Jessica Herzstein

Screening for Depression in Adults: US Preventive Services Task Force Recommendation Statement

DESCRIPTION Update of the 2009 US Preventive Services Task Force (USPSTF) recommendation on screening for depression in adults. METHODS The USPSTF reviewed the evidence on the benefits and harms of screening for depression in adult populations, including older adults and pregnant and postpartum women; the accuracy of depression screening instruments; and the benefits and harms of depression treatment in these populations. POPULATION This recommendation applies to adults 18 years and older. RECOMMENDATION The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. (B recommendation).

Screening for High Blood Pressure in Adults: U.S. Preventive Services Task Force Recommendation Statement

DESCRIPTION Update of the 2007 U.S. Preventive Services Task Force (USPSTF) reaffirmation recommendation statement on screening for high blood pressure in adults. METHODS The USPSTF reviewed the evidence on the diagnostic accuracy of different methods for confirming a diagnosis of hypertension after initial screening and the optimal rescreening interval for diagnosing hypertension. POPULATION This recommendation applies to adults aged 18 years or older without known hypertension. RECOMMENDATION The USPSTF recommends screening for high blood pressure in adults aged 18 years or older. (A recommendation) The USPSTF recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment.

Screening for Vitamin D Deficiency in Adults: U.S. Preventive Services Task Force Recommendation Statement

DESCRIPTION New USPSTF recommendation on screening for vitamin D deficiency in adults. METHODS The USPSTF reviewed the evidence on screening for and treatment of vitamin D deficiency, including the benefits and harms of screening and early treatment. POPULATION This recommendation applies to community-dwelling, nonpregnant adults aged 18 years or older who are seen in primary care settings and are not known to have signs or symptoms of vitamin D deficiency or conditions for which vitamin D treatment is recommended. RECOMMENDATION The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for vitamin D deficiency in asymptomatic adults. (I statement).

Screening for Oral Cancer: U.S. Preventive Services Task Force Recommendation Statement

