Practice Alert

USPSTF: What’s recommended, what’s not

Author and Disclosure Information

Twenty-six recommendations were issued last year. Two screening procedures previously unsupported by good evidence are now firmly advocated; 4 interventions still commonly practiced are recommended against.


 

References

The United States Preventive Services Task Force (USPSTF) was busy in 2013, issuing 26 recommendations on 16 topics (TABLES 1-3). We have covered some of these topics previously in Practice Alerts or audiocasts—vitamin D for bone health and fall prevention,1 screening for lung cancer,2 human immunodeficiency virus infection,3 and the use of multivitamins to prevent cancer and cardiovascular disease (CVD).4 Another Practice Alert on chronic hepatitis C virus infection reviewed recommendations of the Centers for Disease Control and Prevention,5 which agree with those of the USPSTF. This Practice Alert discusses the remaining USPSTF recommendations.

Alcohol and tobacco

The Task Force (TF) reports that 30% of adults are affected by alcohol-related problems and that alcohol causes 85,000 deaths per year, making it the third leading cause of preventable death.6 The TF reviewed evidence on screening and counseling and now recommends screening adults ≥18 years for alcohol misuse and providing brief counseling to reduce alcohol use for those who engage in risky or hazardous drinking.6 The TF recommends any of 3 screening tools: using either the Alcohol Use Disorders Identification Test (AUDIT) or the abbreviated AUDIT-Consumption (AUDIT-C), or asking a single-question, such as “How many times in the past year have you had 5 (for men) or 4 (for women and all adults >65 years) or more drinks in a day?”6

Counseling for 5 to 15 minutes during the initial clinical encounter and then at subsequent visits is more effective than very brief (<5 minutes) or single-episode counseling. Counseling can include action plans, drinking diaries, stress management, or problem solving, and it can be done face-to-face or with written self-help materials, computer- or Web-based programs, or telephone support. Despite the importance of alcohol misuse as a health problem, the TF could find no evidence that screening and behavioral counseling is effective for adolescents.

For tobacco use, however, the TF now recommends providing prevention advice to school-age children and adolescents,7 presented in person or through written materials, videos, or other media. Over 8% of middle school children and close to 24% of high school students use tobacco.7 Tobacco is the leading cause of preventable deaths in the United States, and most smokers start before they are adults.7

Cancer screening and prevention

In addition to the recommendation for lung cancer screening, 2 other cancer screening/prevention recommendations were made in 2013. One is a modification of the previous recommendation on the use of BRCA gene testing to detect increased risk of breast and ovarian cancer. The recommendation now states that if a woman has a family member with breast, ovarian, tubal, or peritoneal cancer, her physician should use a screening tool to determine if her family history suggests high risk for having either BRCA1 or BRCA2. With a positive screening result, referral for genetic counseling is warranted. After counseling, the patient may choose to undergo BRCA testing. Screening tools reviewed by the TF are the Ontario Family History Assessment Tool, the Manchester Scoring System, the Referral Screening Tool, the Pedigree Assessment Tool, and the Family History Screening-7 instrument.8

The USPSTF recommends screening asmyptomatic pregnant women for gestational diabetes after 24 weeks of gestation.

The second recommendation is complex and concerns whether to prescribe tamoxifen or raloxifene to prevent breast cancer in women at high risk—ie, a 5-year risk ≥3%.9 One tool for estimating risk can be found at http://www.cancer.gov/bcrisktool/. It calculates risk based on age, race, genetic profile, age at menopause and menarche, family history of breast cancer, and personal history of breast cancer and biopsies. The TF recommends that physicians share decision making with women who are at high risk of breast cancer and offer medication to those at low risk of complications (those who have had a hysterectomy). Use of tamoxifen or raloxifene can reduce risk of the invasive cancer by 7 to 9 cases per 1000 women over 5 years. However, the risk of venous thromboembolism increases by 4 to 7 cases per 1000 over 5 years, and tamoxifen increases the risk of endometrial cancer by 4 in 1000. Both medications can cause hot flashes.9

Gestational diabetes

For a number of years the TF has assigned an “I” statement (insufficient evidence to assess benefits and harms) to screening for gestational diabetes. It recently changed that to a “B” recommendation for all pregnant women after the 24th week of pregnancy. Screening before 24 weeks is still listed as an I. Possible screening tools include a fasting blood glucose test, a 50-g oral glucose challenge test, or an assessment of risk factors. The TF did not find evidence of superiority with any of these methods. The TF found that diet modifications, glucose monitoring, and use of insulin can, in some cases, moderately reduce the incidence of preeclampsia, macrosomia, and shoulder dystocia.10

Next Article: