Fecal Immunochemical Test (FIT) or Guaiac-based Fecal Occult Blood Test (gFOBT): Annually.
  • Stool DNA-FIT (Cologuard): Every 3 years.
  • CT Colonography or Flexible Sigmoidoscopy: Every 5 years.

Lung Cancer Screening

• Recommendation: Annual screening with low-dose computed tomography (LDCT) in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years (Grade B).
• Discontinuation: Stop screening once a person has not smoked for 15 years, develops a health problem that limits life expectancy, or is unable/unwilling to undergo curative lung surgery.

Prostate Cancer Screening

• Age 55–69 Years: Individualized shared decision-making using Prostate-Specific Antigen (PSA) screening (Grade C).
• Age 70 Years or Older: Do not screen routinely (Grade D).

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Cardiovascular and Metabolic Screening

Abdominal Aortic Aneurysm (AAA)

• Recommendation: One-time screening with abdominal ultrasonography in men aged 65 to 75 years who have ever smoked (defined as 100 or more cigarettes in their lifetime) (Grade B).
• Women: Do not screen women who have never smoked (Grade D).

Hypertension (HTN)

• Recommendation: Screen all adults aged 18 years or older (Grade A). Confirm the diagnosis outside of the clinical setting (e.g., home blood pressure monitoring) before initiating treatment.

Diabetes Mellitus and Prediabetes

• USPSTF Recommendation: Screen for prediabetes and type 2 diabetes in asymptomatic adults aged 35 to 70 years who are overweight or obese (Grade B).
• ADA Guidelines: Screen all adults starting at age 35, or earlier if overweight/obese with additional risk factors. Repeat every 3 years if normal.

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Immunizations & Beers Criteria

Immunizations

• Pneumococcal: Age 65+ (PCV20 alone or PCV15 followed by PPSV23 in 1 year). Also for ages 19–64 with chronic conditions (COPD, diabetes, smoking).
• Shingrix: 2-dose series for ages 50+ (spaced 2–6 months apart).
• Tdap: 1-time dose for adults, then Td/Tdap booster every 10 years. Give Tdap during each pregnancy (weeks 27–36).

Beers Criteria

Key inappropriate medications for adults aged 65+:

• Anticholinergics (diphenhydramine): Cognitive decline, sedation, dry mouth, urinary retention, falls.
• Benzodiazepines (diazepam): Cognitive impairment, delirium, falls.
• NSAIDs (ibuprofen): GI bleed, renal failure, fluid retention/heart failure.
• Sulfonylureas (glyburide): Severe, prolonged hypoglycemia.

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Clinical Traps and Worked Scenario

Clinical Traps to Avoid

1. Cervical Screening in Under-21s: Do not perform a Pap smear on a 19-year-old female, even if sexually active. Transient HPV clearance is high; screening leads to unnecessary procedures.
2. AAA Screening in Females: Do not order an ultrasound for AAA in a female patient, regardless of her smoking history, as a routine screening measure.
3. Mammography Frequency: Recommend biennial screening, not annual, under USPSTF guidelines.

Worked Scenario

A 53-year-old male presents for a wellness exam. He has a 22 pack-year smoking history but quit 8 years ago. He is overweight (BMI 28 kg/m²) but asymptomatic.

• Action Plan:
  1. Lung Cancer Screening: The patient is eligible. He is 53, has a >20 pack-year history, and quit less than 15 years ago. Order an annual low-dose chest CT (LDCT).
  2. Colorectal Cancer Screening: He is over 45. Order a screening colonoscopy (or discuss stool-based alternatives).
  3. Diabetes Screening: He is over 35 and overweight. Order a fasting plasma glucose or HbA1c.
  4. AAA Screening: Do not order yet. AAA screening is a one-time test for men aged 65 to 75. He is too young.
  5. Pneumococcal Vaccine: Under current CDC guidelines, cigarette smoking is a high-risk indication for adults aged 19–64 to receive a single dose of pneumococcal vaccine (PPSV23 or PCV20).