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 understand 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 concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for oral cancer in asymptomatic adults. (I statement) See the Clinical Considerations section for additional information and suggestions for practice regarding the I statement. See the Figure for a summary of the recommendation and suggestions for clinical practice. Figure. Screening for oral cancer: clinical summary of U.S. Preventive Services Task Force recommendation. Appendix Table 1 describes the USPSTF grades, and Appendix Table 2 describes the USPSTF classification of levels of certainty about net benefit (both tables are available at www.annals.org). Appendix Table 1. What the USPSTF Grades Mean and Suggestions for Practice Appendix Table 2. USPSTF Levels of Certainty Regarding Net Benefit Supplement. Consumer Fact Sheet Rationale Importance Oral cavity cancer (or oral cancer) and pharyngeal cancer include cancer of the lip, oral cavity, and pharynx (nasopharynx, oropharynx, and laryngopharynx). Ninety percent of all cases of oral cavity and pharyngeal cancer are classified as squamous cell carcinoma (1). An estimated 41 380 new cases of and 7890 deaths from cancer of the oral cavity and pharynx will occur in 2013 (2). At the time of diagnosis, more than 50% of persons with oral and pharyngeal cancer have regional or distant metastases (3). Screening for oral cancer may be helpful if potentially malignant disorders can be identified earlier and treated successfully. Oral and oropharyngeal cancer have different causes. Oral cavity cancer is predominantly caused by tobacco and alcohol use. Oropharyngeal cancer, another subset of neck and head cancer, includes human papillomavirus (HPV) as an important risk factor. The incidence and mortality rate of oral cancer has been decreasing in the United States, presumably because of reduced tobacco and alcohol use. However, HPV-related oropharyngeal cancer is increasing in incidence. Oropharyngeal cancer includes lesions of the tonsil, oropharynx, and base of the tongue. The epidemiology of HPV-related oropharyngeal cancer is evolving and could have important implications for identifying high-risk populations that might benefit from screening. Detection The USPSTF found inadequate evidence that the oral screening examination accurately detects oral cancer. Benefits of Detection and Early Treatment The USPSTF found inadequate evidence that screening for oral cancer and treatment of screen-detected oral cancer improves morbidity or mortality. Harms of Detection and Early Treatment The USPSTF found inadequate evidence on the harms of screening. No study reported on harms from the screening test or from false-positive or false-negative results. Potential diagnostic harms are primarily related to the harms of biopsy for suspected oral cancer or its potential precursors. Harms of treatment for screen-detected oral cancer and its potentially malignant precursors (leukoplakia and erythroplakia) may result from complications of surgery (first-line treatment), radiation, and chemotherapy. The natural history of screen-detected oral cancer or potentially malignant disorders is unclear; thus, the magnitude of overdiagnosis due to screening is unknown. USPSTF Assessment The USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of screening for oral cancer in asymptomatic adults by primary care providers. Clinical Considerations Patient Population Under Consideration This recommendation applies to asymptomatic adults aged 18 years or older who are seen by primary care providers. This recommendation focuses on screening (visual inspection and palpation) of the oral cavity performed by primary care providers and not dental providers or otolaryngologists. Assessment of Risk Tobacco and alcohol use are major risk factors for oral cancer. A total of 20% to 30% of cases of oral cancer worldwide are attributable to cigarette smoking (1). In the United States, up to 75% of cases of oral cancer may be attributable to tobacco and alcohol use (4). Additional risk factors include male sex, older age, use of betel quid, ultraviolet light exposure, infection with Candida or bacterial flora, and a compromised immune system (1). Sexually transmitted oral HPV infection (HPV-16) has recently been recognized as an increasingly important risk factor for oropharyngeal cancer. In the United States, the prevalence of oropharyngeal cancer due to oral HPV infection is probably as high as 80% to 95% (5). The prevalence of oral HPV infection is associated with age, sex, number of sexual partners, and number of cigarettes smoked per day. The effect of multifactorial risk assessment and screening for risk factors on oral cancer morbidity and mortality is unknown (1). Screening Tests The primary screening test for oral cancer is a systematic clinical examination of the oral cavity. According to the World Health Organization and the National Institute of Dental and Craniofacial Research, an oral cancer screening examination should include a visual inspection of the face, neck, lips, labial mucosa, buccal mucosa, gingiva, floor of the mouth, tongue, and palate. Mouth mirrors can help visualize all surfaces. The examination also includes palpating the regional lymph nodes, tongue, and floor of the mouth. Any abnormality that lasts for more than 2 weeks should be reevaluated and considered for biopsy (1, 6). Oropharyngeal cancer is difficult to visualize and is usually located at the base of the tongue (the back third of the tongue), the soft palate (the back part of the roof of the mouth), the tonsils, and the side and back walls of the throat. A comprehensive examination of the oropharynx may require referral to a dental provider or specialist, which is outside the scope of this recommendation. Additional tests proposed as adjuncts to the oral cancer screening examination include toluidine blue dye staining, chemiluminescent and autofluorescent lighting devices, and brush cytopathology. These screening and adjunct tests have not been adequately tested in primary care nondental settings. Although there is interest in screening for oral HPV infection, medical and dental organizations do not recommend it. Currently, no screening test for oral HPV infection has been approved by the U.S. Food and Drug Administration (FDA). Evaluating the accuracy of tests that detect oral HPV infection is a potentially promising area of research. Suggestions for Practice Regarding the I Statement This recommendation is intended for primary care providers and does not pertain to dental providers or otolaryngologists. Dental care providers and otolaryngologists may conduct a comprehensive examination of the oral cavity and pharynx during the clinical encounter. In deciding whether to screen for oral cancer, primary care providers should consider the following factors. Potential Preventable Burden Up to 75% of cases of oral cancer may be attributed to tobacco and alcohol use (4). Since 1979, the incidence rate of oral cavity cancer in the United States has been decreasing because of the reduced consumption of alcohol and smoking prevalence (1). During this period, the incidence of HPV-positive oropharyngeal squamous cell carcinoma has increased. Cancer registry data have shown that from 1988 to 2004, HPV-negative oropharyngeal cancer has decreased from 2.0 cases to 1.0 case per 100 000 persons and HPV-positive oropharyngeal cancer has increased more than 3-fold from 0.8 case to 2.6 cases per 100 000 persons (7). The overall prevalence of oral HPV infection is estimated to be 6.9% in adults aged 14 to 69 years in the United States. However, HPV prevalence can be as high as 20% for persons who have more than 20 lifetime sexual partners or currently use tobacco (more than 1 pack of cigarettes per day) (8). The prevalence of type-specific HPV-16 oral infection is estimated at 1% in adults aged 14 to 69 years (an estimated 2.13 million infected persons) (8). Human papillomavirus-16 is associated with approximately 85% to 95% of cases of HPV-positive oropharyngeal cancer (5). Therefore, the increasing role of oral HPV infection as a risk factor for oropharyngeal cancer may warrant future assessment of the independent effect of HPV-16 on incidence and outcomes of oropharyngeal cancer and the health effect of screening persons who are HPV-16positive. Potential Harms Suspected oral cancer or its precursors (such as erythroplakia, due to its high risk for transformation to cancer) detected through examination require confirmation by tissue biopsy, which may lead to harms. Harms of treatment of screen-detected oral cancer and its potential precursors (leukoplakia and erythroplakia) may result from complications of surgery, radiotherapy, and chemotherapy. The natural history of screen-detected oral cancer is not well-understood, and as a result, the harms from overdiagnosis and overtreatment are unknown. Current Practice In a 2008 survey of U.S. adults, 29.4% of those aged 18 years or older reported ever having an oral cancer examination in which a physician, dentist, or other health professional pulled on their tong

