US Preventive Services Task Force Update

Transcription

1 US Preventive Services Task Force Update REBECCA HART, MD, FAAFP 2018 C. FRANK WEBBER AND INTERIM SESSION RENAISSANCE AUSTIN HOTEL AUSTIN, TEXAS FRIDAY, APRIL 13, 2018

2 Speaker Disclosure 2 Dr. Hart has disclosed that she has no actual or potential conflict of interest in relation to this topic.

3 Objectives 3 By completing this educational activity, the participant should be better able to: 1. Consider the relevance of the strength of evidence in the guideline grading system. 2. Review the most recent updates in USPSTF guidelines Decide how to use USPSTF guidelines versus other national guidelines when counselling patients. 4. Discriminate between the UPSFTP guidelines and AAFP guidelines in colon and lung cancer screening.

4 Screening Test Grading Systems 4 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

5 Insufficient Evidence 5 FROM THE USPSTF: The USPSTF issues a statement of insufficient evidence when the current available evidence is insufficient to assess the balance of benefits and harms of 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 across studies, 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 against providing a service. Rather, it means that the USPSTF cannot determine whether there is an overall benefit or harm to providing the service, and more information in the future may allow an estimation of effects on health outcomes. An I statement is also a call for research to close gaps in the evidence.

6 Screening vs. Testing 6 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

7 USPSTF RECOMMENDATIONS

8 2016 Guidelines: New / Updated 8 Updated recommendations Colorectal Cancer Aspirin and statin use Depression screening adults I recommendations for 6 topics New Recommendation Autism Spectrum Disorder

9 USPSTF Colorectal Cancer Recommendations 9 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 CDC differences

10 Aspirin Use for Primary Prevention 10 Use a risk assessment tool: The Pooled Cohort Equations Aspirin use prevents nonfatal CV events and reduces the risk of colorectal death after 10 yrs of use Use aspirin in adults yrs old who have a 10 year CV event risk of at least 10%, will take aspirin for at least 10 years, and not at risk for bleeding.

11 Statin Use for Primary Prevention 11 Again, use a risk assessment tool: The Pooled Cohort Equations Grade B rating for low or moderate-dose statin for patients with 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

12 Depression Screening In Adults 12 Now includes pregnant and postpartum women Recommended Screening Tool: The Edinburgh Postnatal Depression Scale Grade B

13 2016 Guideline Updates: I Recommendations 13 Not enough evidence to determine the benefit of screening for: 1. Skin Cancer 2. Lipid Disorders in children and adolescents 3. Impaired Visual Acuity in Older Adults 4. Depression in Children younger than 12 years old 5. Aspirin use in Adults younger than 50 years or older than Statin use in Adults older than 75 years with no CV history

14 2016 Guideline Updates Grade I Recommendations 14 Skin 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 the balance of benefit and harms of visual skin examination by a clinician to screen for skin cancer in asymptomatic adults cannot be determined. The optimal interval for visual skin examination by a clinician to screen for skin cancer, 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.

15 2016 Guidelines I Recommendations: 15 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 the atherosclerotic process and thereby reduce the incidence of premature ischemic cardiovascular events in adults. The USPSTF found inadequate evidence on the quantitative difference in diagnostic yield between universal and selective screening for familial hypercholesterolemia or multifactorial dyslipidemia. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for lipid disorders in children and adolescents 20 years or younger.

16 Lipid Screening in Children 16 Screening rates for dyslipidemia in children and adolescents seen in primary care have been low. 2.5% of well-child visits included lipid testing in % included it in 2010 Claims data from health insurance plans report rare use of lipidlowering pharmacotherapy in 8- to 20-year-olds. Among more than 13 million children, 665 children initiated lipidlowering pharmacotherapy between 2005 and 2010, for an overall incidence rate of 2.6 prescriptions per 100,000 person-years.

17 2016 Recommendations: Should You Screen for Visual Acuity in Older Adults? 17 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 any underlying visual condition The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for impaired visual acuity in the primary 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.

18 2016 I Recommendations Should You Screen for Depression in Children? 18 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 appropriate follow-up.

19 Depression in Children 19 Little is known about the prevalence of MDD in children aged 11 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.

20 2016 Guideline Updates Should All Adults Use Aspirin as Preventive Medicine? 20 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 primary prevention of CVD and CRC in adults younger than 50 years or over age 70.

21 Aspirin Prophylaxis Other Age Groups 21 Grade B AGE 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 years who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years. Grade C Age 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 an individual one. Persons who are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years are more likely to benefit. Persons who place a higher value on the potential benefits than the potential harms may choose to initiate low-dose aspirin.

22 2016 Guideline Updates Statins in the Elderly 22 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 statin use for the primary prevention of CVD events and mortality in adults 76 years and older without a history of heart attack or stroke.

23 2016 Guideline Updates New Autism Spectrum Disorder Recommendation 23

24 Screening for Autism Spectrum Disorder 24 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 for autism spectrum disorder (ASD) in young children for whom no concerns of ASD have been raised by their parents or a clinician. Siu AL; US Preventive Services Task Force. Screening for autism spectrum disorder in young children: US Preventive Services Task Force recommendation statement. JAMA. doi: /jama

25 Autism CDC Criteria An Alternative View 25 All children should be screened for developmental delays and disabilities during regular well-child doctor visits at: 9 months 18 months 24 or 30 months All children should be screened specifically for ASD during regular well-child doctor 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 behaviors sometimes associated with ASD are present

26 USPSTF RECOMMENDATIONS

27 2017 USPSTF Recommendations 27 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

28 Folic Acid Supplementation 28 For the prevention of Neural Tube Defects The USPSTF recommends that all women who are planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid. Grade A (Not Changed from the 2009 statement)

29 Vision Screening in Children Aged 6 Months to 5 y=years 29 The USPSTF recommends vision screening at least once in all children 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 vision screening in children younger than 3 years. GRADE I

30 Obesity Screening in Children and Adolescents 6 yrs and Older 30 GRADE B The USPSTF recommends that clinicians screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status. Screening and intensive behavioral interventions for obesity in children and adolescents 6 years and older can lead to improvements in weight status. The magnitude of this benefit is moderate.

31 2017 Insufficient Evidence Grade I 31 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

32 Thyroid Cancer 32 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 in asymptomatic persons. The USPSTF found adequate evidence to bound the magnitude of the overall harms of screening and treatment as at least moderate, based on adequate evidence of serious harms of treatment of thyroid cancer and evidence that overdiagnosis and overtreatment are likely consequences of screening.

33 2018 UPDATES 33 Preeclampsia Ovarian Cancer Obesity in Adults Hormone Therapy for Prevention of Chronic Disease

34 2018 Recommendations 34 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

35 Ovarian Cancer UPDATE Still Grade D 35 Ovarian Cancer facts: 14,000 deaths per year 5 th 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!

36 Ovarian Cancer UPDATE Grade D 36 STATEMENT: The USPSTF found adequate evidence That screening for ovarian cancer does not reduce ovarian cancer mortality. That the harms from screening for ovarian cancer are at least moderate and may be substantial in some cases, and include unnecessary surgery for women who do not have cancer. Given the lack of mortality benefit of screening, and the moderate to substantial harms that could result from falsepositive screening test results and subsequent surgery, the USPSTF concludes with moderate certainty that the harms of screening for ovarian cancer outweigh the benefit, and the net balance of the benefit and harms of screening is negative.

37 Ovarian Cancer UPDATE Grade D 37 CONCLUSIONS AND RECOMMENDATION: The USPSTF recommends against screening for ovarian cancer in asymptomatic women. This recommendation applies to asymptomatic women who are not known to have a high-risk hereditary cancer syndrome.

38 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 Trial CA125 and transvaginal ultrasound No 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 US Good 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): Epub 2013 Dec 3 Ovarian cancer screening- current status, future directions. 38

39 39 Know the Signs From: National Ovarian Cancer Coalition 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

40 Obesity in Adults 40 GRADE B The USPSTF recommends screening all adults for obesity. Clinicians should offer or refer patients with a body mass index (BMI) of 30 kg/m 2 or higher to intensive, multicomponent behavioral interventions. What s New?? Intensive, multicomponent behavioral interventions for obese adults was found to improve glucose tolerance and risk factors for cardiovascular disease. Only valid for individuals with a BMI of 30 kg/m 2 or higher Does not address the effectiveness of screening in overweight adults (BMI of 25 to 29.9 kg/m 2)

41 Hormone Therapy to Prevent Chronic Disease 41 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 have had a hysterectomy, taken at or after the time of menopause. For this recommendation, the USPSTF considered evidence on the benefits and harms of systemic menopausal hormone therapy but not local formulations (eg, creams or rings) of hormone therapy, because these are not generally used for the primary prevention of chronic conditions. The review did not address hormone therapy for preventing or treating menopausal symptoms. JAMA. 2017;318(22): doi: /jama

42 HRT for Chronic Disease Prevention Statement 42 The USPSTF recommends against the use of combined estrogen and progestin for the primary prevention of chronic conditions in postmenopausal women. GRADE D The USPSTF recommends against the use of estrogen alone for the primary prevention of chronic conditions in postmenopausal women who have had a hysterectomy. GRADE D

43 HRT and Chronic Disease Risk Hazard Ratios 43 HRT Improved these: Breast cancer risk, estrogen alone group (CEE) HR 0.79 Fractures HR (E +P group only) Diabetes - both Groups reduced risk 0.65 HR Colorectal Cancer HR (EP) Endometrial Cancer HR (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 HR Stroke E+P group HR Dementia WHI E+P 2.05 HR Gallbladder disease 1.59 HR Urinary Incontinence 1.39 HR JAMA. 2017;318(22): doi: /jama

44 Compare USPSTF to Other Organization Statements 44 AHA, ACOG Recommend against HRT for the use of 1 or 2 prevention of CVD ACOG effect on CVD differs from early initiation to late initiation CTF (Canada s PTF) and AAFP against HRT for prevention of any chronic conditions AACE (American Assoc. of Clin Endo): consider age, CV risk and time from menopause onset to assess and use HRT in symptomatic menopausal women. Notes FDA approval HRT for women at increased risk of osteoporosis and fractures NAMS focuses on menopausal symptoms Endocrine Society focuses on HRT for women with menopausal symptoms HOW DO YOU WEIGH IN???

45 When AAFP Guidelines Differ from USPSTF Guidelines 45

46 AAFP Guideline Endorsement Process 46 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 guideline provides some benefit for family physicians. (3) NOT ENDORSED - The AAFP does not endorse the guideline and the reasons are stated.

47 Where AAFP and USPSTF Differ 47 Colorectal Screening Lung Cancer Screening

48 Colorectal Screening 48 USPSTF Grade: A The USPSTF recommends screening for colorectal cancer starting at age 50 years and continuing until age 75 years. Use one of 7 methods AAFP GRADE: B The AAFP recommends screening for colorectal cancer with fecal immunochemical tests, flexible sigmoidoscopy, or colonoscopy starting at age 50 years and continuing until age 75 years. Only 3 recommended tests

49 Colorectal Screening AAFP 49 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 50 years and continuing until age 75 years. The risks, benefits, and strength of supporting 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's overall health and prior screening history. (2016)

50 Colorectal Screening AAFP RATIONALE 50 Flexible sigmoidoscopy and guaiac-based fecal occult blood testing are the only screening methods which have reduced colorectal cancer mortality in randomized controlled trials. Fecal immunochemical tests (FIT) have improved accuracy compared with gfobt, and can be performed with a single fecal specimen. Optical colonoscopy as a screening strategy can be performed less frequently than flexible sigmoidoscopy or stool-based tests, and may detect precancerous lesions that would be missed by these tests. However, the incremental mortality benefit is uncertain, and it is associated with greater harms.

51 AAFP Rationale for 3 Tests Only 51 Although advanced adenoma detection rates for CT colonography and FIT-DNA appear to be comparable to those of colonoscopy based on cross-sectional studies, both of these screening methods have insufficient evidence of harms. CT colonography exposes patients to radiation, and there is insufficient evidence about the harms of associated extra-colonic findings, which are common (occurring in 40% to 70% of screening examinations). FIT-DNA has a higher false positive rate than FIT, a higher rate of unsatisfactory samples than FIT, and information is lacking on appropriate screening intervals and follow-up intervals for patients with positive FIT-DNA but a negative colonoscopy.

52 Colorectal Cancer Screening Age NO DIFFERENCE 52 USPSTF Grade C The decision to screen for colorectal cancer in adults aged 76 to 85 years should be an individual one, taking into account the patient s overall health and prior screening history. Adults in this age group who have never been screened for colorectal cancer are more likely to benefit. Screening would be most appropriate among adults who 1) are healthy enough to undergo treatment if colorectal cancer is detected and 2) do not have comorbid conditions that would significantly limit their life expectancy. AAFP GRADE: C 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's overall health and prior screening history. (2016)

