US Preventive Services Task Force UpdateREBECCA HART, MD, FAAFP2018 C. FRANK WEBBER AND INTERIM SESSIONRENAISSANCE AUSTIN HOTEL AUSTIN, TEXAS FRIDAY, APRIL 13, 2018

Speaker Disclosure

Dr. Hart has disclosed that she has no actual orpotential conflict of interest in relation to this topic.

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Objectives

By completing this educational activity, the participant should be better able to:

1. Consider the relevance of the strength of evidence in theguideline grading system.

2. Review the most recent updates in USPSTF guidelines 2016-2018.

3. Decide how to use USPSTF guidelines versus other nationalguidelines when counselling patients.

4. Discriminate between the UPSFTP guidelines and AAFPguidelines in colon and lung cancer screening.

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Screening Test Grading Systems A Recommendation

High certainty of substantial benefit B Recommendation

Moderate certainty of moderate benefit C Recommendation

Moderate certainty of small net benefit D Recommendation

No Benefit or Net Harm – the preventive service is not recommended I Recommendation

Low level or certainty – no recommendation can be made

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Insufficient EvidenceFROM THE USPSTF: The USPSTF issues a statement of insufficient evidence when the current

available evidence is insufficient to assess the balance of benefits and harmsof a service.

Evidence may be insufficient because of the limited number or size of studies,important flaws in study design or methods, inconsistency of findings acrossstudies, findings that are not generalizable to routine US primary care practice,or a lack of information on important health outcomes.

An “I” statement does not mean that the USPSTF recommends againstproviding a service. Rather, it means that the USPSTF cannot determinewhether there is an overall benefit or harm to providing the service, and moreinformation in the future may allow an estimation of effects on healthoutcomes.

An “I” statement is also a call for research to close gaps in the evidence.

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Screening vs. Testing

Screening Test Asymptomatic patient Benefits must outweigh risks of test Performed on a population at risk

i.e. Adults, children, pregnant women, age group

Testing Performing a test based on presenting symptoms Not a true screening of a population Patient specific

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2016 USPSTF RECOMMENDATIONS

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2016 Guidelines: New / Updated

Updated recommendations Colorectal Cancer Aspirin and statin use Depression screening – adults “I” recommendations for 6 topics

New Recommendation Autism Spectrum Disorder

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USPSTF Colorectal Cancer Recommendations

Grade A Recommendation Offer one of 7 options for colorectal screening age 50-75:

Annual Fecal immunochemical testing (FIT) Colonoscopy every 10 years FIT plus fecal DNA (Cologuard) every one to 3 years CT colonography every 5 years Flex sig q 10 yrs plus FIT q 5 years Annual guaiac based fecal occult blood testing

See more on this later in talk – AAFP versus USPSTF versus CDCdifferences

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Aspirin Use for Primary Prevention

Use a risk assessment tool: The Pooled Cohort Equations http://tools.acc.org/ascvd-risk-estimator

Aspirin use prevents nonfatal CV events and reduces the riskof colorectal death after 10 yrs of use

Use aspirin in adults 50-69 yrs old who have a 10 year CVevent risk of at least 10%, will take aspirin for at least 10 years,and not at risk for bleeding.

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Statin Use for Primary Prevention

Again, use a risk assessment tool: The Pooled Cohort Equations http://tools.acc.org/ascvd-risk-estimator

Grade B rating for low or moderate-dose statin for patientswith a 10 year CV event risk of 10% or greater

Grade C rating for those with a 7.5%-10% risk. This is much less aggressive recommendation than the

ACC/AHA guideline that would result in more statin use

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Depression Screening In Adults

Now includes pregnant and postpartum women Recommended Screening Tool: The Edinburgh Postnatal Depression Scale http://pesnc.org/wp-content/uploads/EPDS.pdf Grade B

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2016 Guideline Updates:“I” Recommendations

Not enough evidence to determine the benefit of screening for:1. Skin Cancer2. Lipid Disorders in children and adolescents3. Impaired Visual Acuity in Older Adults4. Depression in Children younger than 12 years old5. Aspirin use in Adults younger than 50 years or older than 706. Statin use in Adults older than 75 years with no CV history

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2016 Guideline UpdatesGrade “I” RecommendationsSkin Cancer Not enough research available to determine benefit/risk adequately. In 2016, an estimated 76,400 US men and women will develop melanoma and

10,100 will die from the disease.1

The USPSTF concludes that the current evidence is insufficient and that thebalance of benefit and harms of visual skin examination by a clinician to screenfor skin cancer in asymptomatic adults cannot be determined.

