Update on the Methods of the U.S. Preventive Services Task Force: Insufficient Evidence Update on the Methods of the U.S. Preventive Services Task Force: Estimating Certainty and Magnitude of Net Benefit Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Preventive health care, 1999 update: prevention of oral cancer mortality. The Canadian Task Force on Preventive Health Care. Screening for Type 2 Diabetes Mellitus in Adults: Recommendations and Rationale Prostate Needle Biopsy Outcomes in the Era of the U.S. Preventive Services Task Force Recommendation against Prostate Specific Antigen Based Screening. Screening for Family and Intimate Partner Violence: Recommendation Statement Screening for Prostate Cancer: US Preventive Services Task Force Recommendation Statement A clinical trial of tailored office systems for preventive service delivery. The Study to Enhance Prevention by Understanding Practice (STEP-UP). Screening for Lung Cancer: U.S. Preventive Services Task Force Recommendation Statement Screening for Breast Cancer: Recommendations and Rationale Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement A randomized controlled trial of a community-based behavioral counseling program. Preventive Services Task Force recommends against PSA screening after age 75. Improving preventive service delivery at adult complete health check-ups: the Preventive health Evidence-based Recommendation Form (PERFORM) cluster randomized controlled trial Sustainability of a practice-individualized preventive service delivery intervention. Screening for Depression: Recommendations and Rationale Developing the Guide to Community Preventive Services--overview and rationale. The Task Force on Community Preventive Services. Physician versus non-physician delivery of alcohol screening, brief intervention and referral to treatment in adult primary care: the ADVISe cluster randomized controlled implementation trial Screening for Abdominal Aortic Aneurysm: US Preventive Services Task Force Recommendation Statement. Implementation of a New Screening Recommendation in Health Care: The Veterans Health Administration's Approach to Lung Cancer Screening Evaluating Test Strategies for Colorectal Cancer Screening: A Decision Analysis for the U.S. Preventive Services Task Force Reducing neuropsychiatric symptoms in persons with dementia and associated burden in family caregivers using tailored activities: Design and methods of a randomized clinical trial.
The U.S. Preventive Services Task Force ( USPSTF ) is an independent panel of experts that is convened and supported by the Agency for Healthcare Research and Quality ( AHRQ ) . The U.S. Congress has charged the USPSTF to review the scientific evidence for clinical preventive services and develop evidence -based recommendations about their delivery . In its recommendations , the USPSTF seeks to maximize population health benefits while minimizing harms . The target audience for USPSTF recommendations is primary care clinicians , but the recommendations are widely used by others as well ( 1 ) . The USPSTF processes and methods are continually examined , and recent up date s have been published ( 13 ) . The USPSTF Procedure Manual is posted on the AHRQ Web site ( 4 ) . In this issue , the USPSTF reports that it concluded that the evidence to determine whether the benefits of skin cancer screening outweigh the harms was insufficient ( 5 ) . No recommendation was made , and no letter grade was assigned . Instead , the USPSTF issued an I statement ( 2 ) . Evidence is often found to be insufficient for topics considered by the USPSTF . Even for screening topics that pertain to all or a large majority of adults , children , or adolescents , evidence is often insufficient ( Table 1 ) ( 6 ) . Table 1 . Insufficient Evidence Statements for Screening of Large Population Subgroups The release of the I statement for skin cancer screening provides an opportunity for the USPSTF to describe its plan to exp and the kinds of information it commissions to be collected and reported routinely by Evidence -based Practice Centers , to describe the process that led to selection of this information , and to illustrate the uses of the information with examples . Problem Statement Primary care physicians and their professional societies expressed frustration with the frequency with which the USPSTF concluded that evidence is insufficient to make a recommendation . In the past , the USPSTF coupled this conclusion with a recommendation worded as follows : the USPSTF concludes that the evidence is insufficient to recommend for or against routine provision of xxx service . Clinicians pointed out that this wording is not a recommendation . Anecdotally , the statement was characterized as useless and sometimes as worse than useless . In focus groups of practicing primary care providers , a common request was for USPSTF guidance on a course of action with individual patients in situations in which evidence about net benefit is insufficient . Professional society representatives reinforced the need for guidance . The USPSTF and other bodies have generally held that the strongest argument for providing an intervention is based on scientific evidence from multiple large , well-conducted , r and omized clinical trials ( RCTs ) . However , for most clinical preventive services , this st and ard of evidence is unattainable . Requirements for RCTs of behavioral counseling interventions are especially problematic because the study interventions in gold-st and ard RCTs may be artificial . Tucker and Roth ( 7 ) discuss this problem in the context of behavioral interventions for substance abuse . They point out that requiring fidelity in treatment delivery in a gold-st and ard RCT may eliminate the context ual aspects of the treatment experience and the adaptation of treatment to individual needs that underlies treatment success . Requiring a no-treatment or usual-treatment control condition may produce insurmountable barriers to recruitment . Requiring a control condition with the same number of contact hours as the treatment condition can compromise retention . For different reasons , the conduct of RCTs for preventive services delivered to infants , children , and adolescents also presents challenges . For some preventive services , the long timeline required to improve health outcomes makes RCTs impractical . Consensus is lacking about the appropriate outcomes for preventive interventions in children , although agreement is universal that decreasing mortality is not the only goal of preventive services provided to this age group . Finally , many valuable preventive interventions will never be evaluated in an RCT because a trial would be too expensive , recruiting enough participants is not feasible , or investigator interest or funding is lacking . Acknowledging the Contribution of Non- RCT Evidence and Persisting Issues Recognizing the paucity of evidence from RCTs , the USPSTF and other groups consider evidence from non- RCT study design s ( such as cohort , cross-sectional , casecontrol , or quasi-experimental ) as a st and ard strategy . Use of an analytic framework , which is an organizing principle for all recent or current USPSTF systematic review s , permits incorporation of evidence from studies with a variety of design s and yields certainty that can in theory approach the certainty of evidence derived from RCTs . In constructing an analytic framework , clinical problems are conceptualized in terms of a sequence of key questions ( 8) . A systematic review is generally done to answer each key question . When considered together , the key question evidence forms a chain of evidence that permits firm conclusions about net benefit . In the case of skin cancer , notwithst and ing the use of an analytic framework and consideration of study design s other than RCTs , the USPSTF could not conclude with even moderate certainty that the benefits of skin cancer screening by inspection outweighed the harms or that the harms outweighed the benefits , making the evidence insufficient to make a recommendation ( 9 ) . Even when non- RCT evidence is considered within a structured causal framework , the problem of insufficient evidence persists . A New Approach : Process and Outcome In response to the concerns about the frequency of I statements , the frustration expressed by clinicians , and the call for guidance , the USPSTF held a workshop in spring 2005 to consider how better to meet the needs of its constituents when evidence is insufficient . The workshop involved members of the USPSTF , AHRQ staff , and scientists from the Evidence -based Practice Center supporting the USPSTF . The charge to workshop participants was to develop a strategy that would reduce confusion created by the wording I recommendation , and to consider whether the USPSTF should nuance the Ithat is , make a suggestion in favor of or against providing the service . At the workshop , attendees heard presentations from AHRQ and Evidence -Based Practice Center staff involved in the efforts of the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) working group ( 1012 ) . Other publications about approaches to grading recommendations were identified and review ed ( 13 ) . The workshop result ed in a decision to transform what was formerly called an I recommendation into an I statement , as described elsewhere ( 2 ) . The workshop also led to a group decision to reject the proposal to nuance the I. Nuancing would have result ed in recommendations that clinicians act routinely to offer a service even in the absence of at least moderate certainty that the preventive service has net benefits at the population level , thus violating an underlying principle guiding the work of USPSTF : avoidance of overall harm . Before the workshop , attendees were charged with bringing to the meeting suggestions for criteria that might be used to nuance the I , with practice relevance for clinicians , patients , or systems as the basis for these suggestions . During the workshop , further criteria were identified by using a brainstorming technique . The product of these processes was a list of possible factors that could be used to nuance the I. After rejecting the idea of nuancing the I , the USPSTF decided to explore , after the workshop , whether provision of information about the factors identified during this process might be useful to clinicians . This follow-up work was delegated to the Methods Workgroup and members of the Evidence -based Practice Center . The follow-up group noted that almost all of the factors fell into 1 of 4 groups . The 4 information groups came to be described as domains , a term that connotes hierarchical ranking and is apt , even if accidental . That is , these information domains constitute a limited number of broadly applicable collection s of factors , considerations , or attributes pertinent to decision making about preventive services when evidence is insufficient to conclude , with certainty , that there is net benefit or net harm . After more deliberation , the Methods Workgroup proposed in 2006 that the Evidence -based Practice Center gather pertinent information in the 4 domains as part of its evidence retrieval process . The full USPSTF accepted the proposal , and members provided further input to the descriptions of the domains . The authors of this article were asked to prepare a manuscript about the process and product on behalf of the USPSTF . Domains and Rationale The first domain is potential preventable burden of suffering from the condition . When evidence is insufficient , provision of an intervention design ed to prevent a serious condition ( such as dementia ) might be viewed more favorably than provision of a service design ed to prevent a condition that does not cause as much suffering ( such as rash ) . The USPSTF recognized that burden of suffering is subjective and involves judgment . In clinical setting s , it should be informed by patient values and concerns . The second domain is potential harm of the intervention . When evidence is insufficient , an intervention with a large potential for harm ( such as major surgery ) might be viewed less favorably than an intervention with a small potential for harm ( such as advice to watch less television ) . The USPSTF again acknowledges the subjective nature and the difficulty of assessing potential harms : For example , how bad is a mild stroke ? The third domain is costnot just monetary cost , but opportunity cost , in particular the amount of time a provider spends to provide the The major goal of the U.S. Preventive Services Task Force ( USPSTF ) is to provide clinicians and policymakers with a reliable and accurate source of evidence -based recommendations on a wide range of preventive services . To accomplish this goal , the USPSTF systematic ally review s the evidence concerning both the benefits and harms of widespread implementation of a preventive service . It then assesses the certainty of the evidence and the magnitude of the benefits and harms . On the basis of this assessment , the USPSTF assigns a letter grade to each preventive service signifying its recommendation about provision of the service ( Table 1 ) . Table 1 . U.S. Preventive Services Task Force Recommendation Grid * An important , but often challenging , step is determining the balance between benefits and harms to estimate net benefit ( that is , benefits minus harms ) . In this issue , the Task Force reports an up date to its recommendation for carotid artery stenosis screening ( 1 , 2 ) . Because carotid artery stenosis screening has both known benefits and harms , estimating net benefit was critical in the final USPSTF recommendation that clinicians not provide carotid artery stenosis screening in asymptomatic people ( recommendation letter grade D ) . Release of this recommendation provides an opportunity for the Task Force to up date and explain to a clinical audience the process by which it evaluates evidence , determines the certainty and magnitude of net benefit , and gives a letter grade to the recommendation . We will do this by considering 3 questions : 1 ) What evidence does the Task Force consider to estimate net benefit ? 2 ) How does the Task Force estimate the certainty of net benefit ? and 3 ) How does the Task Force estimate the magnitude of net benefit ? What Evidence Does the Task Force Consider to Estimate Net Benefit ? The overarching question that the Task Force seeks to answer for every preventive service is whether evidence suggests that provision of the service would improve health outcomes if implemented in a general primary care population . For screening topics , this st and ard could be met by a large r and omized , controlled trial ( RCT ) in a representative asymptomatic population with follow-up of all members of both the group invited for screening and the group not invited for screening . For example , the Multicentre Aneurysm Screening Study ( 3 ) was a population -based RCT of screening for abdominal aortic aneurysm in which 67800 asymptomatic men age 65 to 74 years in the United Kingdom were r and omly assigned to be invited or not to be invited for screening . Both groups were followed for a mean of 4.1 years , and abdominal aortic aneurysmrelated mortality and all-cause mortality were compared . No RCTs of carotid artery stenosis screening have been published ; however , RCTs comparing carotid endarterectomy to medical management of asymptomatic carotid artery stenosis are available . The distinction between RCTs that r and omly assign people to undergo screening  versus RCTs that r and omly assign people known to have a condition to an intervention is important . In contrast to the latter , RCTs of screening take into account the false-positive and false-negative rates of the screening test , the possibility of adverse events from the test , the accuracy and potential for adverse events of any subsequent confirmatory diagnostic tests , and the inevitable failure to follow through on the test or any subsequent steps needed before the therapeutic intervention is delivered . In addition , conditions detected by screening may have different biological characteristics than those detected in other ways . The benefits of treating screened individuals , therefore , can not be assumed to be the same as those of treating symptomatic individuals . Screening trials directly answer a simple question important to the primary care setting : Does screening for a certain condition improve health outcomes ? Direct RCT evidence about screening is often unavailable , so the Task Force considers indirect evidence . To guide its selection of indirect evidence , the Task Force constructs a chain of evidence within an analytic framework . Figure 1 of the evidence up date ( 2 ) in this issue ( page 861 ) shows the analytic framework for the Task Force assessment of carotid artery stenosis screening . Each arrow in the framework defines a key question , and each key question represents a link in the chain of evidence . Rectangles in the framework represent the intermediate outcomes ( rounded corners ) or the health outcomes ( square corners ) ; ovals represent harms . To form an unbroken chain , evidence must support each link in the chain , thereby connecting the target population ( far left side of the framework ) to the improved health outcome ( far right side of the framework ) . For each key question , the body of pertinent literature is critically appraised , focusing on 6 questions ( Table 2 ) . The USPSTF will now describe its judgment about the evidence for each key question as convincing , adequate , or inadequate . Evidence may be considered convincing when derived from several high- quality studies with consistent , logical results that are generalizable to the U.S. primary care population and setting . Evidence may be deemed adequate when , on the basis of judgment , most but not all of these 6 questions are answered favorably . When evidence is conflicting or the studies are of poor quality individually or in aggregate , the evidence for a key question is considered inadequate . Inadequate evidence may create a critical gap in the evidence chain . Table 2 . Questions Considered by the U.S. Preventive Services Task Force for Evaluating Evidence Related Both to Key Questions and to the Overall Certainty of the Evidence of Net Benefit for the Preventive Service How Does the Task Force Estimate the Certainty of Net Benefit ? The next step in the Task Force process is to use the evidence from the key questions to assess whether there would be net benefit if the service were implemented . In 2001 , the USPSTF published an article that documented its systematic processes of evidence evaluation and recommendation development ( 4 ) . At that time , the Task Force 's overall assessment of evidence was described as good , fair , or poor . The Task Force realized that this rating seemed to apply only to how well studies were conducted and did not fully capture all of the issues that go into an overall assessment of the evidence about net benefit . To avoid confusion , the USPSTF has changed its terminology . Whereas individual study quality will continue to be characterized as good , fair , or poor , the term certainty will now be used to describe the Task Force 's assessment of the overall body of evidence about net benefit of a preventive service and the likelihood that the assessment is correct . Certainty will be determined by considering all 6 questions in Table 2 ; the judgment about certainty will be described as high , moderate , or low . In making its assessment of certainty about net benefit , the evaluation of the evidence from each key question plays a primary role . It is important to note that the Task Force makes recommendations for real-world medical practice in the United States and must determine to what extent the evidence for each key question even evidence from screening RCTs or treatment RCTs can be applied to the general primary care population . Frequently , studies are conducted in highly selected population s under special conditions . The Task Force must consider differences between the general primary care population and the population s studied in RCTs and make judgments about the likelihood of observing the same effect in actual practice . For carotid artery stenosis screening , the Task Force search ed for evidence about the true prevalence of high- grade carotid artery stenosis in the general population , the generalizability of treatment effectiveness estimates based on RCTs conducted in selected population s , and the complication rate from carotid endarterectomy in asymptomatic individuals if performed in nontrial setting s ( for example , community hospitals ) . It is also important to note that 1 of the key questions in the analytic framework refers to the potential harms of the preventive service . The Task Force considers the evidence about the benefits and harms of preventive services separately and equally . Data about harms are often obtained from observational studies because harms observed in RCTs may not be representative of those found in usual practice and because some harms are not completely measured and reported in RCTs . For example , the surgeons who enrolled patients in RCTs of carotid artery stenosis were selected on the basis of their low postoperative stroke and mortality rates . Widespread screening for carotid artery stenosis would invariably lead to surgical treatment provided in hospitals ( or by surgeons ) with higher rates of complications . The harms of screening for carotid artery stenosis , including the harms from carotid angiography to confirm the diagnosis of carotid artery stenosis in patients screening positive by carotid ultrasonography  , were not captured in some treatment RCTs . Putting the body of evidence for all key questions together as a chain , the Task Force assesses the certainty of net benefit of a preventive service by asking the 6 major questions in Table 2 . The Task Force would rate a body of convincing evidence about the benefits of a service that , for example , derives from several RCTs of screening in which the estimate of benefits can be generalized to the general primary care population as high certainty ( Table 3 ) . The Task Force would rate a body of evidence that was not clearly applicable to general practice or has other defects in quality , research design , or consistency of studies as moderate certainty . Certainty is low when , for example , there are gaps in the evidence linking parts of the analytic framework , when evidence to determine the harms of treatment is unavailable , or DESCRIPTION Up date of the 2002 U.S. Preventive Services Task Force ( USPSTF ) recommendation statement about screening for prostate cancer . METHODS The USPSTF evaluated r and omized , controlled trials of the benefits of prostate cancer screening ; cohort and cross-sectional studies of the psychological harms of false-positive prostate-specific antigen test results ; and evidence on the natural history of prostate-specific antigen-detected prostate cancer to address previously identified gaps in the evidence from the 2002 USPSTF recommendation . RECOMMENDATIONS Current evidence is insufficient to assess the balance of benefits and harms of screening for prostate cancer in men younger than age 75 years ( I statement ) . Do not screen for prostate cancer in men age 75 years or older ( Grade D recommendation ) BACKGROUND Approximately 3,000 new cases of oral cancer are diagnosed each year in Canada . Most of these cases occur among older adults with a history of tobacco use or excessive alcohol consumption . Preventive interventions for oral cancer include counselling of patients to modify risk factors and screening to identify precancerous and early-stage lesions . This report presents evidence -based guidelines on the prevention of oral cancer and precancer among asymptomatic patients . METHODS Literature search es of the 1966 - 1999 MEDLINE and CANCERLIT data bases were completed using the major MeSH heading mouth neoplasms . References from articles and recommendations of organizations were also review ed . The evidence -based methods of the Canadian Task Force on Preventive Health Care were used to assess evidence and to develop guidelines . Advice from experts and other recommendations were taken into consideration . RESULTS In cohort and case-control studies , smoking cessation decreased the risk of oral cancer and precancer . R and omized controlled trials ( RCTs ) indicate counselling by trained health care professionals is effective in promoting smoking cessation . Although counselling has been effective for the reduction of excessive alcohol consumption in RCTs , no studies have examined whether alcohol reduction reduces the risk of oral cancer or precancer . The usefulness of general population screening is limited by the low prevalence and incidence of the disease , the potential for false-positive diagnoses and the poor compliance with screening and referral . There is no evidence that screening of the general population or high-risk groups leads to a reduction in mortality or morbidity from oral cancer . INTERPRETATION There is good evidence to specifically consider smoking cessation counselling in a periodic health examination ( grade A recommendation ) . For population screening , there is fair evidence to specifically exclude screening for oral cancer ( grade D recommendation ) . For opportunistic screening during periodic examinations , there is insufficient evidence to recommend inclusion or exclusion of screening for oral cancer ( grade C recommendation ) . For patients at high risk , annual examination by physician or dentist should be considered . Risk factors include tobacco use and excessive consumption of alcohol . These recommendations are similar to those made by the Canadian Task Force on the Periodic Health Examination in 1994 and by the U.S. Preventive Services Task Force in 1996 Summary of the Recommendations The U.S. Preventive Services Task Force ( USPSTF ) concludes that the evidence is insufficient to recommend for or against routinely screening asymptomatic adults for type 2 diabetes , impaired glucose tolerance , or impaired fasting glucose . This is a grade I recommendation . ( See Appendix Table 1 for a description of the USPSTF classification of recommendations . ) The USPSTF found good evidence that available screening tests can accurately detect type 2 diabetes during an early , asymptomatic phase . ( See Appendix Table 2 for a description of the USPSTF classification of levels of evidence . ) The USPSTF also found good evidence that intensive glycemic control in patients with clinical ly detected ( not screening detected ) diabetes can reduce the progression of microvascular disease . However , the benefits of tight glycemic control on microvascular clinical outcomes take years to become apparent . It has not been demonstrated that beginning diabetes control early as a result of screening provides an incremental benefit compared with initiating treatment after clinical diagnosis . Existing studies have not shown that tight glycemic control significantly reduces macrovascular complications , including myocardial infa rct ion and stroke . The USPSTF found poor evidence to assess possible harms of screening . As a result , the USPSTF could not determine the balance of benefits and harms of routine screening for type 2 diabetes . The USPSTF recommends screening for type 2 diabetes in adults with hypertension or hyperlipidemia . This is a grade B recommendation . The USPSTF found good evidence that , in adults who have hypertension and clinical ly detected diabetes , lowering blood pressure below conventional target blood pressure values reduces the incidence of cardiovascular events and cardiovascular mortality ; this evidence is considered fair when extrapolated to cases of diabetes detected by screening . Among patients with hyperlipidemia , there is good evidence that detecting diabetes substantially improves estimates of individual risk for coronary heart disease , which is an integral part of decisions about lipid-lowering therapy . Clinical Considerations In the absence of evidence of direct benefits of routine screening for type 2 diabetes , the decision to screen individual patients is a matter of clinical judgment . Patients at increased risk for cardiovascular disease may benefit most from screening for type 2 diabetes , since management of cardiovascular risk factors leads to reductions in major cardiovascular events . Clinicians should assist patients in making that choice . In addition , clinicians should be alert to symptoms suggestive of diabetes ( for example , polydipsia and polyuria ) and test anyone with these symptoms . Screening for diabetes in patients with hypertension or hyperlipidemia should be part of an integrated approach to reduce cardiovascular risk . Lower targets for blood pressure ( that is , diastolic blood pressure 80 mm Hg ) are beneficial for patients with diabetes and high blood pressure . The third report of the Adult Treatment Panel III of the National Cholesterol Education Program recommends lower targets for low-density lipoprotein cholesterol for patients with diabetes . Attention to other risk factors , such as physical inactivity , diet , and overweight , is also important , both to decrease risk for heart disease and to improve glucose control . Three tests have been used to screen for diabetes : fasting plasma glucose ( FPG ) , 2-hour postload plasma glucose , and hemoglobin A1c .  The American Diabetes Association ( ADA ) has recommended the FPG test for screening ( values 6.99 mmol/L [ 126 mg/dL ] indicate diabetes ) because it is easier and faster to perform , more convenient and acceptable to patients , and less expensive than other screening tests . The FPG test is more reproducible than the 2-hour plasma glucose test , has less intraindividual variation , and has similar predictive value for development of microvascular complications of diabetes . Compared with the FPG test , the 2-hour plasma glucose test may lead to more individuals being diagnosed as diabetic . Hemoglobin A1c is more closely related to FPG than to 2-hour plasma glucose , but at the usual cut-points it is less sensitive in detecting lower levels of hyperglycemia . The r and om  capillary blood glucose test has been shown to have reasonable sensitivity ( 75 % at a cut-point of 6.66 mmol/L [ 120 mg/dL ] ) in detecting persons who have an FPG level greater than or equal to 6.99 mmol/L ( 126 mg/dL ) or a 2-hour plasma glucose level greater than or equal to 11.1 mmol/L ( 200 mg/dL ) , if results are interpreted according to age and time since last meal ; however , the r and om blood glucose test is less well st and ardized for screening for diabetes . The ADA recommends confirmation of a diagnosis of diabetes with a repeated FPG test on a separate day , especially for patients with borderline FPG results and patients with normal FPG levels for whom suspicion of diabetes is high . The optimal screening interval is not known . The ADA , on the basis of expert opinion , recommends an interval of every 3 years but shorter intervals in high-risk persons . Regardless of whether the clinician and patient decide to screen for diabetes , patients should be encouraged to exercise , eat a healthy diet , and maintain a healthy weight , choices that may prevent or forestall the development of type 2 diabetes . More aggressive interventions to establish and maintain these behaviors should be considered for patients at increased risk for diabetes , such as those who are overweight , have a family history of diabetes , or have a racial or ethnic background associated with an increased risk ( for example , Native American persons ) .  