Specific Screening Tests

Screening for Chronic Diseases

Lipid Disorder
The USPSTF strongly recommends screening all men 35 years of
age and older for lipid disorders.

Screening is also recommended in men 20 to 34 years of age and

older if risk factors for atherosclerotic cardiovascular disease
(ASCVD) are present (diabetes mellitus, personal history of
coronary heart disease or noncoronary atherosclerosis, family
history of cardiovascular disease before age 50 years in male
relatives or age 60 years in female relatives, tobacco use,
hypertension, obesity [BMI 30]).

the USPSTF states that it is reasonable to rescreen every 5

years, or at a shorter interval if the patient's lipid levels are
approaching those that would indicate therapy.

Diabetes mellitus
screening for abnormal blood glucose and type 2 diabetes in
adults with risk factors, including age 45 years or older, obesity or
overweight, first-degree relative with diabetes, history of
gestational diabetes or polycystic ovary syndrome, and certain
high-risk ethnic backgrounds (African Americans, American
Indians/Alaska Natives, Asian Americans, Hispanics/Latinos, and
Native Hawaiians/Pacific Islanders).

Recommended screening tests include fasting plasma glucose

level, hemoglobin A1c or 2-hour oral glucose tolerance test. The
American Diabetes Association recommends screening every 3
years if test results are normal.
Obesity

According to the USPSTF, all adults should be screened for

obesity using BMI. A 2013 joint guideline from the AHA, ACC, and
The Obesity Society recommends screening for obesity at least
annually. Adults with BMI of 30 or higher should be referred for
intensive behavioral interventions.

AAA

The USPSTF recommends one-time screening for abdominal

aortic aneurysm (AAA) with abdominal ultrasonography in all men
aged 65 to 75 years who have smoked at least 100 cigarettes in
their lifetime and selective screening in men in this age group who
have never smoked. There is insufficient evidence to recommend
for or against screening for AAA in women aged 65 to 75 years
who have ever smoked. Women who have never smoked should
not be screened for AAA.

Osteoporosis

The USPSTF recommends screening for osteoporosis by

measurement of bone mineral density in women aged 65 years
and older and in younger women who have a fracture risk equal
to or higher than a 65-year-old white woman (9.3%).

The physician can use the Fracture Risk Assessment Tool (FRAX)
to determine if the 10-year fracture risk for younger women is
greater than or equal to 9.3%. The USPSTF concludes that the
current evidence is insufficient to recommend routine screening
for osteoporosis in men. The ACP recommends periodic
individualized assessment of risk factors for osteoporosis in older
men. By age 65 years, at least 6% of men have dual-energy x-ray
absorptiometry (DEXA)determined osteoporosis, so risk factor
assessment before this age is reasonable.

Thyroid Disease

The USPSTF concludes that there is insufficient evidence to

recommend for or against screening for thyroid disease. The ACP
recommends screening women over age 50 years who have at
least one symptom that can be attributed to thyroid disease. The
American Thyroid Association and the American Association of
Clinical Endocrinologists recommend measuring thyroid-
stimulating hormone (TSH) in individuals with risk factors for
hypothyroidism (for example, personal history of autoimmune
disease, neck radiation, or thyroid surgery) and consideration of
TSH testing in adults age 60 years and older

Depression

According to the USPSTF, all adults should be screened for

depression if adequate resources are available to provide support
and treatment. A useful clinical tool for screening is the two-item
Patient Health Questionnaire (PHQ-2), which has an 83%
sensitivity and 90% specificity for depression, which is
comparable to longer, more complex screening instruments.
Using this tool, the clinician asks, During the past 2 weeks, how
often have you been bothered by any of the following problems:
(1) little interest or pleasure in doing things, or (2) feeling down,
depressed, or hopeless? If the patient responds positively to
either question, further evaluation is indicated.
Screening for Infectious Diseases

Chlamydia

The USPSTF recommends screening for chlamydia in all sexually

active women age 24 years and younger and in women older than
24 years who are at increased risk of infection. Women who are
at increased risk include those with a history of sexually
transmitted infection (STI), those with new or multiple sexual
partners, those who use condoms inconsistently, and commercial
sex workers.
The USPSTF concludes that there is insufficient evidence to
recommend for or against chlamydia screening in men.