The optimal interval for visual skin examination by a clinician to screen for skincancer, if it exists, is unknown.

Benefits of Early Detection and Treatment Evidence is inadequate to reliably conclude that early detection of skin cancer

through visual skin examination by a clinician reduces morbidity or mortality.

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2016 Guidelines “I” Recommendations:

Lipid Disorders in children and adolescents 7.8% of children aged 8 to 17 years have elevated levels of TC (≥200 mg/dL) 7.4% of adolescents aged 12 to 19 years have elevated LDL-C (≥130 mg/dL) The rationale for screening for lipid disorders in children and adolescents is that

early identification and treatment of elevated levels of LDL-C could delay theatherosclerotic process and thereby reduce the incidence of prematureischemic cardiovascular events in adults.

The USPSTF found inadequate evidence on the quantitative difference indiagnostic yield between universal and selective screening for familialhypercholesterolemia or multifactorial dyslipidemia.

The USPSTF concludes that the current evidence is insufficient to assess thebalance of benefits and harms of screening for lipid disorders in children andadolescents 20 years or younger.

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Lipid Screening in Children

Screening rates for dyslipidemia in children and adolescents seen inprimary care have been low.

2.5% of well-child visits included lipid testing in 1995 3.2% included it in 2010 Claims data from health insurance plans report rare use of lipid-

lowering pharmacotherapy in 8- to 20-year-olds. Among more than 13 million children, 665 children initiated lipid-

lowering pharmacotherapy between 2005 and 2010, for an overallincidence rate of 2.6 prescriptions per 100,000 person-years.

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2016 Recommendations:Should You Screen for Visual Acuity in Older Adults? “I” recommendation Screening for Impaired Visual Acuity in Older Adults >65 Compared with a detailed ophthalmological examination, no visual acuity

screening test has both high sensitivity and specificity for the diagnosis of anyunderlying visual condition

The USPSTF concludes that the current evidence is insufficient to assess thebalance of benefits and harms of screening for impaired visual acuity in theprimary care setting.

Not enough studies have been done on this topic. The balance of benefits and harms cannot be determined. This recommendation statement does not include screening for glaucoma.

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2016 ”I” Recommendations

Should You Screen for Depression in Children? “I” recommendation: Screening for Depression in Children younger than

12 years old Evidence supports screening for depression in adolescents age 12-18,

but is inconclusive for screening for depression in children under 12. This is mainly based on incidence of depression in these age groups.

GRADE B statement for screening of adolescents: The USPSTF recommends screening for major depressive disorder

(MDD) in adolescents aged 12 to 18 years. Screening should be implemented with adequate systems in place to

ensure accurate diagnosis, effective treatment, and appropriatefollow-up.

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Depression in Children

Little is known about the prevalence of MDD in children aged11 years or younger.

The mean age of onset of MDD is about 14 to 15 years. Early onset is associated with worse outcomes. The average duration of a depressive episode in childhood

varies widely, from 2 to 17 months.

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2016 Guideline UpdatesShould All Adults Use Aspirin as Preventive Medicine? “I” recommendation Aspirin use in adults younger than 50 years or older than 70 The current evidence is insufficient to assess the balance of

benefits and harms of initiating aspirin use for the primaryprevention of CVD and CRC in adults younger than 50 years orover age 70.

