Routine Disease Screening

Routine Disease Screening is a topic covered in the Harrison's Manual of Medicine.

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A primary goal of health care is to prevent disease or to detect it early enough that interventions will be more effective. In general, screening is most effective when applied to relatively common disorders that carry a large disease burden and have a long latency period. Early detection of disease has the potential to reduce both morbidity and mortality; however, screening asymptomatic individuals carries some risk. False-positive results can lead to unnecessary laboratory tests and invasive procedures and can increase pt anxiety. Several measurements have been derived to better assess the potential gain from screening and prevention interventions:

  • Number of subjects needed to be screened to alter the outcome in one individual
  • Absolute impact of screening on disease (e.g., lives saved per thousand screened)
  • Relative impact of screening on disease outcome (e.g., the % reduction in deaths)
  • The cost per year of life saved
  • The increase in average life expectancy for a population

As part of a routine health care examination, history should include medication use, allergies, vaccination history, dietary history, use of alcohol and tobacco, sexual practices, safety practices (seat belt and helmet use, gun possession), and a thorough family history. Routine measurements should include assessments of height, weight, body-mass index, and blood pressure. Screening should also be considered for domestic violence and depression.

Counseling by health care providers should be performed at health care visits. Tobacco and alcohol use, diet, and exercise represent the vast majority of factors that influence preventable deaths. While behavioral changes are frequently difficult to achieve, it should be emphasized that studies show even brief (<5 min) tobacco counseling by physicians results in a significant rate of long-term smoking cessation. Instruction about self-examination (e.g., skin, breast, testicular) should also be provided during preventative visits.

The top causes of age-specific mortality and corresponding preventative strategies are listed in Table 201-1. Formal recommendations from the U.S. Preventive Services Task Force are listed in Table 201-2.

Age GroupLeading Causes of Age-Specific MortalityScreening Prevention Interventions to Consider for Each Specific Population
  1. Accident
  2. Homicide
  3. Suicide
  4. Malignancy
  5. Heart disease
  • Counseling on routine seat belt use, bicycle/motorcycle/all terrain vehicle helmets (1)
  • Counseling on diet and exercise (5)
  • Discuss dangers of alcohol use while driving, swimming, boating (1)
  • Ask about vaccination status (tetanus, diphtheria, pertussis, hepatitis B, MMR, varicella, meningitis, HPV)
  • Ask about gun use and/or gun possession (2,3)
  • Assess for substance abuse history including alcohol (2,3)
  • Screen for domestic violence (2,3)
  • Screen for depression and/or suicidal/homicidal ideation (2,3)
  • Pap smear for cervical cancer screening, discuss STD prevention (4)
  • Recommend skin, breast, and testicular self-exams (4)
  • Recommend UV light avoidance and regular sun screen use (4)
  • Measurement of blood pressure, height, weight and body mass index (5)
  • Discuss health risks of tobacco use, consider emphasis of cosmetic and economic issues to improve quit rates for younger smokers (4,5)
  • Chlamydia screening and contraceptive counseling for sexually active females
  • HIV, hepatitis B, gonorrhea, and syphilis testing if there is high-risk sexual behavior(s) or any prior history of sexually transmitted disease
  1. Accident
  2. Malignancy
  3. Heart disease
  4. Suicide
  5. Homicide
  6. HIV

As above plus consider the following:

  • Readdress smoking status, encourage cessation at every visit (2,3)
  • Obtain detailed family history of malignancies and begin early screening/prevention program if pt is at significant increased risk (2)
  • Assess all cardiac risk factors (including screening for diabetes and hyperlipidemia) and consider primary prevention with aspirin for pts at >3% 5-year risk of a vascular event (3)
  • Assess for chronic alcohol abuse, risk factors for viral hepatitis, or other risks for development of chronic liver disease
  • Begin breast cancer screening with mammography at age 40 (2)
  1. Malignancy
  2. Heart disease
  3. Accident
  4. Diabetes mellitus
  5. Cerebrovascular disease
  6. Chronic lower respiratory disease
  7. Chronic liver disease and cirrhosis
  8. Suicide
  • Consider prostate cancer screen with annual PSA and digital rectal examination at age 50 (or possibly earlier in African Americans or pts with family history) (1)
  • Begin mammography screening by age 50 (1)
  • Begin colorectal cancer screening at age 50 with either fecal occult blood testing, flexible sigmoidoscopy, or colonoscopy (1)
  • Reassess vaccination status at age 50 and give special consideration to vaccines against Streptococcus pneumoniae, influenza, tetanus, and viral hepatitis
  • Zoster vaccination at age 60
  • Consider screening for coronary disease in higher risk pts (2,5)
  1. Heart disease
  2. Malignancy
  3. Cerebrovascular disease
  4. Chronic lower respiratory disease
  5. Alzheimer’s disease
  6. Influenza and pneumonia
  7. Diabetes mellitus
  8. Kidney disease
  9. Accidents
  10. Septicemia

