| Alcohol and drug screening | The USPSTF recommends that adults 18 years of age and older, including pregnant women, should be screened for unhealthy alcohol use (USPSTF, 2020f). The USPSTF recommends using 1 to 3-question screening tools, specifically the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) or the Single Alcohol Screening Question (SASQ).
Audit-C: - How often do you have a drink containing alcohol?
- How many standard drinks containing alcohol do you have on a typical day?
- How often do you have six or more drinks on one occasion?
The answers are scored from 0 to 4; the total score indicates the risk for problematic alcohol consumption.
SASQ: How many times in the past year have you had 4 or more drinks in a day (women), 5 or more drinks in a day (men)?
The Tobacco, Alcohol, Prescription medication, and other Substance Use Tool (TAPS) is a screening tool that has been validated for use in primary care settings (National Institute on Drug Abuse, 2023; Carter et al., 2022). For assessment/screening of drug misuse/abuse, the TAPS screen asks questions about abuse/misuse of prescription drugs and/or illicit drugs. Examples: - In the past 12 months, how often have you used any prescription medications just for the feeling, more than prescribed, or that were not prescribed for you?
- In the past 12 months, how often have you used any drugs including marijuana, cocaine or crack, heroin, methamphetamine (crystal meth), hallucinogens, ecstasy/MDMA?
- In the past 3 months, have you used heroin? After the patient has completed the screening questions, the provider follows up with the patient and provides the appropriate care.
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| Diabetes | The USPSTF recommends that adults aged 35-70 who are overweight or obese be screened for prediabetes and type 2 diabetes mellitus (USPSTF, 2021f). The American Diabetes Association (ADA) recommends that anyone with one or more risk factors for type 2 diabetes, e.g., hypertension (HTN), hypercholesterolemia, ethnic risk factors, obesity/overweight, first-degree relative who has diabetes, be tested for prediabetes and type 2 diabetes. The ADA recommends all adults 35 years of age or older should be screened for prediabetes and type 2 diabetes (ADA, 2023b). Screening is done by an assessment of risk factors or with a validated risk calculator (ADA. 2024a). Screening, detection, and implementation of lifestyle changes have been shown to significantly reduce the incidence of type 2 diabetes and the progression from prediabetes to type 2 diabetes (Elsayed et al., 2023a). |
| Breast cancer | The USPSTF recommends that women aged 50 to 74 should have biennial mammography screening (USPSTF, 2016). The decision to have screening mammography before age 50 should be made by the patient (USPSTF, 2016). The USPSTF recommends that women who have a family or personal history of breast, peritoneal, ovarian, or tubal cancer or who have ancestry associated with breast cancer susceptibility (BRCA 1 and 2 gene mutations) be screened with an appropriate family risk assessment tool. If the result is positive, patients should receive genetic counseling and, if needed, genetic testing. (USPSTF, 2019b).
The ACS recommendations for breast cancer screening in women who have an average risk for the disease are: - Aged 40 to 44, the patient should be offered the option of yearly screening via mammography,
- Aged 45 to 54, yearly mammography screening,
- 55 years of age and older- yearly or biennial mammography, and
- Screening should continue as long as a woman is in good health and is expected to live at least 10 more years (ACS, 2023b).
For women who have a high risk for breast cancer, e.g., the patient or a first-degree relative has BRCA 1 or 2 mutations, the ACS recommends a breast MRI and yearly mammogram, the latter beginning at age 30.
The ACS does not recommend regular breast self-examinations or clinical breast exams, but for high-risk women, a provider may offer breast examinations (ACS, 2023b).
The American Society of Breast Surgeons recommends: - Women age > 25 should undergo formal risk assessment for breast cancer,
- Women with an average risk of breast cancer should start yearly screening mammography at age 40,
- Women with a higher-than-average risk of breast cancer should have yearly screening mammography and be offered yearly supplemental imaging; this screening should be initiated at a risk-based age and
- Screening mammography should not be done if a patient’s life expectancy is < 10 years (American Society of Breast Surgeons, 2019).