Intensive programs of lifestyle modification ( diet , exercise , and behavior ) should also be considered for patients who have impaired fasting glucose or impaired glucose tolerance , since several large trials have demonstrated that these programs can significantly reduce the incidence of diabetes in these patients . Evidence and recommendations regarding counseling about diet , physical activity , and obesity are provided in the USPSTF evidence summaries Counseling to Promote a Healthy Diet , Counseling to Promote Physical Activity , and Screening and Treatment for Obesity in Adults , available on the Agency for Healthcare Research and Quality Web site at www.preventiveservices.ahrq.gov . The brief review of the evidence that is normally included in USPSTF recommendation statements is available in the complete recommendation and rationale statement on the USPSTF Web site ( www.preventiveservices.ahrq.gov ) . Recommendations of Others The ADA acknowledged that data from prospect i ve studies were insufficient to determine the benefits of diabetes screening and thus concluded that the decision to test for diabetes should be based on clinical judgment and patient preference ( 1 ) . On the basis of expert consensus , the ADA recommends clinicians consider screening for diabetes with the FPG test beginning at age 45 years and at a younger age for individuals with such risk factors as family history , overweight , and hypertension , among others . The American College of Obstetricians and Gynecologists endorses the ADA recommendations ( 2 ) . The American Heart Association recommends measuring fasting blood glucose in persons 20 years of age and older according to risk for diabetes , as part of overall risk assessment for cardiovascular disease ( 3 ) . The Canadian Task Force on Preventive Health Care is currently updating its recommendations on diabetes screening PURPOSE We determined whether the characteristics of patients undergoing prostate needle biopsies and prostate needle biopsy results changed after the U.S. Preventive Services Task Force recommendation in 2012 against prostate specific antigen based screening for prostate cancer for men of any age . MATERIAL S AND METHODS A prospect i ve data base of patients undergoing prostate needle biopsies at Virginia Mason from 2004 to 2014 was review ed . Welch 's t-test and chi-square tests were used to compare patients seen before to those seen after the USPSTF recommendation . Relative risks and corresponding confidence intervals were estimated by general linear regression . RESULTS Patients in the post-USPSTF group ( 310 ) had a higher prostate specific antigen ( p < 0.001 ) , were more likely to be diagnosed with higher clinical stage ( 2b , p=0.003 ; 2c-3a , p=0.027 ) and D'Amico high risk prostate cancer ( p=0.036 ) , with an adjusted relative risk for high risk prostate cancer of 1.25 ( 95 % CI 1.02 - 1.52 ) compared to those in the pre-USPSTF group ( 1,416 ) . Limiting the pre-USPSTF group to the 30 months before the draft guidelines ( 448 patients ) yielded similar results . The absolute number of biopsies performed decreased by 31 % , with the majority of the decrease occurring in the detection of intermediate risk tumors . CONCLUSIONS In the 2 and a half years after the USPSTF recommendation against prostate specific antigen based screening , patients undergoing prostate needle biopsies were significantly more likely to be diagnosed with high risk disease . However , a reduction in the number of prostate needle biopsies performed occurred concomitantly with a decrease in the detection of intermediate risk , potentially curable prostate cancer . Future focus on informed application of screening techniques may prevent the reversal of decades of improvement in the prostate cancer mortality rate Summary of the Recommendation The U.S. Preventive Services Task Force ( USPSTF ) found insufficient evidence to recommend for or against routine screening of parents or guardians for the physical abuse or neglect of children , of women for intimate partner violence , or of older adults or their caregivers for elder abuse . This is a grade I recommendation . ( See Appendix Table 1 for a description of the USPSTF classification of recommendations . ) Appendix Table 1 . U.S. Preventive Services Task Force Recommendations and Ratings The USPSTF found no direct evidence that screening for family and intimate partner violence leads to decreased disability or premature death . The USPSTF found no existing studies that determine the accuracy of screening tools for identifying family and intimate partner violence among children , women , or older adults in the general population . The USPSTF found fair to good evidence that interventions reduce harm to children when child abuse or neglect has been assessed ( see Clinical Considerations ) . The USPSTF found limited evidence as to whether interventions reduce harm to women and no studies that examined the effectiveness of interventions in older adults . No studies have directly addressed the harms of screening and interventions for family and intimate partner violence . As a result , the USPSTF could not determine the balance between the benefits and harms of screening for family and intimate partner violence among children , women , or older adults . ( See Appendix Table 2 for a description of the USPSTF classification of levels of evidence . ) Appendix Table 2 . U.S. Preventive Services Task Force Strength of Overall Evidence Clinical Considerations The USPSTF did not review the evidence for the effectiveness of case-finding tools ; however , all clinicians examining children and adults should be alert to physical and behavioral signs and symptoms associated with abuse or neglect . Patients in whom abuse is suspected should receive proper documentation of the incident and physical findings ( for example , photographs , body maps ) ; treatment for physical injuries ; arrangements for skilled counseling by a mental health professional ; and the telephone numbers of local crisis centers , shelters , and protective service agencies . Victims of family violence are primarily children , female spouses/intimate partners , and older adults . Numerous risk factors for family violence have been identified , although some may be confounded by socioeconomic factors . Factors associated with child abuse or neglect include low income status , low maternal education , non-white race , large family size , young maternal age , single-parent household , parental psychiatric disturbances , and presence of a stepfather . Factors associated with intimate partner violence include young age , low income status , pregnancy , mental health problems , alcohol or substance use by victims or perpetrators , separated or divorced status , and history of childhood sexual and /or physical abuse . Factors associated with the abuse of older adults include increasing age , non-white race , low income status , functional impairment , cognitive disability , substance use , poor emotional state , low self-esteem , cohabitation , and lack of social support . Several instruments to screen parents for  child abuse have been studied , but their ability to predict child abuse or neglect is limited . Instruments to screen for intimate partner violence have also been developed , and although some have demonstrated good internal consistency ( for example , the HITS [ Hurt , Insulted , Threatened , Screamed at ] instrument , the Partner Abuse Interview , and the Women 's Experience with Battering [ WEB ] Scale ) , none have been vali date d against measurable outcomes . Only a few screening instruments ( for example , the  Caregiver Abuse Screen [ CASE ] and the HwalekSengstock Elder Abuse Screening Test  [ HSEAST ] ) have been developed to identify older potential victims of abuse or their abusive caretakers . Both of these tools correlated well with previously vali date d instruments when administered in the community but have not been tested in the primary care clinical setting ( 1 ) . Home visit programs directed at high-risk mothers ( identified on the basis of sociodemographic risk factors ) have improved developmental outcomes and decreased the incidence of child abuse and neglect , as well as decreased rates of maternal criminal activity and drug use . Discussion Approximately 1 million abused children are identified in the United States each year ( 2 ) . In 1999 , an estimated 1100 children died of abuse and neglect ( 3 ) . It is likely that reported abuse captures only a fraction of all cases . Estimates of the prevalence of intimate partner violence in the United States indicate that 1 to 4 million women are physically , sexually , or emotionally abused by their intimate partners each year ( 4 , 5 ) , with 31 % of all women reporting abuse at some point in their lifetimes ( 6 ) . Although violence by women against men also occurs , women are 7 to 14 times more likely to suffer severe physical injury from an assault by an intimate partner ( 7 ) . The National Elder Abuse Incidence Study ( NEAIS ) estimates that approximately 551000 older adults in domestic setting s were abused and /or neglected during 1996 ( 8) . The abuse of older adults takes many forms , including physical , sexual , and psychological abuse ; financial exploitation ; and neglect ( 9 ) . In 90 % of cases , the perpetrator of such abuse is a family member , usually an adult child or spouse ( 8) . Harmful outcomes of family violence may include not only repercussions of acute trauma , including death or unwanted pregnancy , but also long-term physical problems and psychiatric disorders , such as depression , post-traumatic stress disorder , somatization , suicide , and substance abuse ( 10 - 20 ) . In addition , children who witness intimate partner violence are at risk for developmental delay ; school failure ; violent behavior ; and a variety of psychiatric disorders , including depression and oppositional defiant disorder ( 21 - 23 ) . The USPSTF focused this review on children , women , and older adults because they are the largest groups at risk for domestic violence in the general primary care setting and are most likely to have been the subjects of published studies . The USPSTF review ed the evidence for the effectiveness of screening procedures and interventions in the primary care setting in reducing harmful outcomes of domestic violence against children , women , and older adults . Because no studies were found that directly addressed the impact of screening on reducing harmful outcomes , the USPSTF examined the accuracy of clinical screening instruments in identifying risk for current or future abuse and the efficacy of clinic-based interventions in reducing harmful outcomes . Screening for child abuse in the primary care setting can involve a variety of techniques , including physical examination as well as screening question naires . Findings during a routine physical examination suggestive of abuse and /or neglect , such as burns , bruises , and repeated suspicious traumatic injury , have been described ( 24 ) . All instruments design ed to screen for child abuse and neglect were directed at parents , particularly pregnant mothers . Limited evidence suggests that these instruments had fairly high sensitivity but low specificity for identifying future child maltreatment when administered in the study population s , particularly when self-administered question naires were provided to pregnant mothers in a 2-step method , such as the Hawaii Risk Indicators Screening Tool followed by the Kempe Family Stress Inventory ( 25 , 26 ) . These question naires have not been widely tested in different population s. Newer brief instruments design ed to identify women who are victims of intimate partner violence in primary care setting s compare well with lengthier , previously vali date d instruments ( 1 ) . Studies indicate that self-administered question naires elicit more positive responses than interviewer-administered question naires in emergency department setting s ( 27 ) , but the opposite was true in a Planned Parenthood clinic ( 28 ) . No studies have evaluated the performance of screening instruments using verified outcomes of reported intimate partner abuse , although self-reported abuse may be a more accurately measured outcome than some verified outcomes ( for example , police or social services reports ) . The USPSTF found few screening instruments for the detection of older adults who are the potential victims of abuse or their caretakers . None of the instruments available have been widely vali date d. The USPSTF review ed the evidence for the efficacy of interventions with children , women , and older adults in reducing harmful outcomes of family and intimate partner violence . The intervention trials identified high-risk women and children on the basis of various inclusion criteria that have not been vali date d , including sociodemographic characteristics , maternal substance use , low infant birthweight , and homelessness . A r and omized , controlled trial with 15 years of follow-up indicated that nurse home visit programs ( for example , the NurseFamily Partnership program ) during the prenatal and 2-year postpartum periods for low-income , first-time mothers can improve the short-term and long-term outcomes of child abuse and neglect ( 29 , 30 ) . When compared with the nonintervention group , the home visit group had improved outcomes , including decreased reports of child maltreatment , child injuries/toxic ingestions and emergency department visits , and maternal criminal activity and drug use . Several trials utilizing nurse home visits for varying lengths of time and with various program components for pregnant and postpartum mothers support these findings , although the outcomes in these studies were short-term measures of child abuse and related factors ( 1 ) . There were 2 studies of interventions to decrease intimate partner violence in women ; both studies , Importance In the United States , the lifetime risk of being diagnosed with prostate cancer is approximately 13 % , and the lifetime risk of dying of prostate cancer is 2.5 % . The median age of death from prostate cancer is 80 years . Many men with prostate cancer never experience symptoms and , without screening , would never know they have the disease . African American men and men with a family history of prostate cancer have an increased risk of prostate cancer compared with other men . Objective To up date the 2012 US Preventive Services Task Force ( USPSTF ) recommendation on prostate-specific antigen (PSA)–based screening for prostate cancer . Evidence Review The USPSTF review ed the evidence on the benefits and harms of PSA-based screening for prostate cancer and subsequent treatment of screen-detected prostate cancer . The USPSTF also commissioned a review of existing decision analysis models and the overdiagnosis rate of PSA-based screening . The review s also examined the benefits and harms of PSA-based screening in patient sub population s at higher risk of prostate cancer , including older men , African American men , and men with a family history of prostate cancer . Findings Adequate evidence from r and omized clinical trials shows that PSA-based screening programs in men aged 55 to 69 years may prevent approximately 1.3 deaths from prostate cancer over approximately 13 years per 1000 men screened . Screening programs may also prevent approximately 3 cases of metastatic prostate cancer per 1000 men screened . Potential harms of screening include frequent false-positive results and psychological harms . Harms of prostate cancer treatment include erectile dysfunction , urinary incontinence , and bowel symptoms . About 1 in 5 men who undergo radical prostatectomy develop long-term urinary incontinence , and 2 in 3 men will experience long-term erectile dysfunction . Adequate evidence shows that the harms of screening in men older than 70 years are at least moderate and greater than in younger men because of increased risk of false-positive results , diagnostic harms from biopsies , and harms from treatment . The USPSTF concludes with moderate certainty that the net benefit of  PSA-based screening for prostate cancer in men aged 55 to 69 years is small for some men . How each man weighs specific benefits and harms will determine whether the overall net benefit is small . The USPSTF concludes with moderate certainty that the potential benefits of PSA-based screening for prostate cancer in men 70 years and older do not outweigh the expected harms . Conclusions and Recommendation For men aged 55 to 69 years , the decision to undergo periodic PSA-based screening for prostate cancer should be an individual one and should include discussion of the potential benefits and harms of screening with their clinician . Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men . However , many men will experience potential harms of screening , including false-positive results that require additional testing and possible prostate biopsy ; overdiagnosis and overtreatment ; and treatment complications , such as incontinence and erectile dysfunction . In determining whether this service is appropriate in individual cases , patients and clinicians should consider the balance of benefits and harms on the basis of family history , race/ethnicity , comorbid medical conditions , patient values about the benefits and harms of screening and treatment-specific outcomes , and other health needs . Clinicians should not screen men who do not express a preference for screening . ( C recommendation ) The USPSTF recommends against PSA-based screening for prostate cancer in men 70 years and older . ( D recommendation BACKGROUND The potential of primary care practice setting s to prevent disease and morbidity through health habit counseling , screening for asymptomatic disease , and immunizations has been incompletely met . This study was design ed to test a practice -tailored approach to increasing preventive service delivery with particular emphasis on health habit counseling . DESIGN Group r and omized clinical trial and multi method process assessment . SETTING / PARTICIPANTS Seventy-seven community family practice s in northeast Ohio . INTERVENTION After a 1-day practice assessment , a nurse facilitator met with practice clinicians and staff and assisted them with choosing and implementing individualized tools and approaches aim ed at increasing preventive service delivery . MAIN OUTCOME MEASURE Summary scores of the health habit counseling , screening and immunization services recommended by the U.S. Preventive Services Task Force up to date for consecutive patients during r and omly selected chart review days . RESULTS A significant increase ( p=0.015 ) in global preventive service delivery rates at the 1-year follow-up was found in the intervention group ( 31 % to 42 % ) compared to the control group ( 35 % to 37 % ) . Rates specifically for health habit counseling ( p=0.007 ) and screening services ( p=0.048 ) were increased , but not for immunizations . CONCLUSIONS An approach to increasing preventive service delivery that is individualized to meet particular practice needs can increase global preventive service delivery rates The U.S. Preventive Services Task Force ( USPSTF ) makes recommendations about the effectiveness of specific preventive care services for patients without related signs or symptoms . It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance . The USPSTF does not consider the costs of providing a service in this assessment . The USPSTF recognizes that clinical decisions involve more considerations than evidence alone . Clinicians should underst and the evidence but individualize decision making to the specific patient or situation . Similarly , the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms . Summary of Recommendation and Evidence The USPSTF recommends annual screening for lung cancer with low-dose 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 . ( B recommendation ) See the Clinical Considerations section for suggestions for implementation in practice . See the Figure for a summary of the recommendation and suggestions for clinical practice . Figure . Screening for lung cancer : clinical summary of U.S. Preventive Services Task Force recommendation . Appendix Table 1 describes the USPSTF grade s , and Appendix Table 2 describes the USPSTF classification of levels of certainty about net benefit . Appendix Table 1 . What the USPSTF Grade s Mean and Suggestions for Practice Appendix Table 2 . USPSTF Levels of Certainty Regarding Net Benefit Supplement . Consumer Fact Sheet . Rationale Importance Lung cancer is the third most common cancer and the leading cause of cancer-related death in the United States ( 1 ) . The most important risk factor for lung cancer is smoking , which results in approximately 85 % of all U.S. lung cancer cases ( 2 ) . Although the prevalence of smoking has decreased , approximately 37 % of U.S. adults are current or former smokers ( 2 ) . The incidence of lung cancer increases with age and occurs most commonly in persons aged 55 years or older . Increasing age and cumulative exposure to tobacco smoke are the 2 most common risk factors for lung cancer . Lung cancer has a poor prognosis , and nearly 90 % of persons with lung cancer die of the disease . However , early-stage nonsmall cell lung cancer ( NSCLC ) has a better prognosis and can be treated with surgical resection . Detection Most lung cancer cases are NSCLC , and most screening programs focus on the detection and treatment of early-stage NSCLC . Although chest radiography and sputum cytologic evaluation have been used to screen for lung cancer , LDCT has greater sensitivity for detecting early-stage cancer ( 3 ) . Benefits of Detection and Early Treatment Although lung cancer screening is not an alternative to smoking cessation , the USPSTF found adequate evidence that annual screening for lung cancer with LDCT  in a defined population of high-risk persons can prevent a substantial number of lung cancerrelated deaths . Direct evidence from a large , well-conducted , r and omized , controlled trial ( RCT ) provides moderate certainty of the benefit of lung cancer screening with LDCT in this population ( 4 ) . The magnitude of benefit to the person depends on that person 's risk for lung cancer because those who are at highest risk are most likely to benefit . Screening can not prevent most lung cancerrelated deaths , and smoking cessation remains essential . Harms of Detection and Early Intervention and Treatment The harms associated with LDCT screening include false-negative and false-positive results , incidental findings , overdiagnosis , and radiation exposure . False-positive LDCT results occur in a substantial proportion of screened persons ; 95 % of all positive results do not lead to a diagnosis of cancer . In a high- quality screening program , further imaging can resolve most false-positive results ; however , some patients may require invasive procedures . The USPSTF found insufficient evidence on the harms associated with incidental findings . Overdiagnosis of lung cancer occurs , but its precise magnitude is uncertain . A modeling study performed for the USPSTF estimated that 10 % to 12 % of screen-detected cancer cases are overdiagnosedthat is , they would not have been detected in the patient 's lifetime without screening . Radiation harms , including cancer result ing from cumulative exposure to radiation , vary depending on the age at the start of screening ; the number of scans received ; and the person 's exposure to other sources of radiation , particularly other medical imaging . USPSTF Assessment The USPSTF concludes with moderate certainty that annual screening for lung cancer with LDCT is of moderate net benefit in asymptomatic persons who are at high risk for lung cancer based on age , total cumulative exposure to tobacco smoke , and years since quitting smoking . The moderate net benefit of screening depends on limiting screening to persons who are at high risk , the accuracy of image interpretation being similar to that found in the NLST ( National Lung Screening Trial ) , and the resolution of most false-positive results without invasive procedures ( 4 ) . Clinical Considerations Patient Population Under Consideration The risk for lung cancer increases with age and cumulative exposure to tobacco smoke and decreases with time since quitting smoking . The best evidence for the benefit of screening comes from the NLST , which enrolled adults aged 55 to 74 years who had at least a 30 pack-year smoking history and were current smokers or had quit within the past 15 years . As with all screening trials , the NLST tested a specific intervention over a finite period . Because initial eligibility extended through age 74 years and participants received 3 annual screening computed tomographic scans  , the oldest participants in the trial were aged 77 years . The USPSTF used modeling studies to predict the benefits and harms of screening programs that use different screening intervals , age ranges , smoking histories , and times since quitting . A program that annually screens 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 is projected to have a reasonable balance of benefits and harms . The model assumes that persons who achieve 15 years of smoking cessation during the screening program discontinue screening . This model predicts the outcomes of continuing the screening program used in the NLST through age 80 years . Screening may not be appropriate for patients with substantial comorbid conditions , particularly those at the upper end of the screening age range . The NLST excluded persons who were unlikely to complete curative lung cancer surgery and those with medical conditions that posed a substantial risk for death during the 8-year trial . The baseline characteristics of the NLST showed a relatively healthy sample , and fewer than 10 % of enrolled participants were older than 70 years ( 5 ) . Persons with serious comorbid conditions may experience net harm , no net benefit , or at least substantially less net benefit . Similarly , persons who are unwilling to have curative lung surgery are unlikely to benefit from a screening program . Assessment of Risk Age , total exposure to tobacco smoke , and years since quitting smoking are important risk factors for lung cancer and were used to determine eligibility in the NLST . Other risk factors include specific occupational exposures , radon exposure , family history , and history of pulmonary fibrosis or chronic obstructive lung disease . The incidence of lung cancer is relatively low in persons younger than 50 years but increases with age , especially after age 60 years . In current and former smokers , age-specific incidence rates increase with age and cumulative exposure to tobacco smoke . Smoking cessation substantially reduces a person 's risk for developing and dying of lung cancer . Among persons enrolled in the NLST , those who were at highest risk because of additional risk factors or a greater cumulative exposure to tobacco smoke experienced most of the benefit ( 6 ) . A vali date d multivariate model showed that persons in the highest 60 % of risk accounted for 88 % of all deaths preventable by screening . Screening Tests Low-dose computed tomography has shown high sensitivity and acceptable specificity for the detection of lung cancer in high-risk persons .  Chest radiography and sputum cytologic evaluation  have not shown adequate sensitivity or specificity as screening tests . Therefore , LDCT is currently the only recommended screening test for lung cancer . Treatment Surgical resection is the current st and ard of care for localized NSCLC . This type of cancer is treated with surgical resection when possible and also with radiation and chemotherapy . Annual LDCT screening may not be useful for patients with life-limiting comorbid conditions or poor functional status who may not be c and i date s for surgery . Other Approaches to Prevention Smoking cessation is the most important intervention to prevent NSCLC . Advising smokers to stop smoking and preventing nonsmokers from being exposed to tobacco smoke are the most effective ways to decrease the morbidity and mortality associated with lung cancer . Current smokers should be informed of their continuing risk for lung cancer and offered cessation treatments . Screening with LDCT should be viewed as an adjunct to tobacco cessation interventions . Useful Re sources Clinicians have many re sources to help patients stop smoking . The Centers for Disease Control and Prevention has developed a Web site with many such re sources , including information on tobacco quit lines , available in several language s ( www.cdc.gov/tobacco/campaign/tips ) . Quit Summary of the Recommendations The U.S. Preventive Services Task Force ( USPSTF ) recommends screening mammography , with or without clinical breast examination ( CBE ) , every 1 to 2 years for women aged 40 and older . This is a grade B recommendation . ( See Appendix Table 1 for a description of the USPSTF classification of recommendations . ) The USPSTF found fair evidence that mammography screening every 12 to 33 months significantly reduces mortality from breast cancer . ( See Appendix Table 2 for a description of the USPSTF classification of levels of evidence . ) Evidence is strongest for women aged 50 to 69 , the age group generally included in screening trials . For women aged 40 to 49 , the evidence that screening mammography reduces mortality from breast cancer is weaker , and the absolute benefit of mammography is smaller , than it is for older women . Most , but not all , studies indicate a mortality benefit for women undergoing mammography at ages 40 to 49 , but the delay in observed benefit in women younger than 50 makes it difficult to determine the incremental benefit of beginning screening at age 40 rather than at age 50 . The absolute benefit is smaller because the incidence of breast cancer is lower among women in their 40s than it is among older women . The USPSTF concluded that the evidence is also generalizable to women aged 70 and older ( who face a higher absolute risk of breast cancer ) if their life expectancy is not compromised by comorbid disease . The absolute probability of benefits of regular mammography  increases along a continuum with age , whereas the likelihood of harms from screening ( false-positive results and unnecessary anxiety , biopsies , and cost ) diminishes from ages 40 to 70 . The balance of benefits and potential harms , therefore , grows more favorable as women age . The precise age at which the potential benefits of mammography justify the possible harms is a subjective choice . The USPSTF did not find sufficient evidence to specify the optimal screening interval for women aged 40 to 49 ( see Clinical Considerations ) . The USPSTF concludes that the evidence is insufficient to recommend for or