As above plus consider the following:

  • Readdress smoking status, encourage cessation at every visit (1,2,3)
  • One-time ultrasound for AAA in men 65–75 who have ever smoked
  • Consider pulmonary function testing for all long-term smokers to assess for development of chronic obstructive pulmonary disease (4,6)
  • Vaccinate all smokers against influenza and S. pneumoniae at age 50 (6)
  • Screen all postmenopausal women (and all men with risk factors) for osteoporosis
  • Reassess vaccination status at age 65, emphasis on influenza and S. pneumoniae (4,6)
  • Screen for dementia and depression (5)
  • Screen for visual and hearing problems, home safety issues, and elder abuse (9)
Note: The numbers in parentheses refer to areas of risk in the mortality column affected by the specified intervention.
Abbreviations: AAA, abdominal aortic aneurysm; HPV, human papilloma virus; MMR, measles-mumps-rubella; PSA, prostate-specific antigen; STD, sexually transmitted disease.
Test or DisorderPopulation,a YearsFrequency
Abdominal aortic aneurysm (ultrasound)Men 65–75 who have ever smokedOnce
Adult immunization
 Human papillomavirus (HPV)Up to age 26If not done prior
 Measles, mumps, rubella (MMR)Women, childbearing ageOne dose
 Pneumococcal>65One dose
 Tetanus-diphtheria (Td)>18Every 10 years
 Varicella (VZV)Susceptibles only, >18Two doses
 Zoster>60One dose
Alcohol use>18Periodically
Blood pressure, height and weight>18Periodically
Breast cancer (mammography and clinical breast examination)aWomen 50–75Every 2 years
Cervical cancercWomen 21–65Every 3 years
 Pap smearWomen 30–65Every 5 years if
 Pap smear and HPV testing HPV negative
Chlamydia/GonorrheaSexually active women <25Unknown
CholesterolMen >35Every 5 years
Women >45Every 5 years
Colorectal cancera fecal occult blood and/or sigmoidoscopy or colonoscopy50–75
Every year
Every 5 years
Every 10 years
DepressionAll adultsPeriodicallyb
Diabetes>45 or earlier, if there are additional risk factorsEvery 3 years
Hepatitis CAdults born between 1945–1965Once
Intimate partner violenceWomen of childbearing ageUnknown
Obesity (BMI)All adultsUnknown
OsteoporosisWomen >65; >60 at riskUnknown
Vision, hearing>65Periodically
aScreening is performed earlier and more frequently when there is a strong family history. Randomized, controlled trials have documented that fecal occult blood testing (FOBT) confers a 15–30% reduction in colon cancer mortality. Although randomized trials have not been performed for sigmoidoscopy or colonoscopy, well-designed case-control studies suggest similar or greater efficacy relative to FOBT.
bIf staff support is available.
cIn the future, Pap smear frequency may be influenced by HPV testing and the HPV vaccine.
Note: Prostate-specific antigen (PSA) testing is capable of enhancing the detection of early-stage prostate cancer, but evidence is inconclusive that it improves health outcomes. PSA testing is recommended by several professional organizations and is widely used in clinical practice, but it is not currently recommended by the U.S. Preventive Services Task Force.
Source: Adapted from the U.S. Preventive Services Task Force, Guide to Clinical Prevention Services, 2010–2011.

In addition to the general recommendations applicable to all persons, screening for specific diseases and preventive measures need to be individualized based on family history, travel history, or occupational history. For example, when there is a significant family history of breast, colon, or prostate cancer, it is prudent to initiate screening about 10 years before the age at which the youngest family member developed cancer.

Specific recommendations for disease prevention can also be found in subsequent chapters on “Cardiovascular Disease Prevention” (Chap. 202), “Prevention and Early Detection of Cancer” (Chap. 203), “Smoking Cessation” (Chap. 204), and “Women’s Health” (Chap. 205).

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