Nucleic acid amplification tests can be performed on first-voided

urine or vaginal or endocervical swabs. The Centers for Disease
Control and Prevention (CDC) recommends that any patient who
has a positive test result be retested 3 months after treatment.

Gonorrhea

Screening for gonorrhea is recommended by the USPSTF for all

pregnant and nonpregnant sexually active women who are at
increased risk of infection (same risk factors as with chlamydia).
The USPSTF has not determined that there is sufficient evidence
to recommend for or against screening for gonorrhea in men at
high risk, and the task force recommends against screening for
men and women who are at low risk.

Nucleic acid amplification tests can be performed on first-voided

urine or urethral swabs from men and vaginal or endocervical
swabs from women. The CDC recommends that any patient who
has a positive test result be retested 3 months after treatment.
HIV

The USPSTF recommends one-time HIV screening for all adults

aged 15 to 65 years.
Individuals with risk factors for HIV should be screened
regardless of age, and repeated screening is recommended in
this population. Based on prevalence data, men who have sex
with men (MSM) and active injection drug users have a very high
risk for HIV infection. Other individuals at risk for HIV include
those with behavioral risk factors (those who have unprotected
vaginal or anal intercourse; have sexual partners who are HIV-
infected, bisexual, or injection drug users; or exchange sex for
drugs or money), those who have acquired other STIs, and those
who live and receive care in a high-prevalence setting (HIV
seroprevalence of 1%).

The USPSTF also recommends screening all pregnant women for

HIV. Combined HIV antibody immunoassay/p24 antigen testing is
the preferred screening test for HIV infection.

Hepatitis B

The USPSTF also recommends screening for hepatitis B virus

(HBV) in all adults at high risk, which includes persons born in
countries with at least a 2% prevalence of HBV infection, persons
receiving dialysis or cytotoxic or immunosuppressive treatments,
HIV-positive persons, injection drug users, MSM, and household
contacts or sexual partners of persons with HBV infection.
Screening is performed with hepatitis B surface antigen (HBsAg)
serologic studies; antibodies to hepatitis B antigens (anti-HBs and
anti-HBc) are also obtained to differentiate between immunity and
infection. All pregnant women should also be screened for HBV.
Hepatitis C

According to the USPSTF, all adults born between 1945 and

1965 should receive one-time screening for hepatitis C virus
(HCV) with anti-HCV antibody testing. Additionally, all adults at
high risk (injection and intranasal drug users, persons who
received a blood transfusion before 1992, persons on long-term
hemodialysis, prisoners, and persons who received unregulated
tattoos) should receive HCV screening. The CDC recommends
that HIV-positive patients undergo annual HCV screening.
Screening is performed with anti-HCV antibody followed by
polymerase chain reaction (PCR) viral load testing if positive

Syphilis

The USPSTF recommends syphilis screening for all pregnant

women and all adults at increased risk for infection. Populations
at risk are prisoners, MSM, and persons who exchange sex for
money or drugs. Initial screening tests include the VDRL test and
rapid plasma reagin (RPR) test.

Tuberculosis

The CDC has issued guidelines for tuberculosis (TB) screening

that recommend screening in high-risk individuals, including
injection drug users, persons who are positive for HIV, those who
have close contact with persons with known or suspected TB,
those who live or work in high-risk settings, and recent immigrants
from countries with a high prevalence of TB. Appropriate
screening tests include tuberculin skin testing or the interferon-
release assay.
Screening for Substance Use Disorders

Alcohol

According to the USPSTF, all adults should be screened for

alcohol misuse. The Alcohol Use Disorders Identification Test
(AUDIT) is the most validated screening test for identifying
hazardous and harmful drinking in primary care patients

Shorter tests that are comparable to AUDIT include the AUDIT-C

test (three items from AUDIT) and single-item screening (How
many times in the past year have you had five [four for women] or
more drinks in one day?). The physician also should provide
persons engaged in risky or hazardous drinking with brief