against routine CBE alone to screen for breast cancer . This is a grade I recommendation . No screening trial has examined the benefits of CBE alone ( without accompanying mammography ) compared to no screening , and design characteristics limit the generalizability of studies that have examined CBE . The USPSTF could not determine the benefits of CBE alone or the incremental benefit of adding CBE to mammography . The USPSTF therefore could not determine whether potential benefits of routine CBE outweigh the potential harms . The USPSTF concludes that the evidence is insufficient to recommend for or against teaching or performing routine breast self-examination ( BSE ) . This is a grade I recommendation . The USPSTF found poor evidence to determine whether BSE reduces breast cancer mortality . The USPSTF found fair evidence that BSE is associated with an increased risk of false-positive results and biopsies . Because of design limitations of published and ongoing studies of BSE , the USPSTF could not determine the balance of benefits and potential harms of BSE . Clinical Considerations The precise age at which the benefits from screening mammography justify the potential harms is a subjective judgment and should take into account patient preferences . Clinicians should inform women about the potential benefits ( reduced chance of dying from breast cancer ) , potential harms ( for example , false-positive results , unnecessary biopsies ) , and limitations of the test that apply to women their age . Clinicians should tell women that the balance of benefits and potential harms of mammography improves with increasing age for women between the ages of 40 and 70 . Women who are at increased risk for breast cancer ( for example , those with a family history of breast cancer in a mother or sister , a previous breast biopsy revealing atypical hyperplasia , or first childbirth after age 30 ) are more likely to benefit from regular mammography than women at lower risk . The recommendation for women to begin routine screening in their 40s is strengthened by a family history of breast cancer having been diagnosed before menopause . The USPSTF did not examine whether women should be screened for genetic mutations ( BRCA1 and BRCA2 ) that increase the risk of developing breast cancer , or whether women with genetic mutations might benefit from earlier or more frequent screening for breast cancer . In the trials that demonstrated the effectiveness of mammography in lowering breast cancer mortality , screening was performed every 12 to 33 months . For women aged 50 and older , there is little evidence to suggest that annual mammography is more effective than mammography done every other year . For women aged 40 to 49 , available trials also have not reported a clear advantage of annual mammography over biennial mammography . Nevertheless , some experts recommend annual mammography based on the lower sensitivity of the test and on evidence that tumors grow more rapidly in this age group . The precise age at which to discontinue screening mammography is uncertain . Only two r and omized , controlled trials enrolled women older than 69 , and no trials enrolled women older than 74 . Older women face a higher probability of developing and dying of breast cancer but also have a greater chance of dying of other causes . Women with comorbid conditions that limit their life expectancy are unlikely to benefit from screening . Clinicians should refer patients to  mammography screening centers with proper accreditation and quality assurance st and ards to ensure accurate imaging and radiographic interpretation . Clinicians should adopt office systems to ensure timely and adequate follow-up of abnormal results . A listing of accredited facilities is available at www . fda .gov/cdrh/mammography/certified.html . Clinicians who advise women to perform BSE or who perform routine CBE to screen for breast cancer should underst and that there is currently insufficient evidence to determine whether these practice s affect breast cancer mortality and that they are likely to increase the incidence of clinical assessment s and biopsies . The brief review of the evidence that is normally included in USPSTF recommendations is available in the complete recommendation and rationale statement on the USPSTF Web site ( www.preventiveservices.ahrq.gov ) . Recommendations of Others Nearly all North American organizations support mammography screening , although groups vary in the recommended age to begin screening , the interval for screening , and the role of CBE . The American Medical Association ( AMA ) ( 1 ) , the American College of Radiology ( ACR ) ( 2 ) , and the American Cancer Society ( ACS ) ( 3 ) all support screening with mammography and CBE beginning at age 40 . The American College of Obstetricians and Gynecologists ( ACOG ) ( 4 ) supports screening with mammography beginning at age 40 and CBE beginning at age 19 . The Canadian Task Force on Preventive Health Care ( CTFPHC ) ( 5 ) , the American Academy of Family Physicians ( AAFP ) ( 6 ) , and the American College of Preventive Medicine ( ACPM ) ( 7 ) recommend beginning mammography for average-risk women at age 50 . The AAFP and ACPM recommend that mammography in high-risk women begin at age 40 , and the AAFP recommends that all women aged 40 to 49 be counseled about the risks and benefits of mammography before making decisions about screening ( 6 , 7 ) . A 1997 Consensus Development Panel convened by the U.S. National Institutes of Health concluded that the evidence was insufficient to determine the benefits of mammography among women aged 40 to 49 . This panel recommended that women aged 40 to 49 should be counseled about potential benefits and harms before making decisions about mammography ( 8) . In 2001 , the CTFPHC concluded there was insufficient evidence to recommend for or against mammography in women 40 to 49 ( 9 ) . Organizations differ on their recommendations for the appropriate interval for mammography .  Annual mammography is recommended by the AMA , ACR , and ACS ( 1 - 3 ) . Mammography every 1 to 2 years is recommended by the CTFPHC , AAFP , and ACPM ( 5 - 7 ) . The ACOG recommends mammography every 1 to 2 years for women aged 40 to 49 and annually for women aged 50 and older ( 4 ) . In its 2001 report , the CTFPHC recommends against teaching  BSE  to women aged 40 to 69 ( 10 ) . The AMA , ACS , ACOG , and AAFP support teaching BSE ( 1 , 3 , 4 , 6 ) The U.S. Preventive Services Task Force ( USPSTF ) makes recommendations about the effectiveness of specific preventive care services for patients without related signs or symptoms . It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance . The USPSTF does not consider the costs of providing a service in this assessment . The USPSTF recognizes that clinical decisions involve more considerations than evidence alone . Clinicians should underst and the evidence but individualize decision making to the specific patient or situation . Similarly , the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms . Summary of Recommendations and Evidence The USPSTF recommends biennial screening mammography for women aged 50 to 74 years . ( B recommendation ) The decision to start screening  mammography  in women prior to age 50 years should be an individual one . Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years . ( C recommendation ) For women who are at average risk for breast cancer , most of the benefit of mammography results from biennial screening during ages 50 to 74 years . Of all of the age groups , women aged 60 to 69 years are most likely to avoid breast cancer death through mammography screening . While screening mammography in women aged 40 to 49 years may reduce the risk for breast cancer death , the number of deaths averted is smaller than that in older women and the number of false-positive results and unnecessary biopsies is larger . The balance of benefits and harms is likely to improve as women move from their early to late 40s . In addition to false-positive results and unnecessary biopsies , all women undergoing regular screening mammography are at risk for the diagnosis and treatment of noninvasive and invasive breast cancer that would otherwise not have become a threat to their health , or even apparent , during their lifetime ( known as overdiagnosis ) . Beginning mammography screening at a younger age and screening more frequently may increase the risk for overdiagnosis and subsequent overtreatment . Women with a parent , sibling , or child with breast cancer are at higher risk for breast cancer and thus may benefit more than average-risk women from beginning screening in their 40s . Go to the Clinical Considerations section for information on implementation of the C recommendation . The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women aged 75 years or older . ( I statement ) The USPSTF concludes that the current evidence is insufficient to assess the benefits and harms of digital breast tomo synthesis ( DBT ) as a primary screening method for breast cancer . ( I statement ) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of adjunctive screening for breast cancer using breast ultrasonography , magnetic resonance imaging ( MRI ) , DBT , or other methods in women identified to have dense breasts on an otherwise negative screening mammogram . ( I statement ) These recommendations apply to asymptomatic women aged 40 years or older who do not have preexisting breast cancer or a previously diagnosed high-risk breast lesion and who are not at high risk for breast cancer because of a known underlying genetic mutation ( such as a BRCA1 or BRCA2 gene mutation or other familial breast cancer syndrome ) or a history of chest radiation at a young age . See Figure 1 for a summary of the recommendation and suggestions for clinical practice . Figure 1 . Screening for breast cancer : clinical summary . Appendix Table 1 describes the USPSTF grade s , and Appendix Table 2 describes the USPSTF classification of levels of certainty about net benefit . Appendix Table 1 . What the USPSTF Grade s Mean and Suggestions for Practice Appendix Table 2 . USPSTF Levels of Certainty Regarding Net Benefit Supplement . Consumer Fact Sheet Rationale Importance Breast cancer is the second-leading cause of cancer death among women in the United States . In 2015 , an estimated 232000 women were diagnosed with the disease and 40000 women died of it . It is most frequently diagnosed among women aged 55 to 64 years , and the median age of death from breast cancer is 68 years ( 1 ) . Benefit and Harms of Screening and Early Treatment The USPSTF found adequate evidence that mammography screening reduces breast cancer mortality in women aged 40 to 74 years . The number of breast cancer deaths averted increases with age ; women aged 40 to 49 years benefit the least and women aged 60 to 69 years benefit the most . Age is the most important risk factor for breast cancer , and the increased benefit observed with age is at least partly due to the increase in risk . Women aged 40 to 49 years who have a first-degree relative with breast cancer have a risk for breast cancer similar to that of women aged 50 to 59 years without a family history . Direct evidence about the benefits of screening mammography in women aged 75 years or older is lacking . The USPSTF found adequate evidence that screening for breast cancer with mammography results in harms for women aged 40 to 74 years . The most important harm is the diagnosis and treatment of noninvasive and invasive breast cancer that would otherwise not have become a threat to a woman 's health , or even apparent , during her lifetime ( that is , overdiagnosis and overtreatment ) . False-positive results are common and lead to unnecessary and sometimes invasive follow-up testing , with the potential for psychological harms ( such as anxiety ) . False-negative results ( that is , missed cancer ) also occur and may provide false reassurance . Radiation-induced breast cancer and result ing death can also occur , although the number of both of these events is predicted to be low . The USPSTF found inadequate evidence on the benefits and harms of DBT as a primary screening method for breast cancer . Similarly , the USPSTF found inadequate evidence on the benefits and harms of adjunctive screening for breast cancer using breast ultrasonography , MRI , DBT , or other methods in women identified to have dense breasts on an otherwise negative screening mammogram . In both cases , while there is some information about the accuracy of these methods , there is no information on the effects of their use on health outcomes , such as breast cancer incidence , mortality , or overdiagnosis rates . USPSTF Assessment The USPSTF concludes with moderate certainty that the net benefit of screening  mammography  in women aged 50 to 74 years is moderate . The USPSTF concludes with moderate certainty that the net benefit of  screening mammography  in the general population of women aged 40 to 49 years , while positive , is small . The USPSTF concludes that the evidence on  mammography screening  in women age 75 years and older is insufficient , and the balance of benefits and harms can not be determined . The USPSTF concludes that the evidence on DBT as a primary screening method for breast cancer is insufficient , and the balance of benefits and harms can not be determined . The USPSTF concludes that the evidence on adjunctive screening for breast cancer using breast ultrasound , MRI , DBT , or other methods in women identified to have dense breasts on an otherwise negative screening mammogram is insufficient , and the balance of benefits and harms can not be determined . Clinical Considerations Benefit of Screening The results of the meta- analysis of clinical trials from the systematic evidence review commissioned by the USPSTF are summarized in Table 1 . Over a 10-year period , screening 10000 women aged 60 to 69 years will result in 21 ( 95 % CI , 11 to 32 ) fewer breast cancer deaths . The benefit is smaller in younger women : Screening 10000 women aged 50 to 59 years will result in 8 ( CI , 2 to 17 ) fewer breast cancer deaths , and screening 10000 women aged 40 to 49 years will result in 3 ( CI , 0 to 9 ) fewer breast cancer deaths ( 2 , 3 ) . Most of these trials began enrollment more than 30 years ago , and these estimates may not reflect the current likelihood of avoiding a breast cancer death with contemporary screening mammography technology . Mammography imaging has since improved , which may result in more tumors being detected at a curable stage today than at the time of these trials . However , breast cancer treatments have also improved , and as treatment improves , the advantage of earlier detection decreases , so that some of the women who died of breast cancer in the nonscreened groups in these trials would survive today . Table 1 . Breast Cancer Deaths Avoided ( 95 % CI ) per 10 000 Women Screened by Repeat Screening Mammography Over 10 Years : Data From R and omized , Controlled Trials * Harms of Screening The most important harm of screening is the detection and treatment of invasive and noninvasive cancer that would never have been detected , or threaten health , in the absence of screening ( overdiagnosis and overtreatment ) . Existing science does not allow for the ability to determine precisely what proportion of cancer diagnosed by mammography today reflects overdiagnosis , and estimates vary widely depending on the data source and method of calculation used ( 2 , 4 ) . In the United States , the rate of diagnosis of invasive plus noninvasive breast cancer increased by 50 % during the era of mammography screening ( Figure 2 ) ( 5 ) . It is not possible to know with certainty what proportion of that increase is due to overdiagnosis and what proportion reflects other reasons for a rising incidence . If overdiagnosis is the only explanation for the increase , 1 in 3 women diagnosed with breast cancer today is being treated for cancer that would never have been discovered or caused her health problems in the absence of screening . The best estimates from r and omized , controlled trials ( RCTs ) evaluating BACKGROUND The US Preventive Services Task Force ( USPSTF ) recommends that clinicians refer obese adults for intensive , multicomponent behavioral counseling , yet most obese Americans choose a self-help approach to lose weight . The current study examined weight loss between a community-based , intensive behavioral counseling program ( Weight Watchers program ) and a self-help condition . METHODS A total of 292 participants were r and omized to either a Weight Watchers condition ( WW ) ( n = 147 ) or a self-help condition ( n = 145 ) . Participants in the WW condition were provided with 3 ways to access the treatment : weekly meetings ; WW mobile application ; and WW online tools .  