INTRODUCTION — Quality health care for individuals includes two fundamental elements: appropriate treatment for current illness and appropriate preventive care to attempt to lessen future health decline. Preventive health care is an important aspect of medical practice, leading to significant improvements in overall health .
Several issues are involved in providing effective preventive care. Clinicians need to prioritize and decide which of the many available preventive services to recommend and which to discourage to prevent harm from inappropriate tests or interventions. Clinicians also must find a way to deliver preventive services efficiently within the context of a busy clinical practice.
This topic will discuss the approach to prevention and how to prioritize preventive services. It will also summarize primary prevention and screening recommendations primarily targeting United States adults <65 years old. The recommendations are a compilation of those from individual UpToDate topics, in which the rationale and evidence base for the recommendations are provided.
Preventive care in certain populations and disease-specific screening recommendations are discussed in more detail in specific topic reviews. As examples:
●Gay men (see "Primary care of gay men and men who have sex with men")
●Patients with HIV (see "Primary care of adults with HIV")
●Cancer survivors (see "Overview of cancer survivorship care for primary care and oncology providers")
●Patients with diabetes mellitus (see "Overview of general medical care in nonpregnant adults with diabetes mellitus")
Basic epidemiologic principles of screening in adults are presented elsewhere. (See "Evidence-based approach to prevention".)
PRIORITIZING PREVENTIVE SERVICES — Preventive services should focus on priority health problems and effective interventions. Rather than performing a standardized comprehensive examination ("full physical") on all patients, clinicians should individualize screening and prevention interventions to maximize value, which encompasses the tradeoffs between benefits, harms, and costs [2,3].
We recommend referring to the US Preventive Services Task Force (USPSTF) website for the most up-to-date screening recommendations based on systematic reviews of available evidence. We provide a review of screening, prevention, and counseling recommendations for older adults elsewhere. (See "Geriatric health maintenance".)
Factors to consider — Priority services may differ from patient to patient depending upon age, sex, and other risk factors. The effects of recommended preventive interventions on longevity or quality of life vary widely, and the potential beneficial effect of any one intervention on an individual patient varies with their lifestyle, medical and family history, and other risk factors . Available tools to help clinicians prioritize preventive services include:
●The Partnership for Prevention, which ranks preventive services based on the clinically preventable burden of disease and the cost-effectiveness of interventions . The list includes aspirin chemoprophylaxis to reduce cardiovascular events, childhood immunizations, and smoking cessation advice.
●The USPSTF provides a convenient tool to identify recommended patient-specific preventive services based upon a patient's sex, age, pregnancy status, tobacco use, and whether they are sexually active.
As with all clinical decisions, patient preferences are also of prime importance . Risks and benefits should be communicated to patients in a way that they can understand, which can be challenging because many patients have a limited understanding of probabilities. A 2014 systematic review found that patients are better able to understand absolute than relative risks, and that visual aids can be helpful . Studies also suggest that patients tend to overestimate the benefits and underestimate the harms of interventions (including screening tests) .
Further, scheduled preventive interventions (eg, cancer screenings) may need to be deferred due to intercurrent individual illness or a larger public health crises (eg, epidemic or pandemic infectious disease) . In such circumstances, patients should be reassured that preventative interventions will be resumed when appropriate. Cancer screening during the coronavirus pandemic is discussed elsewhere. (See "COVID-19: Considerations in patients with cancer", section on 'Impact of the pandemic on cancer screening'.)
Overview of USPSTF recommendations — The USPSTF publishes evidence-based recommendations for multiple clinical preventive services based upon systematic reviews, each of which is graded based on a set of definitions [10,11].
●USPSTF A and B level recommendations – The USPSTF recommends certain screening and counseling interventions either with high certainty that the net benefit is substantial ("Grade A"), with high certainty that the net benefit is moderate, or with moderate certainty that the net benefit is moderate to substantial ("Grade B"). These Grade A and B level recommendations should be offered to patients.
●USPSTF C level recommendations – Preventive services for which there is at least moderate certainty that the net benefit is small are rated as "Grade C." The USPSTF recommends selectively offering or providing these services to individual patients based on professional judgment, patient preferences, and individual circumstances.
●USPSTF D level recommendations – Preventive services for which there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits are rated as "Grade D." The USPSTF recommends against these services.
●USPSTF level I recommendations – Preventive services for which the balance of benefits and harms cannot be determined due to lack of sufficient evidence, or poor quality or conflicting evidence, are rated as "Grade I." If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.
Harms of screening — There are harms associated with screening, including anxiety produced by false-positive screening tests, harms associated with diagnostic testing after a positive screening test, overdiagnosis of conditions that may be treated but would never have become clinically apparent, and cost [12-14]. Comorbid conditions may decrease the benefits and increase the harms associated with screening . The benefits of screening may decrease as patients get older, particularly for cancer screening . Cancer screening in older adults is discussed in detail elsewhere. (See "Geriatric health maintenance", section on 'Cancer screening'.)
Clinicians should make sure that patients understand the potential harms prior to screening and consider comorbidities when discussing screening. Patients may weigh potential benefits and harms of screening and, in some cases, decide against screening. This is a reasonable decision that should be accepted by clinicians. The optimal screening rate is less than 100 percent when patients are adequately counseled regarding the potential benefits and harms of screening.
Screening of patients who are unlikely to benefit from screening is common. As an example, in an observational study including 27,000 patients ≥65 years, 31 to 55 percent of those with ≥75 percent risk of nine-year mortality had received prostate, breast, cervical, or colorectal cancer screening within the previous two to five years .
HOW TO EFFICIENTLY DELIVER PREVENTION
Periodic "check-up" — There are no strict guidelines for the optimal frequency of periodic visits, and there is no evidence on which to base optimal frequency recommendations . Annual examinations are not indicated for most younger patients, although people with chronic health issues (such as diabetes) warrant regular visits, with or without a periodic health maintenance visit, independent of age . In the absence of such indications, we suggest periodic health maintenance visits every three years for adult patients ≤49 years without chronic conditions, and annually for adults ≥50 years. For people who have no chronic conditions and rarely see a clinician, a periodic health evaluation visit may be the only opportunity to discuss preventive care.
Preventive counseling and services are an important component of the periodic health check-up [20-22]. Preventive services are more likely to be discussed when patients have an established relationship with an identified clinician. Studies have shown that patients who were connected to a specific clinician have higher rates of preventive services received [22-25]. Patients with more visits to their primary care providers were more likely to undergo screening for colorectal and breast cancer, have lower incidence and mortality of colorectal and breast cancer, and have lower overall mortality. Periodic visits may have other benefits, such as developing the patient-clinician relationship, relieving patient "worry," and educating patients about how to access the health care system [21,26].
In a 2014 meta-analysis including six randomized trials, general practice-based health checks did not decrease mortality but improved surrogate outcomes (blood pressure control, decreases in total cholesterol and body mass index [BMI]), especially in high-risk patients . In another meta-analysis including 14 randomized trials and over 180,000 participants, there was no beneficial effect of general health checks on total, cardiovascular or cancer mortality despite increased detection of hypertension and hypercholesterolemia as well as increased use of antihypertensives . However, some methodologic problems of the included trials (including the age of some trials which predated the routine use of statins) may limit interpretation of the results.
Discussing stopping or reducing screening — Changes to recommendations that result in a decrease in the intensity of screening or discontinuing screening for those patients with reduced likelihood of benefit may be problematic for patients. In particular, patients may be confused by these changes, especially if they view screening as something they can do to protect themselves from a feared condition . How best to explain the rationale for less-intensive or discontinued screening can be challenging. Although we know of no easy formula for conducting these discussions, some general suggestions may be useful:
●The idea that screening programs can result in harm is often new to patients. Patients should be educated that the primary issue underlying any screening recommendation is the balance between the likelihood of benefit and the risk of harm. A discussion of hypothetical examples that illustrate how screening may lead to unnecessary, difficult, and possibly risky diagnostic procedures (such as lung biopsy) or treatment (such as chemotherapy for cancer that would not have become clinically apparent over the patient's lifetime) may be helpful.
●One may acknowledge the patient's interest in preserving health and longevity and refocus the patient away from more intensive or longer screening toward other prevention activities that bring a higher likelihood of benefit.
●For older patients with limited life expectancy, it may also be useful to start the discussion of stopping screening some years before actual stopping. Older patients, advised over years that screening is an important part of medical care, may view stopping screening as an indication that they are no longer "worth" the expense or effort . Again, hypothetical stories may be used to illustrate the reality that the probability of benefit from screening decreases and the probability of harm from overdiagnosis increases in advanced age. In addition, harm occurs soon after screening while any benefit occurs only years after screening. For example, for colorectal cancer and breast cancer screening, a patient must live 10 years to have a 1 in 1000 probability of having their life extended, and 16 years to have a 2 in 1000 probability . If a patient is overdiagnosed, however, they receive unnecessary treatment (often including surgery) soon after diagnosis.
Supportive office systems — Creative approaches using office systems can assist in delivering needed preventive care . As an example, practices have successfully used databases of eligible patients (eg, for flu shots, mammograms, diabetic eye exams, etc) and automatic reminders to outreach to patients and assist in delivering routine preventive care . In one study of interventions to promote screening for colorectal cancer, mailings to patients were somewhat more effective than electronic reminders to clinicians . Finally, using decision aids and/or training medical assistants to discuss important preventive services before a visit with a clinician can be more efficient and effective in helping patients make informed decisions .
CARDIOVASCULAR DISEASE PREVENTION
Cardiovascular risk assessment — Patients aged ≥20 years should undergo cardiovascular risk assessment every three to five years.
Cardiovascular disease (CVD) risk can be estimated using one of several widely available tools, each with advantages and disadvantages. While all of the risk assessment tools have advantages and disadvantages, no single tool will be appropriate for all patients. We encourage clinicians to become familiar with and use a CVD risk calculator that has been locally endorsed and that has been validated for their locale and for patient-specific race and ethnic groups. (See "Cardiovascular disease risk assessment for primary prevention: Risk calculators".)
The major risk factors for CVD that are modifiable include (see "Overview of primary prevention of cardiovascular disease"):
●Diet (see "Healthy diet in adults")
●Hypertension (see "Cardiovascular risks of hypertension")
●Physical activity (see "The benefits and risks of aerobic exercise", section on 'Cardiovascular disease')
Screening for coronary heart disease in patients with risk factors is discussed in detail elsewhere. (See "Screening for coronary heart disease".)