Tobacco

The USPSTF recommends that all adults be screened for tobacco

use. To engage patients, physicians should consider using the 5
A's (Ask, Advise, Assess, Assist, and Arrange)

Illegal Drugs

Although the USPSTF has concluded that there is not enough

evidence to recommend for or against illicit drug screening, there
are several questionnaires that are valid and reliable in screening
for drug use.
The Drug Abuse Screening Test (DAST-10) is a 10-item survey
similar to the AUDIT tool used for alcohol screening. A single-item
screening question (How many times in the past year have you
used an illegal drug or used prescription medications for
nonmedical reasons?) has been shown to be highly sensitive and
may be used for screening.
Screening for Cancer

Breast cancer screening discussed in this section applies to

asymptomatic average-risk women. Women with significant risk
factors for breast cancer, including family history of breast or
ovarian cancer or personal history of atypia or lobular carcinoma
in situ, should undergo a formal breast cancer risk assessment.

The USPSTF updated its recommendations for breast cancer

screening to endorse biennial screening mammography for all
women aged 50 to 74 years. Additionally, routine mammographic
screening for women younger than 50 years is no longer
recommended; rather, the USPSTF recommends individualized
screening decisions for women younger than 50 years based on
patient context and values regarding specific benefits and harms.
The USPSTF reasons that while the benefit of screening may be
similar in women ages 40 to 49 years (1 breast cancer death
avoided per 1900 invited to screen, 15% relative risk reduction)
compared with women ages 50 to 59 years (1 breast cancer
death avoided per 1300 invited to screen, 14% relative risk
reduction), there is a lower incidence of breast cancer and higher
risk of harms in the younger age group. Harms can include false-
positive screening results, which may lead to unnecessary
emotional stress, biopsies, and unnecessary treatment. The ACP,
AAFP, and Kaiser Permanente Care Management Institute concur
with these guidelines; however, specialty organizations including
the American Cancer Society (ACS), National Comprehensive
Cancer Network, American Congress of Obstetricians and
Gynecologists (ACOG), American College of Surgeons, American
College of Radiology, and Society of Breast Imaging continue to
recommend annual screening mammography starting at age 40
years.
The ACP advises against screening average-risk women younger
than 40 years for breast cancer.
For women age 75 years and older, the USPSTF found
insufficient evidence to recommend for or against screening
mammography, and other organizations recommend shared
decision-making for this age group to develop an individualized
approach.
The ACP advises against screening for breast cancer in average-
risk women age 75 years and older. As with other cancer
screening tests, studies have suggested that women should have
a life expectancy of at least 10 years to benefit from screening
mammography.
The USPSTF does not recommend for or against clinical breast
examination (CBE) and cites potential harms of CBE, including
false-positive test results that lead to anxiety and additional
imaging and biopsies.
The ACS and ACOG recommend CBE every 3 years for women
ages 20 to 39 years and yearly for women older than 40 years.
The USPSTF recommends against breast self-examination
(BSE), citing two trials showing increased imaging and biopsies
for women who performed BSE. The ACS and ACOG have shifted
towards recommending breast self-awareness, encouraging
women to know how their breasts normally look and feel, with
BSE as an option.
Breast density is an increasingly recognized risk factor for breast
cancer. In addition to increasing breast cancer risk, high breast
density is common (present in up to 50% of women) and also
decreases the sensitivity of mammography. Evidence has shown
that digital mammography may be better than film mammography
in women with high breast density; however, currently, high breast
density alone does not necessitate additional breast imaging
other than routine screening mammography. /react-text
Prostate Cancer
In 2012, the USPSTF issued updated guidelines recommending
against prostate-specific antigen (PSA) screening for prostate
cancer. The USPSTF outlined harms associated with PSA
screening, including those resulting directly from screening and
diagnostic procedures (anxiety, additional testing including
biopsies, overdiagnosis), and harms related to treatment of
screen-detected cancer (surgical complications, urinary
incontinence, erectile dysfunction, radiotherapy-induced bowel
dysfunction). The benefit of PSA screening and associated early
treatment is prevention of between 0 and 1 prostate cancer
deaths per 1000 men screened.