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Aspirin Prophylaxis –Other Age Groups

Grade B AGE 50-59 The USPSTF recommends initiating low-dose aspirin use for the primary prevention of

cardiovascular disease (CVD) and colorectal cancer (CRC) in adults aged 50 to 59 yearswho have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, havea life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for atleast 10 years.

Grade C Age 60-69 The decision to initiate low-dose aspirin use for the primary prevention of CVD and CRC in

adults aged 60 to 69 years who have a 10% or greater 10-year CVD risk should be anindividual one.

Persons who are not at increased risk for bleeding, have a life expectancy of at least 10years, and are willing to take low-dose aspirin daily for at least 10 years are more likely tobenefit. Persons who place a higher value on the potential benefits than the potentialharms may choose to initiate low-dose aspirin.

https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/aspirin-to-prevent-cardiovascular-disease-and-cancer

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2016 Guideline UpdatesStatins in the Elderly “I” recommendation Statin use in Adults older than 75 years with no CV history Statement: The USPSTF concludes that the current evidence is insufficient

to assess the balance of benefits and harms of initiating statinuse for the primary prevention of CVD events and mortality inadults 76 years and older without a history of heart attack orstroke.

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2016 Guideline Updates

New Autism Spectrum Disorder Recommendation 23

Screening for Autism Spectrum Disorder “I” Recommendation: For children aged 18 months to 30 months: The USPSTF concludes that the current evidence is insufficient

to assess the balance of benefits and harms of screening forautism spectrum disorder (ASD) in young children for whom noconcerns of ASD have been raised by their parents or aclinician.

Siu AL; US Preventive Services Task Force. Screening for autism spectrum disorder in youngchildren: US Preventive Services Task Force recommendation statement. JAMA.

doi:10.1001/jama.2016.0018.

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Autism – CDC CriteriaAn Alternative View

All children should be screened for developmental delays and disabilities duringregular well-child doctor visits at: 9 months 18 months 24 or 30 months

All children should be screened specifically for ASD during regular well-childdoctor visits at: 18 months 24 months Additional screening might be needed if a child is at high risk for ASD (e.g.,

having a sister, brother or other family member with an ASD) or if behaviorssometimes associated with ASD are present

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2017 USPSTF RECOMMENDATIONS

2017 USPSTF Recommendations

A and B Recommendations: Folic Acid Supplementation Vision Screening for Children Obesity Screening in Children and Adolescents

“I” Recommendations: Celiac Disease OSA Herpes Pelvic exams

D Recommendations Thyroid Cancer – Do not screen asymptomatic adults

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Folic Acid Supplementation

For the prevention of Neural Tube Defects The USPSTF recommends that all women who are planning or

capable of pregnancy take a daily supplement containing0.4 to 0.8 mg (400 to 800 µg) of folic acid.

Grade A

(Not Changed from the 2009 statement)

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Vision Screening in Children Aged 6 Months to 5 y=Years

The USPSTF recommends vision screening at least once in allchildren aged 3-5 years to detect amblyopia or its risk factors.

GRADE B The USPSTF concludes that the current evidence is insufficient

to assess the balance of benefits and harms of visionscreening in children younger than 3 years.

GRADE ”I” https://www.aafp.org/afp/2017/1215/od1.html

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Obesity Screening in Children and Adolescents 6 yrs and Older

• GRADE BThe USPSTF recommends that cliniciansscreen for obesity in children andadolescents 6 years and older and offer orrefer them to comprehensive, intensivebehavioral interventions to promoteimprovements in weight status.

• Screening and intensive behavioralinterventions for obesity in children andadolescents 6 years and older can lead toimprovements in weight status.

• The magnitude of this benefit is moderate.

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2017 Insufficient Evidence –Grade ”I”Not enough good studies to determine clearly for: Celiac Disease OSA screening in asymptomatic adults Genital herpes in asymptomatic adolescents or adults, including pregnant Screening pelvic exams in asymptomatic, non-pregnant adult women Idiopathic Scoliosis in Adolescents 10-18

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Thyroid Cancer

Grade D The USPSTF recommends against screening for thyroid cancer in

asymptomatic adults. The USPSTF found inadequate evidence to estimate the accuracy of

neck palpation or ultrasound as a screening test for thyroid cancer inasymptomatic persons.