Hypertension — Hypertension screening is recommended for adults ≥18 years of age [35,36]. The optimal interval for screening for hypertension is not known. Most patients have their blood pressure checked at each primary care visit.
The 2021 US Preventive Services Task Force (USPSTF) guidelines recommend hypertension screening every year for adults ≥40 years and for those who are at high risk for high blood pressure (eg, patients with mean daytime blood pressure 130 to 139/80 to 89 mmHg, those with overweight or obesity, and African American individuals) [37,38]. Adults aged 18 to 39 years without elevated blood pressure (ie, <130/80 mmHg) and without cardiovascular disease risk factors should be rescreened every three to five years. The USPSTF recommends obtaining out-of-office blood pressure measurements to confirm a diagnosis of hypertension before starting treatment. (See "Blood pressure measurement in the diagnosis and management of hypertension in adults", section on 'Our approach to measuring blood pressure'.)
Recommendations for target blood pressure and treatment differ based on several factors including comorbidities, method of blood pressure measurement (table 1) and age. (See "Blood pressure measurement in the diagnosis and management of hypertension in adults" and "Overview of hypertension in adults", section on 'Definitions' and "Goal blood pressure in adults with hypertension".)
●We suggest that patients aged 17 to 21 years undergo one-time screening for hyperlipidemia with a non-fasting non-high-density lipoprotein (non-HDL) cholesterol; non-HDL cholesterol is the difference between total cholesterol and HDL cholesterol . (See "Dyslipidemia in children and adolescents: Definition, screening, and diagnosis".)
●For patients with a normal screen before age 21 who are also at high risk, we suggest screening for lipid abnormalities starting at age 25 for men and 35 for women. We consider patients at high risk if they have more than one risk factor (eg, diabetes, hypertension, smoking, family history) or a single risk factor that is severe (eg, several siblings with coronary heart disease in their 40s or a very heavy smoker).
●For patients with a normal screen before age 21 who are not at high risk, we suggest screening for lipid abnormalities starting at age 35 for men and 45 for women.
In patients whose lipid measurements place them well below the threshold for treatment (including lifestyle modification or lifestyle modification plus pharmacologic therapy), we suggest repeating measurements every five years. In patients who have had multiple lipid screenings with acceptable measurements, we suggest stopping screening at age 65. Ongoing assessment of cardiovascular risk can be based upon other risk factors and earlier lipid levels. (See "Screening for lipid disorders in adults".)
When a decision is made to screen lipids to assess cardiovascular risk, we suggest measuring the total cholesterol and HDL cholesterol rather than a complete lipid profile or other lipid marker or fractions. Testing for total cholesterol and HDL cholesterol does not require a fasting test. (See "Screening for lipid disorders in adults", section on 'Choice of tests'.)
Obesity — We suggest screening all patients for obesity with a body mass index (BMI) and counseling all patients to maintain a healthy body weight (calculator 1). Selection of patients for treatment should be based upon BMI and risk factor assessment. (See "Obesity in adults: Prevalence, screening, and evaluation" and "Obesity in adults: Overview of management".)
Physical activity — It has been estimated that up to one-third of cardiovascular disease deaths may be preventable by healthy diet and physical activity . We suggest counseling patients about exercise to promote maintenance of healthy weight and physical activity for all patients. (See "The benefits and risks of aerobic exercise" and "Exercise and fitness in the prevention of atherosclerotic cardiovascular disease".)
Diabetes mellitus — For adults with hypertension or hyperlipidemia, as well as for all adults aged 35 to 70 years with a BMI ≥25 kg/m2, we suggest screening for type 2 diabetes as part of cardiovascular risk assessment . (See "Screening for type 2 diabetes mellitus", section on 'A suggested approach'.)
When convenient, we recommend screening using fasting plasma glucose measured in a laboratory using a venous sample rather than a capillary fingerstick. Simultaneously checking a hemoglobin A1C is a reasonable option, especially in patients with the highest risk of diabetes (eg, those with multiple risk factors or a known abnormal glucose metabolism). When obtaining a fasting specimen is inconvenient, we recommend screening using a hemoglobin A1C.
Aspirin for primary prevention — Decisions regarding aspirin for primary prevention of CVD should be made on an individual basis. Factors to be considered are discussed in detail elsewhere. (See "Aspirin in the primary prevention of cardiovascular disease and cancer".)
Routine electrocardiogram — A routine electrocardiogram (ECG), even for a "baseline," is not indicated in asymptomatic adults at low risk for CVD. (See "Screening for coronary heart disease", section on 'Resting ECG and ambulatory ECG monitoring'.)
Nontraditional measures — Coronary artery calcium testing may be useful as a complement to CVD risk assessment in select patients (see "Coronary artery calcium scoring (CAC): Overview and clinical utilization"). We do not recommend screening low-risk patients with other nontraditional measures (eg, C-reactive protein, carotid artery intima-media thickness, homocysteine, or lipoprotein[a]).
However, as discussed separately, these measures may be warranted for patients without known CVD who are at intermediate risk for CVD and for whom a more definite estimate of CVD risk would change management:
●C-reactive protein (see "C-reactive protein in cardiovascular disease")
●Carotid artery intima-media thickness (see "Carotid intima-media thickness")
●Homocysteine (see "Overview of homocysteine")
●Lipoprotein(a) (see "Lipoprotein(a)")
General cancer prevention counseling — A number of measures can be taken to prevent cancer, including:
●Avoidance of tobacco (see 'Tobacco use' below)
●Being physically active
●Maintaining a healthy weight
●Eating a diet rich in fruits, vegetables, and whole grains and low in saturated/trans fat
●Limiting alcohol consumption
●Protecting against sexually transmitted infections (including receiving human papillomavirus [HPV] vaccination)
●Avoiding excess sun exposure
General measures for cancer prevention are discussed in more detail separately. (See "Overview of cancer prevention".)