Screening for Autism Spectrum Disorder in Young Children: US Preventive Services Task Force Recommendation Statement

DESCRIPTION New US Preventive Services Task Force (USPSTF) recommendation on screening for autism spectrum disorder (ASD) in young children. METHODS The USPSTF reviewed the evidence on the accuracy, benefits, and potential harms of brief, formal screening instruments for ASD administered during routine primary care visits and the benefits and potential harms of early behavioral treatment for young children identified with ASD through screening. POPULATION This recommendation applies to children aged 18 to 30 months who have not been diagnosed with ASD or developmental delay and for whom no concerns of ASD have been raised by parents, other caregivers, or health care professionals. RECOMMENDATION The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for ASD in young children for whom no concerns of ASD have been raised by their parents or a clinician. (I statement).

Screening for Obstructive Sleep Apnea in Adults US Preventive Services Task Force Recommendation Statement

Importance Based on data from the 1990s, estimated prevalence of obstructive sleep apnea (OSA) in the United States is 10% for mild OSA and 3.8% to 6.5% for moderate to severe OSA; current prevalence may be higher, given the increasing prevalence of obesity. Severe OSA is associated with increased all-cause mortality, cardiovascular disease and cerebrovascular events, diabetes, cognitive impairment, decreased quality of life, and motor vehicle crashes. Objective To issue a new US Preventive Services Task Force (USPSTF) recommendation on screening for OSA in asymptomatic adults. Evidence Review The USPSTF reviewed the evidence on the accuracy, benefits, and potential harms of screening for OSA in asymptomatic adults seen in primary care, including those with unrecognized symptoms. The USPSTF also evaluated the evidence on the benefits and harms of treatment of OSA on intermediate and final health outcomes. Findings The USPSTF found insufficient evidence on screening for or treatment of OSA in asymptomatic adults or adults with unrecognized symptoms. Therefore, the USPSTF was unable to determine the magnitude of the benefits or harms of screening for OSA or whether there is a net benefit or harm to screening. Conclusions and Recommendation The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for OSA in asymptomatic adults. (I statement)