The USPSTF found adequate evidence to bound the magnitude of theoverall harms of screening and treatment as at least moderate, based onadequate evidence of serious harms of treatment of thyroid cancer andevidence that overdiagnosis and overtreatment are likely consequencesof screening.

https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/thyroid-cancer-screening1

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2018 UPDATES

Preeclampsia Ovarian Cancer Obesity in Adults Hormone Therapy for Prevention of Chronic Disease

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2018 Recommendations

Preeclampsia UPDATE The USPSTF recommends screening for preeclampsia in pregnant women

with blood pressure measurements throughout pregnancy. GRADE B What’s New? Updated from 1996 More rigorous science used to determine the recommendation:

The 1996 review did not contain An analytic framework Key Questions A systematic review

https://www.aafp.org/afp/2018/0115/od1.html

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Ovarian Cancer – UPDATE –Still Grade D

Ovarian Cancer facts: 14,000 deaths per year 5th most common cause of cancer death among US women The leading cause of death from gynecologic cancer. More than 95% of ovarian cancer deaths occur among

women 45 years and older We need a screening test!

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Ovarian Cancer – UPDATE – Grade D STATEMENT: The USPSTF found adequate evidence

That screening for ovarian cancer does not reduce ovarian cancermortality.

That the harms from screening for ovarian cancer are at leastmoderate and may be substantial in some cases, and includeunnecessary surgery for women who do not have cancer.

Given the lack of mortality benefit of screening, and themoderate to substantial harms that could result from false-positive screening test results and subsequent surgery, the USPSTFconcludes with moderate certainty that the harms of screeningfor ovarian cancer outweigh the benefit, and the net balance ofthe benefit and harms of screening is negative.

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Ovarian Cancer – UPDATE – Grade D

CONCLUSIONS AND RECOMMENDATION: The USPSTF recommends against screening for ovarian

cancer in asymptomatic women.

This recommendation applies to asymptomatic women whoare not known to have a high-risk hereditary cancer syndrome.

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Ovarian Cancer Frustrating Evidence of a mortality benefit continues to elude ovarian cancer (OC) screening. 2 Major Trials Ongoing:

US Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening TrialCA125 and transvaginal ultrasoundNo mortality benefit

The United Kingdom Collaborative Trial of Ovarian Cancer Screening - ongoing Uses the “Risk of Ovarian Cancer Time Series Algorithm” to interpret CA125 Transvaginal USGood sensitivity and specificity

What’s needed: New biomarkers A better understanding of the target lesion Improved design of biomarker discovery studies A focus on detecting low volume disease using cancer specific markers Targeted imaging

Menon, U etal, Gynecol Oncol 2014 Feb; 132 (2): 490-5 Epub 2013 Dec 3 Ovarian cancerscreening- current status, future directions.

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From: National Ovarian Cancer Coalition

Other signs Greater than 2 weeks of

Fatigue Upset stomach or

heartburn Back pain Pain during sex Constipation or

menstrual changes

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From: National Ovarian Cancer Coalition

Know the Signs

Obesity in Adults

GRADE B The USPSTF recommends screening all adults for obesity. Clinicians

should offer or refer patients with a body mass index (BMI) of 30kg/m2 or higher to intensive, multicomponent behavioralinterventions.

What’s New?? Intensive, multicomponent behavioral interventions for obese adults

was found to improve glucose tolerance and risk factors forcardiovascular disease.

Only valid for individuals with a BMI of 30 kg/m2 or higher Does not address the effectiveness of screening in overweight

adults (BMI of 25 to 29.9 kg/m2)

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Hormone Therapy to Prevent Chronic Disease Background: In the past, it was thought that estrogen or estrogen plus progestin therapy was

preventative for cardiovascular disease and other chronic diseases Menopausal hormone therapy refers to the use of combined estrogen and

progestin in women with an intact uterus, or estrogen alone in women who havehad a hysterectomy, taken at or after the time of menopause.