Tobacco use — Smoking tobacco products (primarily cigarettes) is the most important risk factor for the development of lung cancer and contributes to a large burden of disease, including other malignancies, cardiovascular disease (CVD), and pulmonary disease. (See "Cigarette smoking and other possible risk factors for lung cancer" and "Cardiovascular risk of smoking and benefits of smoking cessation" and "Overview of cancer prevention", section on 'Tobacco use'.)
We recommend that clinicians ask all patients whether they use tobacco and in what form. Smoking status should be documented; for all patients who use tobacco, clinicians should offer the advice to quit, assess the patient’s interest in quitting, and, for those interested in quitting, offer the necessary tools (including behavioral intervention and pharmacotherapy), techniques, and follow-up . (See "Overview of smoking cessation management in adults".)
Breast cancer — Major risk factors for breast cancer in women are age, genetic predisposition, and estrogen exposure (table 2). Evaluation for hereditary breast and ovarian cancer syndromes should be considered in all individuals with a personal or family history that is concerning. (See "Factors that modify breast cancer risk in women" and "Screening for breast cancer: Strategies and recommendations", section on 'Clinical use of risk prediction models'.)
●Family history – All individuals at risk for hereditary breast and ovarian cancer syndromes should be identified by taking a thorough personal and family history, focusing on both biological sides of the family (table 3). Patients with concerning family history should be referred to a genetic counselor for a formal genetic assessment. Recommendations for screening in patients with a hereditary breast and ovarian cancer syndrome are discussed in detail elsewhere. (See "Overview of hereditary breast and ovarian cancer syndromes" and "Cancer risks and management of BRCA1/2 carriers without cancer".)
●Screening for average-risk individuals – Clinicians should address breast cancer screening starting at age 40, although most guidelines do not recommend initiating breast cancer screening for those at average risk until age 50 (table 4). (See "Screening for breast cancer: Strategies and recommendations", section on 'Age 40 to 49 years'.)
The decision to perform screening mammography should be determined by individual patient risk and values through shared decision-making. It should be emphasized that the relative benefits and harms of screening change as an individual gets older. The absolute benefits, in terms of numbers of lives saved, are lower for younger compared with older people because of both decreased incidence of breast cancer and sensitivity of mammography in younger patients. (See "Screening for breast cancer: Strategies and recommendations", section on 'Shared medical decision-making' and "Screening for breast cancer: Strategies and recommendations", section on 'Benefits and harms of screening'.)
All patients should receive counseling about the benefits and harms of screening and understand that mammography is associated with a substantial risk for false-positive findings and overdiagnosis. Given declining mortality rates from breast cancer after advances in treatment protocols, some people may choose to forego screening.
For those who choose to undergo screening, the ideal interval for screening mammography is not known. We suggest screening every one to two years, depending upon patient preference. (See "Screening for breast cancer: Strategies and recommendations", section on 'Average risk: Screening'.)
●Age to stop screening – We suggest that breast cancer screening with mammography be continued as long as an individual has a life expectancy of at least 10 years.
We suggest that those being screened for breast cancer not undergo clinical breast examination.
We suggest that breast self-examination (BSE) not be performed except by those who express a desire to do so and who have received careful instruction to differentiate normal tissue from suspicious lumps. (See "Screening for breast cancer: Evidence for effectiveness and harms", section on 'Breast self-examination'.)
Cervical cancer — We recommend cervical cancer screening for all individuals with a cervix aged 21 to 65 years. (See "Screening for cervical cancer in resource-rich settings".)
Screening refers to testing in patients who have had all prior normal results. Patients who have had prior abnormal results require surveillance, and the recommended options and frequency differ based on the patient's previous results and underlying risk for developing cervical cancer. (See "Screening for cervical cancer in resource-rich settings", section on 'Surveillance in patients with abnormal screening'.)
We suggest screening in the following patient groups:
●Age 21 to 29 – For average-risk people (ie, without HIV, immunocompromise, or in utero exposure to diethylstilbestrol) aged 21 to 29, we suggest Pap test screening every three years.
Another acceptable approach is to initiate screening at age 25 with primary human papillomavirus (HPV) testing every five years. However, in the United States, this can only be done with HPV tests approved by the US Food and Drug Administration (FDA), and these are not readily available at most institutions. Thus, this option may not be feasible in many United States settings. (See "Screening for cervical cancer in resource-rich settings", section on 'Age 21 to 29'.)
●Age 30 to 65 – For average-risk people aged 30 to 65, either of the following strategies is acceptable (see "Screening for cervical cancer in resource-rich settings", section on 'Age 30 to 65'):
•Co-testing (Pap and HPV testing together) every five years
•Pap test alone every three years
Primary HPV testing (with an FDA-approved test) every five years is also an option, but this may not be feasible as the particular HPV assays required for testing are not widely available.