Weights were measured at baseline and at 3 and 6 months . Additionally , self-report use of access modes was collected at 3 and 6 months . RESULTS Participants in the WW condition significantly decreased their body mass index at 6 months ( F = 36.7 , P < .001 ) and were 8.0 and 8.8 times more likely to achieve a 5 % and 10 % reduction in weight , respectively , compared with those in the self-help condition . In a secondary analysis , high usage of all 3 access modes result ed in the greatest weight loss ( P < .001 ) . CONCLUSION Use of the WW program yielded significantly greater weight loss than a self-help approach , suggesting it is a viable community-based provider of weight loss treatment , as recommended by the USPSTF . Further , high usage of 3 access modes was associated with greater weight loss results For years , physicians and their patients have decided , on an individual basis , whether or not to use a prostate-specific antigen ( PSA ) screening test , which can detect not only life-threatening prostate cancer but also many cancers that may never pose a danger . No clear evidence exists for whether the test provides more benefit or harm , given the aggressive treatments that often follow a positive cancer diagnosis , and so patients and physicians face a difficult choice about whether to use the test . Without definitive data , the U.S. Preventive Services Task Force ( USPSTF ) , part of the federal Agency for Healthcare Research and Quality , issued guidelines in 1996 and again in 2002 that said it can not recommend for or against PSA testing . Many other organizations that provide guidance to physicians ordering PSA tests — such as the American Cancer Society , the American College of Physicians , and the American Academy of Family Physicians (AAFP)—also adopted this position . Despite the lack of evidence , the PSA test became popular , especially for older men . In 2006 , more than 58 % of men aged 50–59 years had a PSA test within the past 2 years , according to prevalence data compiled by the U.S. Centers for Disease Control and Prevention . Older men used the test much more often . The Centers for Disease Control reported that 72 % of men aged 60–64 years had had a PSA test , and for men aged 65 years and older , it was almost 77 % . PSA testing has also led to unprecedented rates of treatment for prostate cancer : More than 90 % of men diagnosed with the disease receive some form of treatment , even though many research ers believe that most prostate cancer cases will never become a health issue . Only about one-sixth of patients diagnosed with prostate cancer ultimately succumb to the disease , but there is no way currently to identify which prostate cancers should be treated aggressively . Now , citing new findings , the USPSTF has recommended that men aged 75 years and older not be screened with the PSA test , and it reiterates that the benefits of the test are still unproven in younger ages . The USPSTF laid out its recommendations in the August 5 issue of the Annals of Internal Medicine , saying that men who have a life expectancy of 10 or fewer years would suffer more immediate harm than long-term benefit from the consequences of a PSA screening test . U.S. population figures show that most men do n't live beyond age 85 . About 71 % of deaths from prostate cancer occurred in men older than 75 years . And because dying from prostate cancer once it is diagnosed often takes at least a decade , men this age will probably die from other causes before the cancer kills them . Therefore , task force members say age 75 years should be the cutoff for prostate cancer screening . But some physicians predict that the USPSTF 's revised guideline will generally be ignored — particularly by urologists — for a variety of reasons , including fears of age discrimination , ingrained medical practice , and health care economics . The new guidelines are “ underst and able and reasonable ” when one considers that there are no r and omized clinical trials that have yet demonstrated a mortality benefit to men who were screened with PSA or digital rectal exams at any age , said Peter Scardino , M.D. , chairman of the department of surgery at Memorial Sloan-Kettering Cancer Center . “ From a public health point of view , screening has not been proven . But what makes sense in theory may not in practice , ” Scardino said . “ If an older man comes in and says he wants a PSA test , I think any doctor will agree to it . ” “ The USPSTF guidelines , for the most part , have been received with indifference by the clinical community , in my opinion , ” said David Penson , M.D. , a urologist at the University of Southern California . Establishing an age-specific cutoff time is “ arbitrary and unfair and might deny men a potentially beneficial intervention , ” he said . In any case , “ the proverbial cat is out of the bag , ” Penson said . “ One of the biggest issues that clinicians face is that patients dem and prostate cancer screening , regardless of their age . It is difficult to convince patients otherwise , even if it is absolutely clear that they will not benefit from screening . Background To determine the effectiveness of a single checklist reminder form to improve the delivery of preventive health services at adult health check-ups in a family practice setting . Methods A prospect i ve cluster r and omized controlled trial was conducted at four urban family practice clinics among 38 primary care physicians affiliated with the University of Toronto .  Preventive Care Checklist Forms © were created to be used by family physicians at adult health check-ups over a five-month period . The sex-specific forms incorporate evidence -based recommendations on preventive health services and documentation space for routine procedures such as physical examination . The forms were used in two intervention clinics and two control clinics . Rates and relative risks ( RR ) of the performance of 13 preventive health maneuvers at baseline and post-intervention and the percentage of up-to- date preventive health services delivered per patient were compared between the two groups . Results R and omly-selected charts were review ed at baseline ( n = 509 ) and post-intervention ( n = 608 ) . Baseline rates for provision of preventive health services ranged from 3 % ( fecal occult blood testing ) to 93 % ( blood pressure measurement ) , similar to other setting s. The percentage of up-to- date preventive health services delivered per patient at the end of the intervention was 48.9 % in the control group and 71.7 % in the intervention group . This is an overall 22.8 % absolute increase ( p = 0.0001 ) , and 46.6 % relative increase in the delivery of preventive health services per patient in the intervention group compared to controls . Eight of thirteen preventive health services showed a statistically significant change ( p < 0.05 ) in favor of the intervention ( adjusted RR ( 95 % C.I. ) ) :  counseling on brushing/flossing teeth  ( 9.2 ( 4.3–19.6 ) ) ,  folic acid counseling  ( 7.5 ( 2.7–20.8 ) ) , fecal occult blood testing ( 6.7 ( 1.9–24.1 ) ) , smoking cessation counseling ( 3.9 ( 2.2–7.2 ) ) , tetanus immunization ( 3.0 ( 1.7–5.2 ) ) , history of alcohol intake ( 1.33 ( 1.2–1.5 ) ) , history of smoking habits ( 1.28 ( 1.2–1.4 ) ) and blood pressure measurement ( 1.05 ( 1.00–1.10 ) ) . Conclusion This simple , low cost , clinical ly relevant intervention improves the delivery of preventive health services by prompting physicians of evidence -based recommendations in a checklist format that incorporates existing practice patterns . Periodic up date s of the Preventive Care Checklist Forms © will allow a feasible and easy-to-use tool for primary care physicians to provide evidence -based preventive health services to adults at routine health check-ups . The forms can also be incorporated into an electronic health record . The Preventive Care Checklist Forms © are accessible in English and French at the College of Family Physicians of Canada web site BACKGROUND The long-term effect of most interventions has not been studied . Changes due to interventions to improve patient care may revert to baseline after the intervention stimulus ends . This analysis reports the 24-month follow-up of a practice -tailored intervention to increase preventive service delivery rates . DESIGN Group r and omized clinical trial with 24-month follow-up of intervention sites . SETTING / PARTICIPANTS Seventy-seven community family practice s in northeast Ohio . INTERVENTION Practice -individualized facilitation of implementation of tools and approaches . MAIN OUTCOME MEASURES Summary scores of health habit counseling , screening , and immunization services recommended by the U.S. Preventive Services Task Force that were up to date for consecutive patients during r and omly selected chart review days . RESULTS Previously reported increases in global preventive service delivery rates , health habit counseling , and screening rates at 12 months were sustained after 24 months . CONCLUSIONS A practice -individualized approach can result in sustainable increases in rates of preventive service delivery , even 1 year after the outside intervention stimulus ends . Tailoring of approaches to the unique characteristics of each practice may result in institutionalization of changes Summary of the Recommendations The U.S. Preventive Services Task Force ( USPSTF ) recommends screening adults for depression in clinical practice s that have systems in place to assure accurate diagnosis , effective treatment , and follow-up . This is a grade B recommendation . ( See Appendix Table 1 for a description of the USPSTF classification of recommendations . ) Appendix Table 1 . U.S. Preventive Services Task Force Grade s and Recommendations The USPSTF found good evidence that screening improves the accurate identification of depressed patients in primary care setting s and that treatment of depressed adults identified in primary care setting s decreases clinical morbidity . ( See Appendix Table 2 for a description of the USPSTF classification of levels of evidence . ) Trials that have directly evaluated the effect of screening on clinical outcomes have shown mixed results . Small benefits have been observed in studies that simply feed back screening results to clinicians . Larger benefits have been observed in studies in which the communication of screening results is coordinated with effective follow-up and treatment . The USPSTF concluded the benefits of screening are likely to outweigh any potential harms . Appendix Table 2 . U.S. Preventive Services Task Force Grade s for Strength of Overall Evidence The USPSTF concludes the evidence is insufficient to recommend for or against routine screening of children or adolescents for depression . This is a grade I recommendation . The USPSTF found limited evidence on the accuracy and reliability of screening tests in children and adolescents and limited evidence on the effectiveness of therapy in children and adolescents identified in primary care setting s. Clinical Considerations Many formal screening tools are available ( for example , the Zung Self-Depression Scale , Beck Depression Inventory , General Health Question naire , and Center for Epidemiologic Study Depression Scale ) ( 1 , 2 ) . Asking two simple questions about mood and anhedonia ( Over the past 2 weeks , have you felt down , depressed , or hopeless ? and Over the past 2 weeks , have you felt little interest or pleasure in doing things ? ) may be as effective as using longer instruments ( 3 ) . There is little evidence to recommend one screening method over another , so clinicians can choose the method that best fits their personal preference , the patient population served , and the practice setting . All positive screening tests should trigger full diagnostic interviews that use st and ard diagnostic criteria ( for example , those from the fourth edition of Diagnostic and Statistical Manual of Mental Disorders ) to determine the presence or absence of specific depressive disorders , such as major depression or dysthymia ( 4 ) . The severity of depression and comorbid psychological problems ( for example , anxiety , panic attacks , or substance abuse ) should be addressed . Many risk factors for depression ( such as female sex , family history of depression , unemployment , and chronic disease ) are common , but the presence of risk factors alone can not distinguish depressed from nondepressed patients . The optimal interval for screening is unknown . Recurrent screening may be most productive in patients with a history of depression , unexplained somatic symptoms , comorbid psychological conditions ( such as panic disorder or generalized anxiety ) , substance abuse , or chronic pain . Clinical practice s that screen for depression should have systems in place to ensure that positive screening results are followed by accurate diagnosis , effective treatment , and careful follow-up . Benefits from screening are unlikely to be realized unless such systems are functioning well . Treatment may include antidepressants or specific psychotherapeutic approaches ( for example , cognitivebehavioral therapy or brief psychosocial counseling ) , alone or in combination . The benefits of routinely screening children and adolescents for depression are not known . The existing literature suggests that screening tests perform reasonably well in adolescents and that treatments are effective , but the clinical impact of routine depression screening has not been studied in pediatric population s in primary care setting s. Clinicians should remain alert for possible signs of depression in younger patients . The predictive value of positive screening tests is lower in children and adolescents than in adults , and research on the effectiveness of primary carebased interventions for depression in this age group is limited . Scientific Evidence Epidemiology and Clinical Consequences Depressive disorders are common , chronic , and costly . The World Health Organization identified major depression as the fourth leading cause of worldwide disease in 1990 , causing more disability than either ischemic heart disease or cerebrovascular disease ( 5 ) . In primary care setting s , the point prevalence of major depression ranges from 5 % to 9 % among adults , and up to 50 % of depressed patients are not recognized ( 6 , 7 ) . Other disabling depressive illnesses include dysthymia ( a chronic low- grade depression ) and minor depression ( an episodic , less severe illness ) . These two illnesses are as common as major depression in primary care setting s.  