Therefore, the USPSTF concluded that the benefits of PSA

screening do not outweigh the harms. Most other organizations
recommend a shared decision-making approach for men in the
age group most likely to benefit (50-69 years of age according to
the ACP, 50 years of age to 10 years of life expectancy according
to the ACS, and 55-69 years of age according to the American
Urological Association [AUA]). As a high value care intervention,
the ACP recommends that clinicians have a one-time discussion
(more if the patient requests) with average-risk men aged 50 to 69
years who inquire about PSA-based prostate cancer screening to
inform them about the limited potential benefits and substantial
harms of screening for prostate cancer using the PSA test. The
ACP and AUA do not recommend PSA screening for men older
than 69 years or those with less than a 10- to 15-year life
expectancy.
Many organizations, including the ACP, ACS, and the American
College of Preventive Medicine, recommend earlier thresholds for
discussing prostate cancer screening in men at increased risk. In
general, PSA discussions are recommended to start at age 45
years for black men or men who have a first-degree relative
younger than 65 years with prostate cancer, and at age 40 years
for men with several family members younger than 65 years with
prostate cancer or men who have known or suspected mutations.
Although the USPSTF acknowledges that certain groups are at
increased risk for prostate cancer, the task force concluded that
there was not enough evidence to make separate
recommendations.
The current USPSTF recommendations do not apply to men with
known mutations.
The digital rectal examination (DRE) in combination with PSA
screening has been shown to increase prostate cancer detection;
however, no studies have suggested benefit of DRE for patient-
important outcomes. Therefore, both the USPSTF and AUA do
not make a recommendation for or against the use of DRE for
screening purposes.

Additional Cancer Screening Tests

Cervical Ca

women ages 21 to 65 years should be screened for cervical

cancer every 3 years with cytology (Pap smear). In women ages
30 to 65 years who want to lengthen the screening interval, a
combination of cytology and human papillomavirus (HPV) testing
can be performed every 5 years.
Screening for cervical cancer is not recommended in women
younger than 21 years, women age 65 years and older who are
not at high risk and have had adequate prior Pap smears (three
consecutive negative cytology results or two consecutive negative
cytology results and HPV testing within the past 10 years, with the
most recent test performed within 5 years), and women who have
had a hysterectomy with removal of the cervix with no history of a
precancerous lesion.
Colorectal Ca

The USPSTF recommends screening all adults ages 50 to 75

years for colorectal cancer using high-sensitivity fecal occult blood
testing (FOBT) every year, flexible sigmoidoscopy every 5 years,
combined high-sensitivity FOBT (every 3 years) plus flexible
sigmoidoscopy (every 5 years), or colonoscopy every 10 years.
According to a guidance statement issued by the ACP in 2012,
patient preference, availability, and benefit and harms should
guide the choice of test. The ACS, U.S. Multi-Society Task Force
on Colorectal Cancer, and the American College of
Gastroenterology (ACG) prefer the use of cancer prevention tests
(colonoscopy, flexible sigmoidoscopy, double contrast barium
enema, or CT colonography) to cancer detection tests (guaiac
FOBT or fecal immunochemical testing). Given higher mortality
rates, the ACP recommends that screening start at age 40 years
for black persons, whereas the ACG recommends that screening
begin at age 45 years in this population. Most guidelines
recommend stopping screening if life expectancy is less than 10
years, and the USPSTF recommends against screening after age
85 years.

Skin Ca

The USPSTF concludes that there is insufficient evidence to

recommend for or against whole-body skin examinations for the
early detection of skin cancer; however, the USPSTF did not
examine outcomes in patients at high risk for skin cancer. The
ACS recommends monthly skin self-examinations as well as skin
examination as part of a periodic health examination for adults
age 20 years and older. Behavioral counseling on minimizing
exposure to ultraviolet radiation is recommended by the USPSTF
for persons younger than 24 years who have fair skin.
Lung Ca

Lung cancer screening is not recommended for the average-risk

patient. Annual low-dose CT is recommended for high-risk
patients, defined as adults ages 55 to 80 years with a 30-pack-
year smoking history, including former smokers who have quit in
the last 15 years.