For this recommendation, the USPSTF considered evidence on the benefits andharms of systemic menopausal hormone therapy but not local formulations (eg,creams or rings) of hormone therapy, because these are not generally used forthe primary prevention of chronic conditions.

The review did not address hormone therapy for preventing or treatingmenopausal symptoms.

JAMA. 2017;318(22):2224-2233. doi:10.1001/jama.2017.18261

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HRT for Chronic Disease Prevention Statement The USPSTF recommends against the use of combined

estrogen and progestin for the primary prevention of chronicconditions in postmenopausal women.

GRADE D The USPSTF recommends against the use of estrogen alone for

the primary prevention of chronic conditions inpostmenopausal women who have had a hysterectomy.

GRADE D

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HRT and Chronic Disease Risk –Hazard Ratios

HRT Improved these:• Breast cancer risk, estrogen alone

group (CEE) – HR 0.79• Fractures - 0.8 HR (E +P group only)• Diabetes - both Groups reduced risk–

0.65 HR• Colorectal Cancer HR -0.62 (EP)• Endometrial Cancer HR 0.58. (EP)HRT had no significant effect on these:• Coronary Heart Disease

• Ovarian Cancer

• Cervical Cancer

• All Cause Mortality HR 1.01 – both groups

HRT Worsened These• Breast Cancer – Estrogen plus progestin

group (CEE plus MPA) after year 1 -HR 1.24

• Thromboembolic Disease (WHI)• E +P 1.98 HR• E only 1.48. HR

• Stroke – E+P group. 1.37 HR• Dementia – WHI E+P 2.05 HR• Gallbladder disease 1.59 HR• Urinary Incontinence 1.39 HR

JAMA. 2017;318(22):2224-2233.doi:10.1001/jama.2017.18261

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Compare USPSTF to Other Organization Statements

AHA, ACOG – Recommend against HRTfor the use of 1 or 2 prevention of CVD

CTF (Canada’s PTF) and AAFP – againstHRT for prevention of any chronicconditions

AACE (American Assoc. of Clin Endo):“consider age, CV risk and time frommenopause onset to assess and use HRT insymptomatic menopausal women”. NotesFDA approval HRT for women atincreased risk of osteoporosis andfractures

ACOG – effect on CVD differs fromearly initiation to late initiation

NAMS – focuses on menopausalsymptoms

Endocrine Society – focuses on HRT forwomen with menopausal symptoms

HOW DO YOU WEIGH IN???

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When AAFP Guidelines Differ from USPSTF Guidelines

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AAFP Guideline Endorsement Process

AAFP Commission on Health of the Public and Science Subcommittee on Clinical Practice Guidelines

Meets to review guidelines from other sources including: Major subspecialty guidelines, AAP, AIM, USPSTF, etc.

Makes recommendations to endorsing existing guidelines in categories. Recommendations are then subject to AAFP Board approval: Categories of endorsement:

(1) ENDORSED - The AAFP fully endorses the guideline; (2) AFFIRMATION OF VALUE - The guideline does not meet the requirements for full

endorsement, or the AAFP cannot endorse all recommendations but the guidelineprovides some benefit for family physicians.

(3) NOT ENDORSED - The AAFP does not endorse the guideline and the reasons arestated.

https://www.aafp.org/patient-care/browse/type.tag-clinical-practice-guidelines.html

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Where AAFP and USPSTF Differ

Colorectal Screening Lung Cancer Screening

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Colorectal Screening

USPSTF Grade: A The USPSTF recommends

screening for colorectalcancer starting at age 50years and continuing untilage 75 years.

Use one of 7 methods

AAFP GRADE: B The AAFP recommends screening

for colorectal cancer with fecalimmunochemical tests, flexiblesigmoidoscopy, or colonoscopystarting at age 50 years andcontinuing until age 75 years.