Depressive disorders  are also relatively common in younger persons , with estimated prevalences of 0.8 % to 2.0 % in children and 4.5 % in adolescents . Accuracy and Reliability of Screening Tests Several depression screening instruments are available ; most instruments have relatively good sensitivity ( 80 % to 90 % ) but only fair specificity ( 70 % to 85 % ) ( 2 ) . Most instruments are easy to use and can be administered in less than 5 minutes . Shorter screening tests , including simply asking questions about depressed mood and anhedonia , appear to detect a majority of depressed patients and , in some cases , perform better than the original instrument from which they were derived ( 3 ) . Assuming optimal test performance and a prevalence of major depression of 5 % to 10 % in primary care setting s , about 24 % to 40 % of patients who screen positive will have major depression . Some patients with false-positive results on screening may have dysthymia or subsyndromal depressive disorders that might benefit from treatment or closer monitoring ; others may have comorbid disorders such as anxiety disorder , substance abuse , panic disorder , post-traumatic stress disorder , or grief reactions ; still others may have no disorder at all . The finding of a positive screen therefore requires further diagnostic question ing by the clinician to establish an appropriate diagnosis and initiate a plan for treatment and follow-up . Screening instruments have been tested in children and adolescents , with sensitivity ranging from 40 % to 100 % and specificity from 49 % to 100 % . Because the underlying prevalence is much lower than in adults , the positive predictive value is low . Effectiveness of Early Treatment Effective treatments are available for patients with depressive illnesses detected in primary care setting s ( 1 , 8) . Antidepressant medications for major depression , including tricyclic antidepressants and selective serotonin reuptake inhibitors , are clearly more effective than placebo . Most of the data supporting effectiveness come from structured trials with selected population s , although more recent studies using usual care comparison groups and real-world setting s have produced similar effects . Newer agents perform similarly to older agents . Psychosocial and psychotherapeutic interventions are probably as effective as antidepressant medications for major depression , but they are clearly more time-intensive ( 7 ) . The benefits of psychotherapy for other depressive illnesses are less well studied . Few studies have examined the effect of combining medications and psychotherapy . No studies have examined treatment outcomes for  children or adolescents  identified by primary care clinicians through screening . Evidence for treating adolescents comes from school and community setting s where selective serotonin reuptake inhibitors and cognitivebehavioral therapy , but not tricyclic antidepressants , appear to be effective . Whether these results can be generalized to primary care setting s or to children is unclear . Effectiveness of Screening The review for the USPSTF identified 14 r and omized , controlled trials that have examined the effectiveness of screening for depression in primary care setting s ( 9 ) . In 8 studies , the only intervention was feedback of screening results to clinicians ; remaining studies combined feedback with other interventions for patients or clinicians . The trials reported various outcomes , including recognition of depression , rates of treatment , and clinical improvement among patients with depression . In 7 trials , routine depression screening with feedback of screening results to providers generally increased recognition of depression , especially major depression , by a factor of two to three compared with usual care . Trials that examined the effect of feedback of screening results on the proportion of depressed patients who received treatment showed mixed results : In 4 fair- to good- quality trials that used feedback alone , there was no significant effect on treatment rates , but 4 of the 5 trials that combined feedback with treatment advice or other system supports reported increased treatment rates in the intervention group compared with usual care . Ten trials measured the effect of  screening and feedback on depression outcomes from 1 month to 2 years after the intervention . Five of these 10 studies reported significant improvements in the clinical outcomes of depressed patients , and 3 others reported improvements that did not reach statistical significance . All three trials that compared the effects of integrated recognition and management programs with usual care in community primary care practice s showed significantly improved patient outcomes . Integrated programs included feedback , provider or patient education , access to When the GUIDE TO COMMUNITY PREVENTIVE SERVICES :  Systematic Review s and Evidence -Based Recommendations ( the Guide ) is published in 2001 , it will represent a significant national effort in encouraging evidence -based public health practice in defined population s ( e.g. , communities or members of specific managed care plans ) . The Guide will make recommendations regarding public health interventions to reduce illness , disability , premature death , and environmental hazards that impair community health and quality of life . The Guide is being developed under the guidance of the Task Force on Community Preventive Services ( the Task Force)-a 15-member , nonfederal , independent panel of experts . Subject matter experts , method ologists , and scientific staff are supporting the Task Force in using explicit rules to conduct systematic literature review s of evidence of effectiveness , economic efficiency , and feasibility on which to base recommendations for community action . Contributors to the Guide are building on the experience of others to confront method ologic challenges unique to the assessment of complex multicomponent intervention studies with nonexperimental or nonr and omized design s and diverse measures of outcome and effectiveness . Persons who plan , fund , and implement population -based services and policies to improve health at the state and local levels are invited to scrutinize the work in progress and to communicate with contributors . When the Guide is complete , readers are encouraged to consider critically the value and relevance of its contents , the implementation of interventions the Task Force recommends , the ab and onment of interventions the Task Force does not recommend , and the need for rigorous evaluation of the benefits and harms of promising interventions of unknown effectiveness Background Unhealthy alcohol use is a major contributor to the global burden of disease and injury . The US Preventive Services Task Force has recommended alcohol screening and intervention in general medical setting s since 2004 . Yet less than one in six US adults report health care professionals discussing alcohol with them . Little is known about methods for increasing implementation ; different staffing models may be related to implementation effectiveness . This implementation trial compared delivery of alcohol screening , brief intervention and referral to specialty treatment ( SBIRT ) by physicians versus non-physician providers receiving training , technical assistance , and feedback reports . Methods The study was a cluster r and omized implementation trial ( ADVISe [ Alcohol Drinking as a Vital Sign ] ) . Within a private , integrated health care system , 54 adult primary care clinics were stratified by medical center and r and omly assigned in blocked groups of three to SBIRT by physicians ( PCP arm ) versus non-physician providers and medical assistants ( NPP and MA arm ) , versus usual care ( Control arm ) . NIH-recommended screening questions were added to the electronic health record ( EHR ) to facilitate SBIRT . We examined  screening  and brief intervention and referral rates by arm . We also examined patient- , physician- , and system-level factors affecting screening rates and , among those who screened positive , rates of brief intervention and referral to treatment . Results Screening rates were highest in the NPP and MA arm ( 51 % ) ; followed by the PCP arm ( 9 % ) and the Control arm ( 3.5 % ) . Screening increased over the 12 months after training in the NPP and MA arm but remained stable in the PCP arm . The PCP arm had higher brief intervention and referral rates ( 44 % ) among patients screening positive than either the NPP and MA arm ( 3.4 % ) or the Control arm ( 2.7 % ) . Higher ratio of MAs to physicians was related to higher screening rates in the NPP and MA arm and longer appointment times to screening and intervention rates in the PCP arm . Conclusion Findings suggest that time frames longer than 12 months may be required for full SBIRT implementation . Screening by MAs with intervention and referral by physicians as needed can be a feasible model for increasing the implementation of this critical and under-utilized preventive health service within currently predominant primary care models . Trial registration : Clinical Trials Importance An abdominal aortic aneurysm ( AAA ) is typically defined as aortic enlargement with a diameter of 3.0 cm or larger . The prevalence of AAA has declined over the past 2 decades among screened men 65 years or older in various European countries . The current prevalence of AAA in the United States is unclear because of the low uptake of screening . Most AAAs are asymptomatic until they rupture . Although the risk for rupture varies greatly by aneurysm size , the associated risk for death with rupture is as high as 81 % . Objective To up date its 2014 recommendation , the USPSTF commissioned a review of the evidence on the effectiveness of 1-time and repeated screening for AAA , the associated harms of screening , and the benefits and harms of available treatments for small AAAs ( 3.0 - 5.4 cm in diameter ) identified through screening . Population This recommendation applies to asymptomatic adults 50 years or older . However , the r and omized trial evidence focuses almost entirely on men aged 65 to 75 years . Evidence Assessment Based on a review of the evidence , the USPSTF concludes with moderate certainty that screening for AAA in men aged 65 to 75 years who have ever smoked is of moderate net benefit . The USPSTF concludes with moderate certainty that screening for AAA in men aged 65 to 75 years who have never smoked is of small net benefit . The USPSTF concludes that the evidence is insufficient to determine the net benefit of screening for AAA in women aged 65 to 75 years who have ever smoked or have a family history of AAA . The USPSTF concludes with moderate certainty that the harms of screening for AAA in women aged 65 to 75 years who have never smoked and have no family history of AAA outweigh the benefits . Recommendations The USPSTF recommends 1-time screening for AAA with ultrasonography in men aged 65 to 75 years who have ever smoked . ( B recommendation ) The USPSTF recommends that clinicians selectively offer screening for AAA with ultrasonography in men aged 65 to 75 years who have never smoked rather than routinely screening all men in this group . ( C recommendation ) The USPSTF recommends against routine screening for  AAA  with ultrasonography in women who have never smoked and have no family history of AAA . ( D recommendation ) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for AAA with ultrasonography in women aged 65 to 75 years who have ever smoked or have a family history of AAA . ( I statement ) Last winter , the U.S. Preventive Services Task Force ( USPSTF ) gave a positive recommendation ( B grade ) for  lung cancer screening with low-dose computed tomography . The recommendation applies to high-risk adults aged 55 to 80 years with a smoking history of at least 30 pack-years who are still smoking or have quit within the past 15 years ( 1 ) . The USPSTF based its recommendation on the l and mark National Lung Screening Trial ( NLST ) ( 2 ) , which provided evidence about the efficacy of screening but did not answer questions about effectiveness when implemented in everyday clinical practice . The recommendation , as noted in an accompanying editorial , leaves many of these critical issues unaddressed ( 3 ) . Indeed , the Medicare Evidence Development & Coverage Advisory Committee recently concluded that there was inadequate evidence to recommend national coverage for lung cancer screening ( 4 ) . This conclusion highlights the controversy over what constitutes sufficient evidence to support widespread implementation of a new technology . It has also heightened the tension between advocates who are eager to see wide deployment of screening quickly and others who are concerned about the ability of health care systems to provide a low-dose computed tomography screening program to the potentially large number of patients meeting criteria while still minimizing harms ( 4 ) . That a new intervention can work in r and omized trials does not guarantee that it will work as well when delivered in real-world practice , nor that the benefits in the community will justify the possible harms and costs ( including opportunity costs ) . Should these unanswered questions delay implementation of screening pending further study , or do the potential benefits compel their early adoption ? A middle-ground approach between early adoption and waiting years for more conclusive evidence is to carefully plan and evaluate a comprehensive approach to lung cancer screening , including a staged and limited implementation and evaluation program before broader implementation . The Veterans Health Administration ( VHA ) , the nation 's largest integrated health care system , has chosen this approach by developing a 2-year clinical demonstration project involving 8 VHA medical centers that serve more than 500000 veterans . This decision is based on some of the uncertainties , as outlined by the Medicare Evidence Development & Coverage Advisory Committee , as well as questions about the effect of screening on our patients , our staff , and our system . At the same time , the compelling results of NLST and high burden of smoking and lung cancer among veterans argue against a wait- and -see approach . Before committing to widespread screening , we want to determine the following : Can we effectively identify the right c and i date s to offer screening in the course of routine care ? What will the uptake of screening be and what re sources ( both technology and people ) are needed to meet that dem and ? Can we provide screening and follow-up ( including for the many patients with benign nodules ) with accuracy , efficiency , and safety similar to that achieved in the NLST ? Are the overall outcomes in our patients with early-stage cancer ( especially those who are older with more comorbid conditions ) compatible with a benefit of early detection ? To ensure that all veterans benefit , and not just those who request them , the VHA takes a proactive approach to all preventive programs . It is critically important to learn how to do this efficiently and effectively . At demonstration sites , annual screening will be provided , as recommended by the USPSTF . Full-time coordinators hired for the project will provide clinical coordination for patients who choose to be screened , using newly developed tracking tools and data bases . Structure , process , and outcome measures have been developed using quantitative and qualitative data from clinical data in