Don’t confuse screening with diagnosis. Screening, by definition, means looking for a condition among asymptomatic persons. Diagnostic tests performed to clarify the cause of symptoms or to improve clinical care are not screening tests. Screening recommendations therefore do not apply in these latter instances. In addition, the task force recognizes that screening recommendations need to be interpreted in light of local epidemiology. In areas of high STD prevalence, more widespread screening might well be justified.
TABLE 3
USPSTF definitions of risk for HIV and gonorrhea
| HIV RISK |
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| GONORRHEA RISK |
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Abdominal aortic aneurysms
The rationale behind these recommendations was discussed in a previous Practice Alert.1 The take-home message for physicians is that any male who has ever smoked can possibly benefit from a one-time abdominal ultrasound.
Women’s health conditions
Two sets of recommendations pertain to hormone replacement therapy (HRT) and screening for breast and ovarian cancer.
When to avoid HRT. The task force recommends against using combined estrogen and progestin in postmenopausal women, and against using estrogen to prevent chronic health conditions in postmenopausal women who have had a hysterectomy.
Estrogen and progestin combinations reduce the risk for fractures and colorectal cancer but have no beneficial effect on (and may increase the risk of) coronary heart disease. Other documented harms include increased risk for breast cancer, venous thromboembolism, stroke, cholecystitis, dementia, and lower global cognitive function. Unopposed estrogen reduces the risk for fractures but increases risk for venous thromboembolism, stroke, dementia, and lower global cognitive functioning, and it has no beneficial effect on coronary heart disease.
When to investigate possible BRCA1 or BRCA2 gene mutations. For women with family histories suggestive of mutations of BRCA1 or BRCA2 genes—which place women at markedly higher lifetime risk of breast and ovarian cancer—the task force recommends referral for counseling and possible genetic testing. While the task force acknowledges the unresolved ethical, social, and legal issues, as well as the unknown benefits of chemoprevention and intensive screening, they believe the potential of prophylactic surgery to prevent breast and ovarian cancer is sufficient to make the recommendation.
Note that the recommendation is for referral for genetic counseling in which genetic testing may be considered. It is not a recommendation for testing by itself.
The following elements of a family history place a woman at risk:
- 2 first-degree relatives with breast cancer, 1 of whom received the diagnosis at age 50 years or younger
- A combination of 3 or more first- or second-degree relatives with breast cancer regardless of age at diagnosis
- A combination of both breast and ovarian cancer among first- and second-degree relatives
- A first-degree relative with bilateral breast cancer
- A combination of 2 or more first-or second-degree relatives with ovarian cancer regardless of age at diagnosis
- A first- or second-degree relative with both breast and ovarian cancer at any age
- A history of breast cancer in a male relative.
For Ashkenazi Jewish women, an increased-risk family history includes any first-degree relative (or 2 second-degree relatives on the same side of the family) with breast or ovarian cancer.
For women without a high-risk family history, the task force believes that counseling or routine testing will lead to more harms than benefits and they recommend against it.
Overweight in children and adolescents
The task force acknowledges the increasing prevalence of overweight and obesity in children and adolescents and the consequent adverse health outcomes caused by this condition. As with many unhealthy conditions or habits, however, it is not known whether screening and counseling in the primary care setting reduce child and adolescent obesity.
Remember that the task force is not recommending for or against measuring height, weight, and body-mass index in the office or talking to young patients about their weight. They are simply summarizing the state of the science, which is unclear about whether such efforts by physicians have any effect.