●Age ≥65 – For average-risk individuals ≥65 years who have had adequate negative prior screening, no further screening is needed. (See "Screening for cervical cancer in resource-rich settings", section on 'If adequate prior and all normal screening'.)
Adequate prior screening is defined as:
•Two consecutive negative co-tests (Pap and HPV testing) within the past 10 years, with the most recent test within the previous five years; or
•Three consecutive negative Pap tests within the past 10 years, with the most recent test within the previous three years; or
•Two consecutive negative primary HPV tests within the past 10 years, with the most recent test within the previous five years
Those ≥65 years who have not had adequate prior screening should continue with cervical cancer screening. For such patients, we perform co-testing annually for three years before spreading out the interval to every five years.
The US Preventive Services Task Force (USPSTF) recommends continuing screening these patients until age 70 to 75 years.
We stop screening patients earlier if their life expectancy is limited to less than 10 years. (See "Screening for cervical cancer in resource-rich settings", section on 'If inadequate prior screening or unknown screening'.)
Individuals who have had a total hysterectomy (ie, hysterectomy with removal of the cervix) for reasons other than cervical cancer or high-grade cervical cancer precursors do not need to be screened. (See "Screening for cervical cancer in resource-rich settings", section on 'Prior benign hysterectomy'.)
Screening recommendations for patients who are at high-risk for cervical cancer include patients with HIV infection, immunosuppression, or in-utero exposure to diethylstilbestrol, and are reviewed elsewhere. (See "Screening for cervical cancer in resource-rich settings", section on 'Screening in higher risk patients'.)
Ovarian cancer — A family history is essential to identifying patients at high risk for ovarian cancer who might benefit from further evaluation. This is described in detail separately. (See "Screening for ovarian cancer", section on 'Family history'.)
Screening for ovarian cancer is not recommended for individuals at average risk. (See "Screening for ovarian cancer", section on 'Average-risk patients'.)
Colorectal cancer — The age of initiation and frequency of colorectal cancer screening varies with the risk:
●No risk factors – We recommend that average-risk patients aged 45 and older be screened for colorectal cancer. We suggest that screening be continued until the life expectancy for an individual patient is estimated as less than 10 years. For most patients, it is reasonable to stop screening at age 75 years or 85 years at the latest. One-time screening with colonoscopy (to age 83) or sigmoidoscopy (to age 84) is advised for adults who have never been screened for colorectal cancer. (See "Screening for colorectal cancer: Strategies in patients at average risk", section on 'Choosing a screening test' and "Screening for colorectal cancer: Strategies in patients at average risk".)
The recommended interval varies depending upon the screening strategy. Patients should be advised of the risks and benefits of different screening options. The decision about which option to select should be made between the patient and clinician, weighing factors of effectiveness, safety, cost, and availability of the screening tests. (See "Screening for colorectal cancer: Strategies in patients at average risk".)
●Family history of colorectal cancer. (See "Screening for colorectal cancer in patients with a family history of colorectal cancer or advanced polyp".)
●Familial adenomatous polyposis. (See "Familial adenomatous polyposis: Screening and management of patients and families".)
●Lynch syndrome. (See "Lynch syndrome (hereditary nonpolyposis colorectal cancer): Cancer screening and management".)
●Peutz-Jeghers syndrome. (See "Juvenile polyposis syndrome".)
●Inflammatory bowel disease. (See "Surveillance and management of dysplasia in patients with inflammatory bowel disease".)
Lung cancer — For patients at increased risk for lung cancer, we suggest annual screening with low-dose helical computed tomography (CT). Further discussion on the appropriateness of lung cancer screening, including information on which patients are at increased risk, can be found elsewhere. (See "Screening for lung cancer", section on 'Synthesizing the available evidence' and "Screening for lung cancer", section on 'Our approach to counseling for screening'.)
Prostate cancer — Individual patient preferences for specific health outcomes are a deciding factor in determining whether to screen for prostate cancer. Patients who are potential candidates for screening should be engaged in discussions or decision-making processes that inform them and evoke these preferences. (See "Screening for prostate cancer", section on 'Approach to screening'.)
Health care providers should periodically discuss prostate cancer screening with patients who are expected to live at least 10 years and are old enough to be at significant risk for prostate cancer. We suggest that discussions begin at age 50 in average-risk individuals. We suggest discussions begin at age 40 to 45 in those at high risk for prostate cancer (including African American patients; those with a family history of prostate cancer, particularly in relatives younger than age 65; and individuals who are known or likely to have the BRCA1 or BRCA2 mutations).
●We do not routinely screen patients at average risk for melanoma; however, we recommend that clinicians remain vigilant for any suspicious lesions identified in the course of a routine or sick visit and make appropriate referrals for further evaluation of all such lesions.
We suggest that individuals at high risk of melanoma have a regular full-body skin examination by a clinician with skin expertise. The optimal frequency of examination is unknown (see "Screening for melanoma in adults and adolescents", section on 'High-risk patients'). The United States Preventive Services Task Force has found insufficient evidence for or against skin cancer screening . Our rationale for screening high-risk patients is presented separately. (See "Screening for melanoma in adults and adolescents", section on 'Rationale for screening'.)
●Surveillance of patients in melanoma-prone kindreds is described separately. (See "Inherited susceptibility to melanoma", section on 'Surveillance in melanoma-prone kindreds'.)