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| BRCA mutation | The BReast CAncer genes 1 and 2, BRCA1 and BRCA2, are genes that produce proteins that help repair damaged deoxyribonucleic acid or DNA (National Cancer Institute, 2020). Sometimes, they are referred to as tumor suppressor genes. BRCA1 and BRCA2 mutations increase the risk of developing breast cancer, ovarian cancer, and several other cancers as well (National Cancer Institute, 2020). Inheriting a BRCA1 or BRCA2 gene mutation significantly increases a woman’s risk of developing breast cancer (National Cancer Institute, 2020). |
| Cardiovascular risk assessment | Cardiovascular disease (CVD) is a group of diseases that affect the heart and the blood vessels, including (but not limited to) atherosclerosis, arrhythmias, cerebrovascular accident (CVA, aka stroke), congestive heart failure, coronary artery disease, HTN, and myocardial infarction. CVD is very common and the leading cause of death in the US (CDC, 2023e). Risk factors for heart disease are very common in US adults, and these include diabetes, excessive alcohol use, hypercholesterolemia, HTN, physical inactivity, obesity, and smoking (CDC, 2023e; Gaziano & Gaziano, 2022). Determining a patient’s baseline risk of developing atherosclerotic cardiovascular disease (ASCVD) is the foundation of prevention against ASCVD (Wong et al., 2022; Arnett et al., 2019).
Multiple risk factor assessment tools include the American College of Cardiology ASCVD Risk Estimator plus, the AHA Predicting Risk of Cardiovascular EVENTS (PREVENTTM), and the Pooled Cohort Risk Estimator Plus. No risk calculator can be used for all patient populations (Arnett et al., 2019). Still, the currently used risk assessment tools use some combination of the known risk factors for ASCVD, e.g., age, blood pressure measurement, diabetes, high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol levels, obesity, and smoking. |
| Cervical cancer | In the US in 2020, there were 11,542 new cases of cervical cancer, 4,272 women died of this disease, and there were 7 new cases for every 100,00 women (CDC, 2023k). Regular screening, done with a Papanicolaou (Pap) smear, can detect and prevent cervical cancer and improve the chances that treatment for cervical cancer will be successful (ACS, 2023b). HPV vaccination has been proven to reduce the incidence of cervical pre-cancer, and data suggest it reduces the incidence of cervical cancer (Rahangdale et al., 2022). Persistent HPV infection is the central cause of cervical cancer and the leading cause of cancer death among women worldwide.
The ACS’s Guidelines for the Prevention and Detection of Cervical Cancer (ACS, 2021) recommend: - Cervical cancer screening should begin at age 25.
- Women aged 25 to 65 should have a primary HPV test every 5 years. If this is not available, screening can be done with a co-test of an HPV test and a Pap test every 5 years or a Pap test every 3 years.
- Women over 65 who have had regular screening for the past 10 years - and the test results were normal – and there is no history of CIN2 or a more serious diagnosis within the past 25 years should stop being screened. Once screening has been stopped, it should not be restarted. (CIN2 refers to a specific level of severity of cervical dysplasia. Cervical dysplasia is a pre-cancerous condition, and CIN2 means that one-third to two-thirds of the cervical epithelium has abnormal cells).
- Women who have had a total hysterectomy should not be screened unless the hysterectomy was done as a treatment for cervical cancer or pre-cancer. If the uterus was removed but the cervix was not, use the previously described guidelines.
- Women who have been vaccinated against HPV should follow the screening recommendations for their age group.
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| Colorectal Cancer | Colorectal cancer is, excluding skin cancers, the third most common cancer in the US (ACS, 2024b), and it is the fourth most common cause of death from cancer (CDC, 2023k). Colorectal cancer screening has been shown to reduce mortality from colorectal cancer, and it may reduce the incidence of the disease (National Cancer Institute, 2023). The ACS’s recommendations for colorectal cancer screening are outlined below. (ACS, 2024a).
For people who have an average risk of colorectal cancer:
The ACS recommends colorectal cancer screening starting at age 45. The screening can be done with a test that detects blood in the stool or a visual inspection of the lower gastrointestinal (GI) tract with an instrument, e.g., a colonoscopy.
A person in good health and who has a life expectancy of > 10 years should continue to be screened until they are 75.
For people aged 76 to 85, the decision to do colorectal cancer screening is made based on life expectancy, overall condition/health, personal preference, and prior screening history.
People over age 85 should not get colorectal cancer screening.
Average risk is defined as someone who does not have: - A family history of colorectal cancer,
- A personal history of colorectal cancer or certain types of polyps,
- A personal history of inflammatory bowel disease,
- Confirmed or suspected colorectal cancer syndrome, and
- A personal history of abdominal or pelvic exposure to therapeutic radiation to treat a prior cancer.