Screening for Latent Tuberculosis Infection in Adults: US Preventive Services Task Force Recommendation Statement

IMPORTANCE Tuberculosis remains an important preventable disease in the United States. An effective strategy for reducing the transmission, morbidity, and mortality of active disease is the identification and treatment of latent tuberculosis infection (LTBI) to prevent progression to active disease. OBJECTIVE To issue a current US Preventive Services Task Force (USPSTF) recommendation on screening for LTBI. EVIDENCE REVIEW The USPSTF reviewed the evidence on screening for LTBI in asymptomatic adults seen in primary care, including evidence dating from the inception of searched databases. FINDINGS The USPSTF found adequate evidence that accurate screening tests for LTBI are available, treatment of LTBI provides a moderate health benefit in preventing progression to active disease, and the harms of screening and treatment are small. The USPSTF has moderate certainty that screening for LTBI in persons at increased risk for infection provides a moderate net benefit. CONCLUSIONS AND RECOMMENDATION The USPSTF recommends screening for LTBI in populations at increased risk. (B recommendation).

Primary care interventions to prevent tobacco use in children and adolescents: U.S. Preventive Services Task Force recommendation statement

DESCRIPTION Update of the 2003 U.S. Preventive Services Task Force (USPSTF) recommendation on primary care interventions to prevent tobacco use in children and adolescents. METHODS The USPSTF reviewed the evidence on the effectiveness of primary care interventions on the rates of initiation or cessation of tobacco use in children and adolescents and on health outcomes, such as respiratory health, dental and oral health, and adult smoking. The USPSTF also reviewed the evidence on the potential harms of these interventions. POPULATION This recommendation applies to school-aged children and adolescents. The USPSTF has issued a separate recommendation statement on tobacco use counseling in adults and pregnant women. RECOMMENDATION The USPSTF recommends that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use in school-aged children and adolescents.

Screening for Celiac Disease: US Preventive Services Task Force Recommendation Statement

Importance Celiac disease is caused by an immune response in persons who are genetically susceptible to dietary gluten, a protein complex found in wheat, rye, and barley. Ingestion of gluten by persons with celiac disease causes immune-mediated inflammatory damage to the small intestine. Objective To issue a new US Preventive Services Task Force (USPSTF) recommendation on screening for celiac disease. Evidence Review The USPSTF reviewed the evidence on the accuracy of screening in asymptomatic adults, adolescents, and children; the potential benefits and harms of screening vs not screening and targeted vs universal screening; and the benefits and harms of treatment of screen-detected celiac disease. The USPSTF also reviewed contextual information on the prevalence of celiac disease among patients without obvious symptoms and the natural history of subclinical celiac disease. Findings The USPSTF found inadequate evidence on the accuracy of screening for celiac disease, the potential benefits and harms of screening vs not screening or targeted vs universal screening, and the potential benefits and harms of treatment of screen-detected celiac disease. Conclusions and Recommendation The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for celiac disease in asymptomatic persons. (I statement)

Screening for depression in children and adolescents

DESCRIPTION: This article describes the update of the 2009 US Preventive Services Task Force (USPSTF) recommendation on screening for major depressive disorder (MDD) in children and adolescents. METHODS: The USPSTF reviewed the evidence on the benefits and harms of screening, accuracy of primary care–feasible screening tests, and benefits and harms of treatment with psychotherapy, medications, and collaborative care models in patients aged 7 to 18 years. POPULATION: This recommendation applies to children and adolescents aged ≤18 years who do not have an MDD diagnosis. RECOMMENDATION: The USPSTF recommends screening for MDD in adolescents aged 12 to 18 years. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up (B recommendation). The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for MDD in children aged ≤11 years (I statement).