53 American Cancer Society Colon Cancer Screening Statement 53 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*

54 ACS Colon Cancer Screening and Prevention 54 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 specifics

55 The USPSTF and AAPF Lung Cancer Screening Controversy 55

56 USPSTF Lung Cancer Screening Guideline: Grade B 56 Adults Aged 55-80, with a History of Smoking The USPSTF recommends annual screening for lung cancer with lowdose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery recommendation

57 Based on the NLST Trial 57 The National Lung Screening Trial (NLST) - the largest and most expensive randomized clinical trial in the USA demonstrated a 20% mortality rate reduction in patients who had undergone chest low-dose computed tomography screening, as compared to patients screened with a conventional chest X-ray. The study was stopped early due to startling results finding cancer much more frequently than the CXR did. (2013) The American Cancer Society just came out with a similar recommendation The European Society of Thoracic Surgeons now recommends same screening for Europe. (2018) UK and China currently doing Lung Cancer studies with CT.

58 AAFP: Lung Cancer Screening 58 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 smoking history. BASED ON ONE STUDY ONLY

59 AAFP Response to USPSTF Lung 59 "The AAFP has reviewed the USPSTF s recommendations on lung cancer screening and had significant concern with basing such a far reaching and costly recommendation on a single study. The National Lung Screening Trial (NLST), whose favorable results were conducted 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 should occur regarding the benefits and potential harms of screening for lung cancer. The long term harms of radiation exposure from necessary follow-up full dose CT scans are unknown. The USPSTF recommends annual CT screening even though the NLST trial was only 3 annual scans. From: AAFP

60 AAFP RESPONDS 60 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 a less strict follow-up protocol in the community is not known.

61 NLST Study Limitations: 61 LOCATION "The NLST was conducted at a variety of medical institutions, many of which are recognized for their expertise in radiology and the diagnosis and 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 all settings. COST The cost-effectiveness of low-dose CT screening must be considered in the context of competing interventions, particularly smoking cessation."

62 American Cancer Society Sums it Up 62 Clinicians with access to high-volume, high-quality lung cancer screening and treatment centers should initiate a discussion about annual lung cancer screening with apparently healthy patients 55 to 74 years of age who have at least a 30 pack-year smoking history and who currently smoke 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 attention in discussions with current smokers, who should be informed of their continuing risk of lung cancer; screening should not be viewed as an alternative to smoking cessation CA Cancer J Clin. March/April 2017;67(2):

63 Summary 63 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 been vetted by groups of experts. Groups of experts may interpret evidence differently.

64 What s Next for the USPSTF? 2018 Updates in Progress Finalization Stage STAY TUNED 64 Screening 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

65 To Learn More: 65 Electronic Preventive Services Selector Ebook: ex/browse-recommendations

66 References 72 Ebell, M, Editorials, USPSTF Recommendations: New and Updated in 2016, American Family Physician Oct 1, 2017, Clinical Preventive Service Recommendation Lung Cancer, Screening for Ovarian Cancer: US preventive Task Force Recommendation Statement, 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 Feb 13;319(6): doi: /jama ionstatementfinal/aspirin-to-prevent-cardiovascular-disease-and-cancer

67 References Should Family Physicians Routinely Screen for Lung Cancer in High-Risk Populations? No: The USPSTF's Recommendation for Lung Cancer Screening Is Overreaching. American Academy of Family Physicians. Clinical recommendations. Lung cancer. Accessed May 3, Lung Cancer: Diagnosis, Treatment Principles, and Screening,

68 References 74 Menon U, et al Gynecol Oncol Feb;132(2): doi: /j.ygyno Epub 2013 Dec 3. Ovarian cancer screening--current status, future directions. Siu AL; US Preventive Services Task Force. Screening for autism spectrum disorder in young children: US Preventive Services Task Force recommendation statement. JAMA. Doi: /jama

69 References 75 US Preventive Service Task Force, JAMA, 2017 Mar 7;317(9): doi: /jama Screening for Gynecologic Conditions With Pelvic Examination: US Preventive Services Task Force Recommendation Statement. CA Cancer J Clin. March/April 2017;67(2): US Preventive Services Task Force. Preeclampsia screening: US Preventive Services Task Force recommendation statement. JAMA. doi: /jama JAMA. 2017;318(22): doi: /jama Hormone Replacement Therapy Screening for Depression in Children and Adolescents: U.S. Preventive Services Task Force Recommendation Statement Ann Intern Med. 2016;164: doi: /m onstatementfinal/thyroid-cancer-screening1

70 Dr. Hart Contact Information 76 Rebecca Hart, MD 201 Enterprise Ave, Suite 900 League City, Texas