electronic medical records , regular reports from pilot sites , quality assessment s of radiology reports , surveys and interviews of key clinical staff , and cost estimates for the screening program ( 5 ) . Clinical data include demographic characteristics , smoking history , and health status of those screened ; descriptions of identified nodules ; numbers and types of scans and other procedures performed initially and to evaluate abnormal findings ; adverse events from invasive procedures ; numbers and types of incidental findings and their follow-up ; and lung cancer cases diagnosed . These data will help assess whether the predominantly older , male VHA population with several chronic conditions has different outcomes with screening from those of the younger , healthier NLST population . At its conclusion , the project team will make recommendations about the processes and re sources needed for wider VHA dissemination of a lung cancer screening program and , if deemed feasible , appropriate metrics to monitor the process going forward . This quality improvement project , which is design ed to assess implementation , will not be able to determine the effect of screening on mortality rates . However , it will help determine whether the VHA can provide high- quality screening while minimizing possible harms , whether outcomes vary by site or patient group , and what re sources would be needed for national implementation . The VHA faces challenges in taking the time to implement screening in a limited way . Public interest in lung cancer screening has helped prompt individual screening programs at many VHA medical centers outside the demonstration project , potentially creating inconsistencies across the organization . Even if the demonstration project is successful , VHA-wide implementation of lung cancer screening will be challenging for a system of 151 medical centers of varying size and capacity , and it will require new processes to monitor quality , ensure adequate capacity , and track outcomes . The complexity of such a program can not be underestimated . In addition , we will need to be careful that a focus on implementation of a screening program does not detract attention from a far more effective means of reducing lung cancer deaths : smoking cessation interventions . The VHA 's experience with implementation of a lung cancer screening program may provide valuable lessons learned for other large health care organizations . This extends beyond the screening registries required by many proponents of screening ( 6 , 7 ) to the development of tools for patient identification , data collection , quality assessment , and patient education . The VHA 's population and its payment structure may limit the generalizability of our experience , but we believe that documenting the VHA 's demonstration project 's challenges , successes , and failures may help the U.S. health care system decrease the morbidity and mortality rates due to lung cancer in a way that provides the best balance between benefits and harms Despite recent declines in both incidence and mortality ( 1 ) , colorectal cancer remains the second most common cause of death from cancer in the United States ( 2 ) . Screening for colorectal cancer reduces mortality by allowing physicians to detect cancer at earlier , more treatable stages , as well as to identify and remove adenomatous polyps ( asymptomatic benign precursor lesions that may lead to colorectal cancer ) . Many tests are available for screening , such as fecal occult blood tests ( FOBTs ) , flexible sigmoidoscopy , and colonoscopy . Screening with FOBT ( Hemoccult II , Beckman Coulter , Fullerton , California ) has been shown to reduce colorectal cancer mortality by 15 % to 33 % in r and omized , controlled trials ( 35 ) , and screening with more sensitive FOBTs , flexible sigmoidoscopy , colonoscopy , or combinations of these tests may reduce the burden of colorectal cancer even more ( 6 , 7 ) . In the absence of adequate clinical trial data on several recommended screening strategies , microsimulation modeling can provide guidance on the risks , benefits , and testing re sources required for different screening strategies to reduce the burden of colorectal cancer . In July 2002 , the U.S. Preventive Services Task Force ( USPSTF ) concluded that there was sufficient evidence to recommend strongly that all average-risk adults 50 years of age or older should be offered colorectal cancer screening ( 8) . However , the logistics of screening , such as the type of screening test , screening interval , and age at which to stop screening , were not evaluated in terms of the balance of benefits and potential harms . The USPSTF has again addressed recommendations for colorectal cancer screening with a systematic review of the evidence ( 9 ) on screening tests . For this assessment , the USPSTF requested a decision analysis to project expected outcomes of various strategies for colorectal cancer screening . Two independent microsimulation modeling groups from the Cancer Intervention and Surveillance Modeling Network ( CISNET ) , funded by the National Cancer Institute , used a comparative modeling approach to compare life-years gained relative to re source use of different strategies for colorectal cancer screening . Methods We used 2 microsimulation models  , MISCAN ( MIcrosimulation Screening Analysis ) ( 1012 ) and SimCRC ( Simulation Model of Colorectal Cancer ) ( 13 ) , to estimate the life-years gained relative to no screening and the colonoscopies required ( that is , an indicator for re source use and risk for complications ) for different colorectal cancer screening strategies defined by test , age at which to begin screening , age at which to stop screening , and screening interval . We aim ed to identify a set of recommendable strategies with similar clinical benefit and an efficient use of colonoscopy re sources . Using 2 models ( that is , a comparative modeling approach ) adds credibility to the results and serves as a sensitivity analysis on the underlying structural assumptions of the models , particularly pertaining to the unobservable natural history of colorectal cancer . Microsimulation Models The Appendix describes the MISCAN and SimCRC models , and st and ardized model profiles are available at cisnet.cancer.gov/profiles/. In brief , both models simulate the life histories of a large population of individuals from birth to death . As each individual ages , there is a chance that an adenoma will develop . One or more adenomas can occur in an individual , and each adenoma can independently develop into pre clinical ( that is , undiagnosed ) colorectal cancer ( Figure 1 ) . The risk for developing an adenoma depends on age , sex , and baseline individual risk . The models track the location and size of each adenoma ; these characteristics influence disease progression and the chance that the adenoma will be found by screening . The size of adenomas can progress from small ( 5 mm ) to medium ( 6 to 9 mm ) to large ( 10 mm ) . Some adenomas eventually become malignant , transforming to stage I pre clinical cancer . Pre clinical cancer has a chance of progressing through stages I to IV and may be diagnosed by symptoms at any stage . Survivorship after diagnosis depends on the stage of disease . Figure 1 . Natural history of disease as modeled by the Microsimulation Screening Analysis and Simulation Model of Colorectal Cancer models . The opportunity to intervene in the natural history through screening is noted . The natural history component of each model was calibrated to 19751979 clinical incidence data ( 14 ) and adenoma prevalence from autopsy studies in the same period ( 1524 ) . We used this period because incidence rates and adenoma prevalence had not yet been affected by screening . We corrected the adenoma prevalence for studies of non-U.S. population s by using st and ardized colorectal cancer incidence ratios . The models use all-cause mortality estimates from the U.S. life tables and stage-specific data on colorectal cancer survival from the 19961999 Surveillance , Epidemiology , and End Results program ( 14 ) . Table 1 compares outcomes from the natural history components of the models . Table 1 . Comparison of the Natural History Outcomes from the Microsimulation Screening Analysis ( MISCAN ) and Simulation Model of Colorectal Cancer ( SimCRC ) Models The effectiveness of a screening strategy is modeled through a test 's ability to detect lesions ( that is , adenomas or pre clinical cancer ) . Once screening is introduced , a simulated person who has an underlying lesion has a chance of having it detected during a screening round depending on the sensitivity of the test for that lesion and whether the lesion is within the reach of the test . Screened persons without an underlying lesion can have a false-positive test result and undergo unnecessary follow-up colonoscopy . Hyperplastic polyps are not modeled explicitly , but their detection is reflected in the specificity of the screening tests . The models incorporate the risk for fatal complications associated with perforation during colonoscopy . Both models have been vali date d against the long-term reductions in incidence and mortality of colorectal cancer with annual FOBT reported in the Minnesota Colon Cancer Control Study ( 3 , 25 , 26 ) and show good concordance with the trial results . Strategies for Colorectal Cancer Screening In consultation with the USPSTF , we included the following basic strategies : 1 ) no screening , 2 ) colonoscopy , 3 ) FOBT ( Hemoccult II , Hemoccult SENSA [ Beckman Coulter ] , or fecal immunochemical testing ) , 4 ) flexible sigmoidoscopy ( with biopsy ) , and 5 ) flexible sigmoidoscopy combined with Hemoccult SENSA . For each basic strategy , we evaluated start ages of 40 , 50 , and 60 years and stop ages of 75 and 85 years . For the FOBT strategies , we considered screening intervals of 1 , 2 , and 3 years , and for the sigmoidoscopy and colonoscopy strategies , we considered intervals of 5 , 10 , and 20 years . These variations result ed in 145 strategies : 90 single-test strategies , 54 combination-test strategies , and 1 no-screening strategy . The stop age reflects the oldest possible age at which to screen , but the actual stopping age is dictated by the start age and screening interval . In the base case , we assumed 100 % adherence for screening tests , follow-up of positive findings , and surveillance of persons found to have adenomas . Individuals with a positive FOBT result or with an adenoma detected by sigmoidoscopy were referred for follow-up colonoscopy . For years in which both tests were due for the combined strategy , the FOBT was performed first ; if the result was positive , the patient was referred for follow-up colonoscopy . In those years , flexible sigmoidoscopy was done only for patients with a negative FOBT result . If findings on follow-up colonoscopy were negative , the individual was assumed to undergo subsequent screening with colonoscopy with a 10-year interval ( as long as results of the repeated colonoscopy were negative ) and did not return to the initial screening schedule , as is the recommendation of the U.S. Multi-Society Task Force and American Cancer Society ( 7 , 27 ) . All individuals with an adenoma detected were followed with colonoscopy surveillance per the Multi-Society guidelines ( 27 , 28 ) . The surveillance interval depended on the number and size of the adenomas detected on the last colonoscopy ; it ranged from 3 to 5 years and was assumed to continue for the remainder of the person 's lifetime . We estimated the test characteristics of colorectal cancer screening from a review of the available literature ( Table 2 ) ( 29 ) . We conducted this review independently of and parallel in time with the systematic evidence review performed for the USPSTF ( 9 ) . Table 2 . Test Characteristics Used in the Microsimulation Screening Analysis and Simulation Model of Colorectal Cancer Models Evaluation of Outcomes Determination of Efficient Strategies The most effective strategy was defined as the one with the greatest life-years gained relative to no screening . However , it is important to consider the relative intensity of test use required to achieve those gains . The more effective strategies tended to be associated with more colonoscopies on average in a person 's lifetime , which translated into an increased risk for colonoscopy-related complications . We used an approach that mirrors that of cost-effectiveness analysis ( 30 ) to identify the set of efficient , or dominant , strategies within each test category . A strategy was considered dominant when no other strategy or combination of strategies provided more life-years with the same number of colonoscopies . We conducted this analysis separately for each of the 5 basic screening strategies because the number of noncolonoscopy tests differed by strategy . We then ranked the efficient screening strategies by increasing effectiveness and calculated the incremental number of colonoscopies ( COL ) per 1000 , the incremental life-years gained ( LYG ) per 1000 , and the incremental number of colonoscopies necessary to achieve 1 year of life ( Among over 5million people in the USA with dementia , neuropsychiatric symptoms ( NPS ) are almost universal , occurring across disease etiology and stage . If untreated , NPS can lead to significant morbidity and mortality including increased cost , distress , depression , and faster disease progression , as well as heightened burden on families . With few pharmacological solutions , identifying nonpharmacologic strategies is critical . We describe a r and omized clinical trial , the Dementia Behavior Study , to test the efficacy of an activity program to reduce significant existing NPS and associated caregiver burden at 3 and 6months compared to a control group intervention . Occupational therapists deliver 8 in-home sessions over 3months to assess capabilities and interests of persons with dementia , home environments , and caregiver knowledge , and readiness from which activities are developed and families trained in their use . Families learn to modify activities for future declines and use strategies to address care challenges . The comparison group controls for time and attention and involves 8 in-home sessions delivered by health educators who provide dementia education , home safety recommendations , and advanced care planning . We are r and omizing 250 racially diverse families ( person with dementia and primary caregiver dyads ) recruited from community-based social services , conferences and media announcements . The primary outcome is change in agitation/aggression at 3 and 6months . Secondary outcomes assess quality of life of persons with dementia , other behaviors , burden and confidence of caregivers , and cost and cost effectiveness . If benefits are supported , this activity intervention will provide a clinical ly meaningful approach to prevent , reduce , and manage NPS
Sensitivity analysis indicates that from both perspectives the service is very cost effective and may be cost saving .
CONCLUSIONS These results make alcohol screening and counseling one of the highest-ranking preventive services among the 25 effective services evaluated using st and ardized methods .
BACKGROUND The U.S. Preventive Services Task Force ( USPSTF ) has recommended screening and behavioral counseling interventions in primary care to reduce alcohol misuse .
This study was design ed to develop a st and ardized rating for the clinical ly preventable burden and cost effectiveness of complying with that recommendation that would allow comparisons across many recommended services .