Only 3 recommended tests

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Colorectal ScreeningAAFP

Colorectal Cancer Screening, Adults GRADE: B RECOMMENDATION The AAFP recommends screening for colorectal cancer with fecal

immunochemical tests, flexible sigmoidoscopy, or colonoscopy starting at age 50years and continuing until age 75 years. The risks, benefits, and strength ofsupporting evidence of different screening methods vary. (2016)

Colorectal Cancer Screening, Seniors GRADE: C RECOMMENDATION The AAFP recommends that the decision to screen for colorectal cancer in adults

aged 76 to 85 years be an individual one, taking into account the patient'soverall health and prior screening history. (2016)

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Colorectal ScreeningAAFP RATIONALE

Flexible sigmoidoscopy and guaiac-based fecal occult blood testing are theonly screening methods which have reduced colorectal cancer mortality inrandomized controlled trials.

Fecal immunochemical tests (FIT) have improved accuracy compared withgFOBT, and can be performed with a single fecal specimen.

Optical colonoscopy as a screening strategy can be performed lessfrequently than flexible sigmoidoscopy or stool-based tests, and may detectprecancerous lesions that would be missed by these tests. However, theincremental mortality benefit is uncertain, and it is associated with greaterharms.

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AAFP Rationale for 3 Tests Only

Although advanced adenoma detection rates for CT colonography andFIT-DNA appear to be comparable to those of colonoscopy based oncross-sectional studies, both of these screening methods have insufficientevidence of harms.

CT colonography exposes patients to radiation, and there is insufficientevidence about the harms of associated extra-colonic findings, which arecommon (occurring in 40% to 70% of screening examinations).

FIT-DNA has a higher false positive rate than FIT, a higher rate ofunsatisfactory samples than FIT, and information is lacking on appropriatescreening intervals and follow-up intervals for patients with positive FIT-DNAbut a negative colonoscopy.

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Colorectal Cancer ScreeningAge 76-85 - NO DIFFERENCE

USPSTF Grade C The decision to screen for colorectal cancer in

adults aged 76 to 85 years should be an individualone, taking into account the patient’s overallhealth and prior screening history.

Adults in this age group who have never beenscreened for colorectal cancer are more likely tobenefit.

Screening would be most appropriate amongadults who 1) are healthy enough to undergotreatment if colorectal cancer is detected and 2)do not have comorbid conditions that wouldsignificantly limit their life expectancy.

AAFP GRADE: C The AAFP recommends that the

decision to screen for colorectalcancer in adults aged 76 to 85 yearsbe an individual one, taking intoaccount the patient's overall healthand prior screening history. (2016)

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American Cancer SocietyColon Cancer Screening Statement Starting at age 50, men and women at average risk for developing

colorectal cancer should use one of the screening tests below: (Unlike USPSTF and AAFP, ACS has no statement based on advanced

age) Tests that find polyps and cancer

Colonoscopy every 10 years CT colonography (virtual colonoscopy) every 5 years* Flexible sigmoidoscopy every 5 years* Double-contrast barium enema every 5 years*

Tests that mainly find cancer Fecal immunochemical test (FIT) every year*,** Guaiac-based fecal occult blood test (gFOBT) every year*,** Stool DNA test every 3 years*

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ACS Colon Cancer Screening and Prevention

There are 2 other risk groups that should be addressed:High risk and Increased risk patients have special screening tests and intervals defined.

Increased Risk Patients Polyps Prior Cancer Family History

High Risk Patients Familial Polyposis Lynch Disease Chron’s or UC

See website for specificshttps://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/acsrecommendations.html

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The USPSTF and AAPF Lung Cancer Screening Controversy

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USPSTF Lung Cancer Screening Guideline: Grade B

Adults Aged 55-80, with a History of Smoking The USPSTF recommends annual screening for lung cancer with low-

dose computed tomography (LDCT) in adults aged 55 to 80 years whohave a 30 pack-year smoking history and currently smoke or have quitwithin the past 15 years.

Screening should be discontinued once a person has not smoked for 15years or develops a health problem that substantially limits lifeexpectancy or the ability or willingness to have curative lung surgery.

