Screening Guidelines & Evidence-Based Health Promotion (USPSTF)

Screening Guidelines & Evidence-Based Health Promotion (USPSTF)

Foundations of Evidence-Based Screening

Health promotion and disease prevention are fundamental pillars of primary care. Preventive care is categorized into three levels:

• Primary Prevention: Preventing initial disease onset in healthy populations (e.g., immunizations, lifestyle counseling).
• Secondary Prevention: Early detection and screening of subclinical disease (e.g., screening mammography, Pap smears, colonoscopy).
• Tertiary Prevention: Managing established chronic disease to prevent disability and complications (e.g., cardiac rehabilitation, diabetic foot care).

The USPSTF Grading System

The United States Preventive Services Task Force (USPSTF) assigns recommendation grades for preventive services in asymptomatic populations:

• Grade A: High certainty of substantial net benefit. Action: Offer service.
• Grade B: High certainty of moderate net benefit, or moderate certainty of substantial net benefit. Action: Offer service.
• Grade C: Offer selectively based on professional judgment and patient preferences (shared decision-making). Small net benefit.
• Grade D: Moderate/high certainty of no net benefit or harms outweigh benefits. Action: Discourage service.
• Grade I: Insufficient evidence to assess benefits versus harms.

Evidence-Based Cancer Screening Guidelines

Breast Cancer Screening (USPSTF 2024 Guidelines)

• Population: Average-risk women aged 40 to 74 years.
• Recommendation: Biennial screening mammography starting at age 40 through age 74 (Grade B). Lowered from age 50 to address rising breast cancer incidence in younger women.
• Women Aged $\ge 75$ Years: Evidence is insufficient (Grade I Statement).
• High-Risk Groups: Women with BRCA mutations or lifetime risk $>20%$ require annual breast MRI and specialized protocols.

Cervical Cancer Screening

• Ages 21 to 29 Years: Cervical cytology (Pap smear) alone every 3 years (Grade A). High-risk HPV (hrHPV) testing is not recommended in this group.
• Ages 30 to 65 Years: Three valid options (Grade A):
  1. Cervical cytology alone every 3 years.
  2. hrHPV co-testing every 5 years.
  3. hrHPV testing alone every 5 years.
• Cessation of Screening ($> 65$ Years): Discontinue screening in women older than 65 with adequate prior negative screening (3 consecutive negative Pap tests or 2 negative hrHPV tests within 10 years, most recent within 5 years) who are not at high risk (Grade D).
• Hysterectomy Exception: Discontinue screening if total hysterectomy with cervix removal was performed for benign disease without prior CIN 2/3 (Grade D).

Colorectal Cancer (CRC) Screening

• Ages 45 to 75 Years: Recommended for all average-risk adults (Grade A for 50-75; Grade B for 45-49).
• Screening Options & Intervals:
  • Colonoscopy: Every 10 years (gold standard).
  • Stool DNA-FIT (sDNA-FIT / Cologuard): Every 1 to 3 years. Positive results require diagnostic colonoscopy.
  • Fecal Immunochemical Test (FIT): Annually.
  • CT Colonography: Every 5 years.
  • Flexible Sigmoidoscopy: Every 5 years (or q10y with annual FIT).
• Ages 76 to 85 Years: Selective screening based on health status and prior screening history (Grade C).

Lung Cancer Screening

• Target Population: Adults aged 50 to 80 years with a 20 pack-year smoking history who currently smoke or quit within the past 15 years.
• Modality: Annual Low-Dose Computed Tomography (LDCT) (Grade B).
• Discontinuation: Stop screening once the person has quit for 15 years or develops a life-limiting health condition.

Prostate Cancer Screening

• Ages 55 to 69 Years: Individualized decision-making regarding PSA screening (Grade C), weighing modest mortality benefit against potential harms.
• Ages $\ge 70$ Years: Recommend against PSA screening (Grade D).

Cardiovascular & Metabolic Screening Recommendations

Abdominal Aortic Aneurysm (AAA) Screening

• Target Group: Men aged 65 to 75 years who have ever smoked ($\ge 100$ cigarettes in lifetime).
• Modality: One-time abdominal ultrasound screening (Grade B).
• Women: Recommend against routine screening in non-smoking women (Grade D).

Diabetes & Prediabetes Screening

• Target Group: Asymptomatic adults aged 35 to 70 years who are overweight or obese (BMI $\ge 25\text{ kg/m}^2$, or $\ge 23$ in Asian Americans) (Grade B).
• Tools: Fasting plasma glucose ($\ge 126\text{ mg/dL}$), HbA1c ($\ge 6.5%$), or OGTT.

Lipid Screening & Primary Cardiovascular Prevention

Initiate low- to moderate-dose statin therapy for primary CVD prevention in adults aged 40 to 75 years with no prior CVD, $\ge 1$ risk factor (dyslipidemia, diabetes, HTN, smoking), AND calculated 10-year ASCVD risk $\ge 10%$ (Grade B).

Adult Immunization Guidelines (CDC ACIP Updates)

APRNs follow the Advisory Committee on Immunization Practices (ACIP) adult schedule:

Pneumococcal Vaccination (Adults $\ge 65$ or High-Risk 19-64)

• Option A: Administer 1 dose of PCV20 (Prevnar 20) alone. No PPSV23 needed.
• Option B: Administer 1 dose of PCV15 followed by PPSV23 at least 1 year later.
• Option C: Administer 1 dose of PCV21 (Capvaxive) for expanded serotype coverage.

Herpes Zoster (Shingles)

Administer 2-dose series of Recombinant Zoster Vaccine (Shingrix / RZV) 2-6 months apart for all adults aged $\ge 50$ years, regardless of prior zoster episodes or live zoster vaccine receipt.

Respiratory Syncytial Virus (RSV)

Single dose of RSV vaccine (Arexvy, Abrysvo, mRESVIA) for adults aged $\ge 75$ years, and adults aged 60 to 74 years at increased risk of severe RSV due to chronic medical conditions, using shared clinical decision-making.

Tetanus, Diphtheria, Pertussis (Tdap / Td)

Administer 1 dose of Tdap, followed by Td or Tdap booster every 10 years. Administer Tdap during every pregnancy (27-36 weeks).