Multi-cancer detection tests — Multi-cancer detection (MCD) tests have the goal of detecting cancer at early stages . MCD tests analyze blood samples for molecular signals (eg, DNA, proteins) that are produced by cancer cells. Although they are intended to serve as adjuncts to standard cancer screening tests, MCDs can result in substantial downstream testing. A positive test result requires additional imaging and diagnostic work-up, particularly since MCD tests often do not specify the type of cancer or the organ(s) that are involved.
Although some MCD tests are commercially available, their clinical utility for cancer screening has not yet been established. Additional studies are required to determine if these tests have acceptable accuracy and, most importantly, reduce cancer morbidity and mortality.
A case-control study of this technique suggested feasibility and good accuracy in detecting cancer signals across a wide diversity of malignancies . Similarly, a multicenter cohort study of 6238 participants in England and Wales evaluated the utility of an MCED test in adult patients who were referred for urgent investigation of non-specific symptoms that were possibly caused by lung, gastrointestinal, or gynecologic cancers . In this cohort of symptomatic patients, the test was highly specific (98 percent) but only moderately sensitive (66 percent). Test sensitivity improved for the detection of higher stage cancers and accurately predicted the cancer's site of origin in 85 percent of cases.
The results in these studies are not reflective of test performance in populations who typically undergo screening (ie, asymptomatic individuals in primary care). Moreover, their utility in improving clinical outcomes, such as cancer-related death, is uncertain, particularly in comparison with existing screening methodologies .
●Iron deficiency – We do not routinely screen every adult for iron deficiency, but we do screen those at higher risk (eg, premenopausal women, particularly those with prior pregnancies or heavy menstrual periods, as well as individuals with conditions that might cause blood loss or iron malabsorption). The frequency of screening is also individualized; annual screening may be reasonable for those at the highest risk, such as a menstruating individual with heavy periods. Screening for iron deficiency is discussed in detail elsewhere. (See "Causes and diagnosis of iron deficiency and iron deficiency anemia in adults", section on 'Screening (asymptomatic individuals)'.)
Screening for iron deficiency in pregnant individuals is discussed elsewhere. (See "Anemia in pregnancy", section on 'Screening during pregnancy'.)
●Hypothyroidism – Although subclinical hypothyroidism is common in the adult population , we do not routinely screen most asymptomatic non-pregnant adults as there is no evidence that early detection and treatment with T4 improves clinically important outcomes in such individuals. However, we do screen individuals who are at increased risk for hypothyroidism, including those with goiter, history of autoimmune disease, previous radioactive iodine therapy, and/or head and neck irradiation, family history of thyroid disease, and use of medications that may impair thyroid function. This is discussed in detail elsewhere. (See "Diagnosis of and screening for hypothyroidism in nonpregnant adults", section on 'Screening'.)
Recommendations for screening pregnant individuals for hypothyroidism are discussed separately. (See "Hypothyroidism during pregnancy: Clinical manifestations, diagnosis, and treatment", section on 'Screening'.)
●Vitamin D deficiency – There are few data regarding screening for vitamin D deficiency in adults, but most experts agree that it is not necessary to perform broad-based screening of serum 25(OH)D levels in the general population. We do, however, screen those at high risk of vitamin D deficiency (eg, limited or no sunlight exposure, individuals with obesity, osteoporosis, malabsorption). Screening for vitamin D deficiency and vitamin D replacement therapy in older adults are reviewed in detail elsewhere. (See "Vitamin D deficiency in adults: Definition, clinical manifestations, and treatment", section on 'Candidates for 25(OH)D measurements' and "Geriatric health maintenance", section on 'Vitamin D'.)
●Glaucoma – Although there is limited evidence to support screening, in populations with sufficient resources we suggest that individuals over age 40 undergo periodic comprehensive eye evaluations by an eye specialist to evaluate for glaucoma. Earlier evaluation may be appropriate for individuals with significant risk factors. This is discussed in detail elsewhere. (See "Open-angle glaucoma: Epidemiology, clinical presentation, and diagnosis", section on 'Screening'.)
IMMUNIZATION — The Centers for Disease Control and Prevention (CDC) makes annual recommendations for immunizations in adults (figure 1 and figure 2). (See "Standard immunizations for nonpregnant adults".)
●Influenza vaccine – We recommend annual influenza vaccination for all adults. (See "Seasonal influenza vaccination in adults".)
●Tetanus, diphtheria, and acellular pertussis vaccination (Td/Tdap) – The CDC recommends a single dose of Tdap in place of Td for all adults aged 19 years and older who have not received Tdap previously . Thereafter, all adults should receive a booster every 10 years with either TdaP or Td and should receive a TdaP with each pregnancy. (See "Tetanus-diphtheria toxoid vaccination in adults" and "Immunizations during pregnancy".)
●Varicella vaccine – We recommend routine varicella vaccination for healthy persons >13 years of age without evidence of immunity. (See "Vaccination for the prevention of chickenpox (primary varicella infection)", section on 'Adolescents and adults'.)
●Human papillomavirus vaccines – We recommend routine vaccination with the human papillomavirus vaccine (HPV) for all individuals through age 26 years. (See "Human papillomavirus vaccination".)
●Zoster vaccine – We suggest zoster vaccination in most individuals who are 50 years of age or older. (See "Vaccination for the prevention of shingles (herpes zoster)".)