2013 recommendation

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Based on the NLST Trial

The National Lung Screening Trial (NLST) - the largest and most expensiverandomized clinical trial in the USA demonstrated a 20% mortality ratereduction in patients who had undergone chest low-dose computedtomography screening, as compared to patients screened with aconventional chest X-ray.

The study was stopped early due to startling results finding cancer much more frequentlythan the CXR did. (2013)

The American Cancer Society just came out with a similar recommendation 2017. The European Society of Thoracic Surgeons now recommends same screening for

Europe. (2018) UK and China currently doing Lung Cancer studies with CT.

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AAFP:Lung Cancer Screening

GRADE “I” RECOMMENDATION The AAFP concludes that the evidence is insufficient to recommend for or

against screening for lung cancer with low-dose computed tomography(LDCT) in persons at high risk for lung cancer based on age and smokinghistory.

BASED ON ONE STUDY ONLY

https://www.aafp.org/patient-care/clinical-recommendations/all/lung-cancer.html

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AAFP Response to USPSTF Lung "The AAFP has reviewed the USPSTF’s recommendations on lung cancer

screening and had significant concern with basing such a far reaching andcostly recommendation on a single study.

The National Lung Screening Trial (NLST), whose favorable results wereconducted in major medical centers with strict follow-up protocols for nodules,have not been replicated in a community setting.

A shared-decision-making discussion between the clinician and patient shouldoccur regarding the benefits and potential harms of screening for lung cancer.

The long term harms of radiation exposure from necessary follow-up full dose CTscans are unknown.

The USPSTF recommends annual CT screening even though the NLST trial wasonly 3 annual scans.”

From: AAFP

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AAFP RESPONDS

Quantitative Analysis of NLST: The number needed to screen to prevent one lung cancer

death over 5 years and 3 screenings is 312. The number needed to screen to prevent one death by any

cause is 208 over 5 years. Therefore, 40% of patients screened will have a positive result

requiring follow-up: CT scans, bronchoscopy or thoracotomy

The harms of these follow-up interventions in a setting with aless strict follow-up protocol in the community is not known.

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LOCATION"The NLST was conducted at a variety of medical institutions, many ofwhich are recognized for their expertise in radiology and the diagnosisand treatment of cancer."

SURGICAL EXPERTISE NOT GENERIZABLE Much of the success of this trial is based on the low mortality associated

with surgical resection of tumors, which may not be reproducible in allsettings.

COST “The cost-effectiveness of low-dose CT screening must be considered in

the context of competing interventions, particularly smoking cessation."

61NLST Study Limitations:

American Cancer Society Sums it Up Clinicians with access to high-volume, high-quality lung cancer screening

and treatment centers should initiate a discussion about annual lungcancer screening with apparently healthy patients 55 to 74 years of agewho have at least a 30 pack-year smoking history and who currentlysmoke or have quit within the past 15 years;

a process of informed and shared decision making with a clinician related to the potential benefits, limitations, and harms associated with screening for lung cancer with low-dose CT should occur before any decision is made to initiate lung cancer screening;

smoking-cessation counseling remains a high priority for clinical attentionin discussions with current smokers, who should be informed of theircontinuing risk of lung cancer; screening should not be viewed as analternative to smoking cessation

CA Cancer J Clin. March/April 2017;67(2):100–121

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Summary• The USPSTF

• Provides us a clearing house for prevention and screening guidelines• Continually updates recommendations• Uses evidence based methodology• Is easy to use, and easy to search on its website

• Other valid guidelines exist for many issues.• Clinicians can safely use guidelines from national medical societies

(USPSTF, ACOG, AAFP, etc.) in their practices as they all have beenvetted by groups of experts.

• Groups of experts may interpret evidence differently.