For people at increased risk or high risk for colorectal cancer, screening may need to be started before age 45, screening may need to be done more frequently, or a specific test may be needed. The ACS does not have guidelines for colorectal cancer screening for people at increased or high risk. |
| Depression | The USPSTF recommends screening for depression in the adult population, including pregnant and postpartum women (USPSTF, 2023a). The conclusions of the USPSTF were that screening improves the detection and identification of depression; depression screening combined with treatment improves outcomes, and screening has a moderate net benefit, and there is inadequate evidence to determine the harm from screening (USPSTF, 2023a). The optimal timing and intervals for depression screening have not been established. The USPSTF does not recommend a specific screening tool. Still, it mentions that the various forms of the Patient Health Questionnaire (PHQ), the Edinburgh Postnatal Depression Scale, and the Geriatric Depression Scale are commonly used.
Pregnant and postpartum women who are at risk for perinatal depression should be referred for counseling. |
| Dyslipidemia | Dyslipidemia refers to disorders of lipid metabolism (Arvantis & Lowenstein, 2023). The lipids that are usually measured are total cholesterol, LDL, HDL, triglycerides, and lipoprotein (a) or Lp(a) (Arvantis & Lowenstein, 2023). Dyslipidemia is a risk factor for the development of ASCVD, and treating dyslipidemia has been shown to prevent the development of ASCVD and reduce the morbidity and mortality associated with ASCVD (Reamy, 2020).
The recommendations of the American College of Cardiology and the AHA for dyslipidemia screening are outlined below (Arvantis & Lowenstein, 2023).
People aged 40 to 75 should be screened for dyslipidemia every 4-6 years.
The test can be done fasting or non-fasting. If the non-fasting triglyceride level is > 400 mg/deciliter (dL), a fasting lipid profile should be done.
The test should be a lipid profile, e.g., HDL and LDL cholesterol, and triglycerides. Apolipoprotein B (apoB) should be measured in people who have hypertriglyceridemia. Lp(a) should be measured in persons who have a family history of premature ASCVD. |
| Hepatitis B | Adults who do not have risk factors for hepatitis B should be tested for hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs), and total hepatitis B core antigen (anti-HBc) (CDC, 2023j). Adults ages 18 to 59 years should receive hepatitis B vaccination (CDC, 2023j). The testing and vaccination recommendations are different for people who have risk factors for hepatitis B. These recommendations are lengthy. They can be viewed here. |
| Intimate partner violence | Intimate partner violence (IPV) is a common and significant public health issue. The CDC estimates that 41% of women and 26% of men during their lifetime have experienced some type of IPV, like sexual and/or physical violence. IPV often results in injuries, and it can result in death. In addition, survivors of IPV can develop physical, psychological, and social harm and disorders (CDC, 2020).
The USPSTF recommends that clinicians screen women of reproductive age for IPV (USPSTF, 2018a). No recommendation was made for a specific screening instrument. There are many available ones like the Humiliation, Afraid, Rape, Kick (HARK), Partner Violence Screen (PVS), Stress, Afraid, Friend, Emergency plan (SAFE), and the Women Abuse Screening Tool (WAST): These are all short screening tools that can be practically used in a clinician’s office. Example: The Hurt, Insulted, Threaten, and Scream (HITS) screen has 4 questions: How often does your partner: - Hurt you physically?
- Insult you or talk down to you?
- Threaten you with harm?
- Scream or curse at you?
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| Latent tuberculosis | Latent tuberculosis (TB) infection is an infection with the TB bacterium, but the immune system has contained the pathogen (USPSTF, 2023d). A person who has latent TB is asymptomatic and not contagious, but if they are not treated, they can develop active TB (USPSTF, 2023d). The CDC estimates that 13 million people in the US have latent TB (CDC, 2022e).
The USPSTF recommends screening for latent TB in adult populations who are at risk for the disease (USPSTF, 2023d). At-risk persons include: - Those who were born in an area or formerly resided in an area with a high prevalence of TB.
- People who live in close proximity to others, e.g., residents of homeless shelters or people who are incarcerated.
- Immunosuppressed people.
- Anyone who has contact with someone who has active TB.
- People who are receiving immunosuppressive treatment like chemotherapy or immunosuppressive drugs that are given post-organ transplant.