●Pneumococcal vaccines – We recommend pneumococcal vaccination for all adults 19 to 64 years who have a condition that increases the risk of pneumococcal disease (table 5). It is also recommended for all adults ≥65 years. (See "Pneumococcal vaccination in adults".)
●Meningococcal vaccines – Meningococcal vaccination is recommended in the United States based on age and/or risk factor. (See "Meningococcal vaccination in children and adults", section on 'Indications and schedules in the United States'.)
●Hepatitis B vaccination – HBV vaccination is recommended for all adults <60 years of age as well as for those ≥60 who are seeking protection against HBV or are at increased risk for acquiring HBV infection (table 6). (See "Hepatitis B virus immunization in adults", section on 'Approach to vaccination'.)
●COVID-19 – We recommend a primary COVID-19 vaccine series and booster for all adults. (See "COVID-19: Vaccines", section on 'Approach to vaccination in the United States'.)
●Respiratory syncytial virus - In 2023, The US Food and Drug Administration approved an adjuvanted recombinant respiratory syncytial virus vaccine (RSVPreF3 OA; Arexvy), for the prevention of lower respiratory tract disease caused by RSV in individuals 60 years of age and older . This approval is based on a randomized trial that found this vaccine prevented RSV-related respiratory infection and lower respiratory tract disease in adults age 60 years and older who received one dose of an AS01E-adjuvanted RSV Prefusion F Protein Vaccine .
A subsequent nonadjuvanted recombinant respiratory syncytial virus vaccine (RSVPreF; Abrysvo) was also FDA approved in 2023 . In a phase 2a randomized trial, RSVPreF prevented symptomatic RSV infection and viral shedding in healthy adults 18 to 50 years of age . In an interim analysis of phase 3 trials, RSVPreF prevented RSV-associated lower respiratory tract illness in adults aged 60 years and older . The use of this vaccine in pregnant persons is discussed elsewhere. (See "Immunizations during pregnancy", section on 'Vaccines under investigation'.)
Additional immunizations may be necessary for patients in particular risk groups (eg, health care workers, asplenia, individuals with cancer), and there are considerations for appropriate vaccinations during pregnancy. Please see appropriate topics for details. (See "Immunizations for health care providers" and "Immunizations in adults with cancer" and "Prevention of infection in patients with impaired splenic function", section on 'Vaccinations' and "Immunizations during pregnancy".)
SEXUALLY TRANSMITTED AND BLOODBORNE INFECTIONS — Prevention and screening for sexually transmitted infections in asymptomatic patients and pregnant individuals are discussed in detail elsewhere. (See "Prevention of sexually transmitted infections" and "Screening for sexually transmitted infections" and "Prenatal care: Initial assessment", section on 'Infection'.)
●Chlamydia – We suggest chlamydia screening for all sexually active women <25 years and sexually active women ≥25 years with risk factors (eg, a history of prior chlamydial or other sexually transmitted infection, new or multiple sex partners, sex partner with concurrent partners, sex partner with a sexually transmitted infection, or exchanging sex for drugs or money). (See "Screening for sexually transmitted infections", section on 'Females'.)
We also suggest screening men in high-risk populations (men attending clinics for sexually transmitted infections, men who have sex with men or men in correctional facilities). (See "Screening for sexually transmitted infections", section on 'Males'.)
●Gonorrhea – Routine screening should be offered to sexually active patients at high risk of infection including (see "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents", section on 'Asymptomatic patients'):
•Sexually active women <25 years old
•Individuals with new or many sexual partners
•Men who have sex with men
•Sexually active individuals living in areas of high Neisseria gonorrhoeae prevalence
•Individuals with a history of other sexually transmitted infection(s)
•Women ≤35 years old and men ≤30 years old entering correctional facilities, at intake
●Hepatitis B – In general, we suggest one-time universal screening for hepatitis B virus for adults >18 years of age. Unvaccinated persons at increased risk may need repeated screening (table 7). More detailed information on hepatitis B screening is presented separately. (See "Hepatitis B virus: Screening and diagnosis in adults", section on 'Approach to screening and testing'.)
●Hepatitis C – We recommend a one-time screening for all United States adults ages between 18 to 79 years. Rescreening is appropriate for those with risk factors that may result in continued exposure to hepatitis C; this is reviewed elsewhere. (See "Screening and diagnosis of chronic hepatitis C virus infection" and "Screening and diagnosis of chronic hepatitis C virus infection", section on 'Those with ongoing risk'.)
●HIV infection – We recommend screening adults for HIV infection until age 75. (See "Screening and diagnostic testing for HIV infection".)
●Syphilis – We recommend screening for syphilis in patients considered high risk. These include men who have sex with men, inmates, persons with multiple sexual partners, patients with another sexually transmitted disease, and sexually active HIV-infected patients. (See "Syphilis: Screening and diagnostic testing", section on 'Whom to test'.)
Additional screening may be necessary for patients in particular risk groups (eg, commercial sex workers, persons in correctional facilities, persons diagnosed with another sexually transmitted infection). (See "Screening for sexually transmitted infections".)
PSYCHOSOCIAL HEALTH CONCERNS
Depression — We suggest screening adolescents and adults (ages 12 and older) for depression, including older adults. Screening is most effective when personnel or systems are in place to ensure appropriate follow-up and management of those who screen positive. (See "Screening for depression in adults".)