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What’s Next for the USPSTF? 2018 Updates in Progress – Finalization Stage – STAY TUNEDScreening for : A fib with EKG CVD risk with EKG CV risk with nontraditional risk

factors Cervical cancer Osteoporosis Syphilis in Pregnant Women

Peripheral Arterial Disease Prostate Cancer Vitamin D for primary Prevention of

Fractures Weight Loss Interventions Falls prevention interventions

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To Learn More:

http://www.uspreventiveservicestaskforce.org Electronic Preventive Services Selector http://epss.ahrq.gov/PDA/index.jsp Ebook: http://www.ahrq/gov/professionals/clinicians-

providers/guidelines-recommendations/guide https://www.uspreventiveservicestaskforce.org/BrowseRec/Ind

ex/browse-recommendations

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References Ebell, M, Editorials, USPSTF Recommendations: New and Updated in 2016,

American Family Physician Oct 1, 2017, www.aafp.org 697-698 Clinical Preventive Service Recommendation Lung Cancer,

https://www.aafp.org/patient-care/clinical-recommendations/all/lung-cancer.html

Screening for Ovarian Cancer: US preventive Task Force RecommendationStatement, US Preventive Services Task Force, Grossman DC, Curry SJ, Owens DK,Barry MJ, Davidson KW, Doubeni CA, Epling JW Jr, Kemper AR, Krist AH, Kurth AE,Landefeld CS, Mangione CM, Phipps MG, Silverstein M, Simon MA, Tseng CW.,JAMA. 2018 Feb 13;319(6):588-594. doi: 10.1001/jama.2017.21926.

https://www.uspreventiveservicestaskforce.org https://www.uspreventiveservicestaskforce.org/Page/Document/Recommendat

ionStatementFinal/aspirin-to-prevent-cardiovascular-disease-and-cancer

72

References https://www.cancer.org/cancer/colon-rectal-cancer/detection-

diagnosis-staging/acs-recommendations.html https://www.aafp.org/afp/2018/0201/p208.html Should Family Physicians Routinely Screen for Lung Cancer in High-Risk

Populations? No: The USPSTF's Recommendation for Lung CancerScreening Is Overreaching.https://www.aafp.org/afp/2014/0715/od3.html

American Academy of Family Physicians. Clinical recommendations.Lung cancer. https://www.aafp.org/patient-care/clinical-recommendations/all/lung-cancer.html. Accessed May 3, 2014.

Lung Cancer: Diagnosis, Treatment Principles, and Screening,https://www.aafp.org/afp/2015/0215/p250.html

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References

Menon U, et al Gynecol Oncol. 2014 Feb;132(2):490-5. doi:10.1016/j.ygyno.2013.11.030. Epub 2013 Dec 3. Ovarian cancerscreening--current status, future directions.

https://www.aafp.org/news/opinion/20161019guidelinesed.html Siu AL; US Preventive Services Task Force. Screening for autism

spectrum disorder in young children: US Preventive Services Task Forcerecommendation statement. JAMA. Doi: 10.1001/jama.2016.0018.

https://www.aafp.org/patient-care/clinical-recommendations/all/lung-cancer.html

https://www.aafp.org/afp/2017/1215/od1.html

74

References US Preventive Service Task Force, JAMA, 2017 Mar 7;317(9):947-953. doi:

10.1001/jama.2017.0807.Screening for Gynecologic Conditions With PelvicExamination: US Preventive Services Task Force Recommendation Statement.

CA Cancer J Clin. March/April 2017;67(2):100–121 US Preventive Services Task Force. Preeclampsia screening: US Preventive Services

Task Force recommendation statement. JAMA. doi:10.1001/jama.2017.3439 JAMA. 2017;318(22):2224-2233. doi:10.1001/jama.2017.18261 – Hormone

Replacement Therapy Screening for Depression in Children and Adolescents: U.S. Preventive Services

Task Force Recommendation Statement Ann Intern Med. 2016;164:360-366.doi:10.7326/M15-2957 www.annals.org

https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/thyroid-cancer-screening1

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Dr. Hart Contact Information

Rebecca Hart, MD201 Enterprise Ave, Suite 900League City, Texas 77573281-334-2826rxhart@icloud.com

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