There are two screening tests: the tuberculin skin tests and interferon-gamma release assays. There does not appear to be a risk of harm from these tests. The optimal timing interval for latent TB screening has not been determined; people should be screened on a case-by-case basis. The USPSTF concluded that there is a moderate net benefit from screening for latent TB in terms of preventing active TB (USPSTF, 2023d). |
| Osteoporosis | Osteoporosis is the most common bone disease (CDC, 2021b). The National Health and Nutrition Examination Survey (2021) found that in 2017-2018, the age-adjusted prevalence of osteoporosis at the femur neck, the lumbar spine, or both in adults ≥ age 50 was 12.6%, 19.6% in women, and 4.4% in men (CDC, 2021b). The USPSTF recommends that to prevent osteoporotic fractures, women ≥ 65 years of age should be screened with bone measurement tests (USPSTF, 2018b). For women < 65 years of age, post-menopausal, and at an increased risk for osteoporosis, the USPSTF recommends bone measurement testing to prevent osteoporotic fractures. (Note: There are several osteoporosis risk assessment calculators.) There is insufficient evidence to determine the benefit-harm ratio of osteoporosis screening in men. The most commonly used bone measurement screening test is the central dual-energy X-ray absorptiometry (DXA), which measures bone density at the hip and the lumbar spine (USPSTF, 2018b). The USPSTF does not have recommendations for screening intervals. |
| Pregnancy | The USPSTF and the ACOG recommend that pregnant women be screened for the following diseases and conditions.
Chlamydia and gonorrhea: Sexually active women, including pregnant women who are 24 years of age or younger or if they are 25 years of age and have a high risk for infection, should be screened for chlamydia (USPSTF, 2021b). Sexually active women, including pregnant women who are 24 years of age or younger or if they are 25 years of age and have a high risk for infection, should be screened for gonorrhea (USPSTF, 2021b).
Syphilis: All pregnant women should be screened for syphilis as soon as possible in their pregnancy (USPSTF, 2018e).
HIV: All pregnant women, including women who are in labor and whose HIV status is not known, should be screened for HIV infection (USPSTF, 2019d).
Hepatitis B: All pregnant women should be screened for hepatitis B virus during the first prenatal visit (USPSTF, 2019c).
Hepatitis C: The ACOG recommends screening all pregnant women for hepatitis C (ACOG, 2023a).
Gestational diabetes: Asymptomatic pregnant women should be screened for gestational diabetes at 24 weeks gestation or after (USPSTF, 2021c).
Hypertensive disorders: A pregnant person should be screened for hypertensive disorders throughout their pregnancy (USPSTF, 2023c). These hypertensive disorders are eclampsia, gestational HTN, and preeclampsia (USPSTF, 2023c).
Laboratory tests: The ACOG recommends that these tests be done for all pregnant women: CBC, urinalysis, blood type, group B streptococcus, Rh factor, rubella, and TB (high-risk persons) (ACOG, 2023b). Clinicians should assess for the possibility of birth defects (ACOG, 2023b).
Anxiety and depression: The ACOG recommends that pregnant women be screened for anxiety and depression (ACOG, 2023c). |
| Prostate cancer | Prostate cancer, after skin cancer, is the most common cancer in men (CDC, 2023i), and screening for prostate cancer with the prostate-specific antigen (PSA) test is effective at detecting the disease and preventing death from prostate cancer (Pinsky & Parnes, 2023).
The ACS (2023a) and the USPSTF (2018e) have essentially the same recommendations for prostate cancer screening.
Clinicians should discuss prostate screening with men, and the ages when this should be done are outlined below (ACS, 2023a). After the discussion, a decision can be made about whether the screening will be done. Screening should be done with the PSA blood test. A digital rectal examination can also be done (ACS, 2023a). Recommendations are for: - Men aged 50 who have an average risk for prostate cancer and are expected to live at least 10 more years.
- Men aged 45, high risk for developing prostate cancer: African American men who have a first-degree relative who was diagnosed with prostate cancer at an early age, < 65 years of age.
- Men aged 40 with a high risk for developing prostate cancer because more than one first-degree relative had prostate cancer at an early age.
The USPSTF recommends that clinicians discuss prostate cancer screening with men aged 55 to 69, and the decision to have prostate cancer screening should be an individual decision. If a patient does not want to be screened, the clinician should not order screening to be done (USPSTF, 2018c). The test itself is safe, but screening may result in false positive results and unneeded treatments (USPSTF, 2018c). |
| Sexually transmitted diseases | Chlamydia: The CDC and USPSTF recommendations for chlamydia screening are for (USPSTF, 2021b) : - All sexually active women < 24 years of age.
- Sexually active women ≥ 25 years of age if they have risk factors for infection, e.g., more than 1 sex partner or sex with someone who has an STI.
