Estimating risk

Large, well-conducted trials have shown reduction in mortality from breast cancer from screening mammography with the greatest benefit in women aged 50–74 years.

Estimating risk

Determine a patient’s risk of developing breast cancer using a detailed history and a risk prediction tool such as the Gail model (www.cancer.gov/bcrisktool/).

An average-risk woman has a less than 15% lifetime risk for developing invasive breast cancer.

Mammography

For an average-risk woman, screening should be discussed beginning at age 40 years. The risks and benefits should be reviewed, and a decision should be made based on the patient’s values and her level of risk.

Women aged 50–74 years should undergo screening mammography every 1 to 2 years.

For women over age 74 years (this age group not included in randomized trials so no data are available), screening should be based on individual discussions regarding risk vs. benefit with the patient and life expectancy.

Clinical breast exam

Clinical breast exam may be used as an adjunct to mammographic screening (insufficient evidence of additional benefit above mammography).

Colonoscopy

Screening with colonoscopy has been shown to decrease mortality from colorectal cancer; screening should be performed in average-risk patients starting at age 50 years and continuing at least until age 75 years.

FOBT (fecal occult blood testing)

Biannual home FOBT screening, followed by colonoscopy for positive results, has also been shown to decrease mortality from colorectal cancer. This should be done with three cards mailed in and rehydrated. No mortality benefit has been found for a single test in the office.

Computed tomography (CT) colonography
Double-contrast barium enema
Sigmoidoscopy

Screening options that directly visualize the entire colon are preferred (colonoscopy). If a patient opts for flexible sigmoidoscopy, CT colonography, or double-contrast barium enema, the interval is every 5 years. Please note that women are more likely to have right-sided lesions that may be missed on these studies.

DXA

A DXA scan is recommended for women age 65 years and older every 2 years and for women aged 60–64 years who are at high risk (weight under 70 kg or 154 pounds, tobacco use, prior fracture) for osteoporosis and pathologic fractures.

Lipids

A lipid panel should be obtained in all males 35 years or older and all women 20 years or older who are at increased risk for cardiovascular disease.

Nonfasting total cholesterol/HDL levels can be obtained as an initial screening test. If total cholesterol is >200 mg/dL and HDL is <40 mg/dL, patient will need a fasting lipid profile.

Fasting lipid profile is obtained after a 12-hour fast, if nonfasting screen is elevated, or as first screening test.

Repeat every 5 years if normal.

HIV

Voluntary HIV testing for all persons aged 13–64 years

Diabetes

Should consider fasting glucose or HgA1C in patients with blood pressure (BP) > 135/80 mm Hg or patients with hyperlipidemia.

BP

Check BP every 2 years if <120/80 mm Hg, yearly if 120–139/80–89 mm Hg. This recommendation is based on the reduction in all-cause mortality for patients who are diagnosed and treated for hypertension (decreased death due to stroke and heart failure).

Influenza vaccine

Recommended for all adults. This vaccine is given every year in the autumn. (Avoid if egg allergy or a history of Guillain-Barré syndrome within 6 weeks of having received an influenza vaccine.)

Pneumococcal vaccine

For adults 65 years and older give pneumococcal polysaccharide vaccine once to prevent 60% of bacteremic disease from pneumococcal infection. Administer to adults < 65 years of age with chronic conditions. One-time revaccination at 5 years. The 13-valent pneumococcal conjugate vaccine has recently been approved by the FDA for use in adults 50 years of age and older.

Meningococcal vaccine

Meningococcal conjugate vaccine is preferred for adults ≤ 55 years of age and in those with risk factors; meningococcal polysaccharide vaccine is preferred for adults > 55 years of age. Revaccinate with conjugate vaccine after 5 years for those at increased risk of infection.

Tetanus-diphtheria-pertussis (Tdap) vaccine

Td vaccine should be administered every 10 years; substitute a one-time dose of Tdap for the Td booster for adults 19–64 years of age.

Tobacco

All patients must be screened for tobacco use. Two simple questions: “Do you smoke?” “Do you want to quit?” Patients who want to quit smoking should be offered pharmacologic therapy in addition to counseling, as this increases cessation rates from 50% to 70%.

Healthy diet

Adults with hyperlipidemia and other risk factors for CAD should be counseled about a healthy diet.