We suggest using a two-question screen or the Patient Health Questionnaire-2 (PHQ-2) because of ease of administration and reasonable sensitivity (table 8). A positive screen should be followed by a thorough clinical assessment, facilitated with the PHQ-9 (table 9) or similar instrument, to diagnose depression. (See "Screening for depression in adults".)
Limited evidence guides the optimal frequency of screening for depression. To facilitate ease of implementation, we support screening at the time of a routine health visit. (See "Screening for depression in adults".)
Anxiety — We suggest screening adolescents and adults ages 13 to 64 for anxiety disorders. Screening should use a validated instrument, such as the Generalized Anxiety Disorder-7 (GAD-7) scale. Although the benefits and harms of screening adults ages 65 and older are likely similar to those for younger individuals, insufficient evidence exists to support screening in this population. Because little data exists to clarify the optimal timing or frequency of screening, we support screening during a routine health visit. (See "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis", section on 'Screening'.)
Substance use-related problems
●Alcohol – We recommend that all adult primary care patients be screened for unhealthy alcohol use. In general, annual screening is suggested. We suggest the single-item alcohol screening question for most primary care practices. Single-item screen starts with the question, "Do you sometimes drink beer, wine, or other alcoholic beverages?" If yes, then the clinician can follow up with, "How many times in the past year have you had five (four for women) or more drinks in a day?"
The AUDIT-C (table 10) is an alternative for offices with more resources (eg, staff, time, and ability to automate administration and scoring). (See "Screening for unhealthy use of alcohol and other drugs in primary care".)
●Other drug use – We also suggest screening patients for unhealthy use of drugs, including illegal drugs and prescription medications that are not used for medical purposes . (See "Screening for unhealthy use of alcohol and other drugs in primary care", section on 'Unhealthy use of other drugs'.)
Intimate partner violence — Given the high prevalence of intimate partner violence, and the lack of harm and potential benefits of screening, we suggest routine screening for all patients on all visits to primary care clinicians, to obstetrician-gynecologists, to the emergency department, and on hospital admission. (See "Intimate partner violence: Diagnosis and screening".)
OSTEOPOROSIS — We suggest osteoporosis screening in the following groups (see "Screening for osteoporosis in postmenopausal women and men" and "Osteoporotic fracture risk assessment"):
●Postmenopausal women <65 years with risk factors for osteoporosis (table 11).
●Men with clinical manifestation of low bone mass, history of low trauma fracture, risk factors for fracture (such as androgen deprivation therapy for prostate cancer, hypogonadism, primary hyperparathyroidism, or intestinal disorders).
●All women ≥65 years. (See "Geriatric health maintenance", section on 'Osteoporosis'.)
There are several modalities to evaluate bone density. Dual-energy x-ray absorptiometry (DXA) is most commonly used. (See "Overview of dual-energy x-ray absorptiometry".)
●Abdominal aortic aneurysm – Screening for abdominal aortic aneurysm (AAA) is not recommended for adults <65 years. (See "Screening for abdominal aortic aneurysm".)
•We recommend one-time ultrasound screening for AAA in men ages 65 to 75 years who are current or former smokers.
•We also suggest one-time ultrasound screening for AAA in men ages 65 to 75 who have never smoked but who have a first-degree relative who required repair of an AAA or died from a ruptured AAA.
●Carotid artery stenosis – We do not recommend screening (either by auscultation for carotid bruit or by carotid ultrasound) asymptomatic patients for carotic artery stenosis. (See "Screening for asymptomatic carotid artery stenosis".)
●Peripheral artery disease – We do not suggest screening for peripheral artery disease. (See "Screening for lower extremity peripheral artery disease".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
SUMMARY AND RECOMMENDATIONS
●Prioritizing preventive care – Appropriate screening and prevention interventions need to be prioritized both for effectiveness in modifying target outcomes and for risk of the condition in the individual patient. (See 'Prioritizing preventive services' above.)
●Periodic health maintenance visits – We suggest periodic health maintenance visits every three years for adult patients ≤49 years without chronic conditions, and annually for adults ≥50 years. Preventive counseling and services are an important component of the periodic health check-up. (See 'Periodic "check-up"' above.)
●Challenges of delivering screening and counseling interventions – Patients may not receive appropriate screening and prevention interventions if the time for addressing these needs is limited to a "routine physical examination." Creative solutions for delivering preventive care include involving use of patient databases and mechanisms for patient outreach, as well as incorporating preventive care into patient sick visits. (See 'Supportive office systems' above.)
●Important targets for disease prevention
•Cardiovascular disease – Key features of cardiovascular disease prevention include risk assessment and treatment of predisposing conditions. (See 'Cardiovascular disease prevention' above.)
•Cancer – Cancer prevention includes counseling to reduce risk factors, most notably smoking, and appropriate screening. (See 'General cancer prevention counseling' above and 'Cancer screening' above.)
•Sexually transmitted and bloodborne infections – Screening for sexually transmitted infections and bloodborne infections is based on age and patient risk. (See 'Sexually transmitted and bloodborne infections' above.)
•Psychological health conditions – Adults should receive screening for psychological conditions such as depression, anxiety and substance use, and referrals for treatment if indicated. (See 'Psychosocial health concerns' above.)
●Immunization – Immunization is an effective method of disease prevention. The Centers for Disease Control and Prevention (CDC) makes annual recommendations for immunizations in adults (figure 1 and figure 2). (See 'Immunization' above.)
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