- The USPSTF has concluded that there was insufficient evidence to recommend routine screening for chlamydia in men. The CDC recommends that men who have sex with men or who are bisexual should be tested for chlamydia once a year and more frequently if they have anonymous or multiple sex partners (CDC, 2021e).
Gonorrhea: The CDC and USPSTF recommendations for gonorrhea screening are for: - Sexually active women < 24 years of age (USPSTF, 2021b).
- Sexually active women ≥ 25 years of age if they have risk factors for infection, e.g., more than 1 sex partner or sex with someone who has an STI (USPSTF, 2021b).
- Men who have sex with men should be tested at least once a year and more frequently if they have anonymous or multiple sex partners (CDC,2021f). Patients should be tested at the sites of contact, e.g., rectum and urethra, even if condoms have been used (CDC, 2024b).
Herpes: - The CDC and the USPSTF do not recommend routine screening for herpes (CDC, 2022c; USPSTF, 2023b). Serologic testing should be considered for people who have genital symptoms of herpes (CDC, 2020).
Syphilis: - Women and men who are asymptomatic should be tested if they have a high risk of syphilis infection (CDC, 2024b).
- All pregnant women should be screened for syphilis at their first prenatal visit. Women should be retested at 28 weeks gestation and at the time of delivery if they have a high risk of syphilis infection (CDC, 2024b). High-risk factors include (but are not limited to) multiple sex partners and an STI during pregnancy.
- Men who have sex with men should be tested annually and more often (every 3-6 months) if they have a high risk of developing syphilis infection (CDC, 2024b). Risk factors for developing syphilis infection include (but are not limited to) incarceration and transactional sex work.
- People who have an HIV infection should be screened annually (CDC, 2024b).
Trichomonas:- Screening for trichomonas should be considered if the patient has a high risk for infection or is receiving care in a high-prevalence setting like an STD clinic or a correctional facility (CDC, 2024b).
- Women who are infected with HIV and are sexually active should be tested at the time of entry to care and, after that, at least once a year (CDC, 2024b).
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| Skin cancer | Skin cancer is the most common cancer in the US (USPSTF, 2023f). The USPSTF concluded that there is no benefit for skin cancer screening in asymptomatic adolescents and adults who do not have a history of premalignant or malignant skin lesions (USPSTF et al., 2023). The USPSTF recommends that clinicians counsel adults (up to age 24) with fair skin to minimize exposure to UV radiation and reduce their risk of developing skin cancer (USPSTF, 2018d). No professional organizations in the US currently recommend visual examination skin cancer screening (USPSTF et al., 2023). |
| Smoking | The USPSTF recommends that clinicians ask all their adult patients about their tobacco use patterns, advise them to stop using tobacco, and provide behavioral interventions and FDA-approved pharmacotherapy (for non-pregnant patients) for smoking cessation, as needed (USPSTF, 2021g). Clinicians should ask all pregnant patients about their tobacco use patterns, advise them to stop smoking, and provide them with behavioral interventions to help them stop (USPSTF, 2021g). The available evidence can’t be used to determine the benefit-harm ratio of pharmacotherapy for smoking cessation in pregnant persons (USPSTF, 2021g). |
| Statins and prevention of CVD disease | Statins are one of the most common therapies for primary and secondary prevention of ASCVD (Frank et al., 2023; Grundy et al., 2019). The USPSTF concluded that statins prevent CVD events and reduce all-cause mortality in people who do not have ASCVD but have one or more risk factors for CVD and who have a 10-year CVD event risk of ≥ 10% (USPSTF, 2022c). Recommendations for prescribing statins for primary prevention and secondary prevention against ASCVD depend on the patient’s age, family history, cholesterol level, the presence of risk factors for ASCVD, the patient’s lipid levels, and the need for moderate-intensity or high-intensity statin therapy (Grundy et al., 2019). The American College of Cardiology’s ASCVD Risk calculator can be used to calculate a patient’s 10-year risk, and it can be viewed here. |
| Immunizations | The adult immunization schedule recommended by the CDC can be viewed here. |
| Vision screening | Approximately 11.6% of the US population has diabetes mellitus (CDC, 2023f). Diabetic retinopathy (DR) is a common complication of diabetes mellitus (Jotte et al., 2023) and a leading cause of blindness (Jotte et al., 2023). Routine vision examinations can prevent diabetes-related vision loss (Jotte et al., 2023). The American Academy of Ophthalmology recommends that all diabetic patients have a yearly dilated eye examination (Jotte et al., 2023). |
