The bread and butter of outpatient medicine. Know the USPSTF A/B recommendations cold -cancer screening, cardiovascular risk assessment, and immunizations. This is what keeps patients out of the hospital.
๐ฌ Cancer Screening (USPSTF)
Cancer
Test
Age / Frequency
Key Notes
Breast
Mammography
40โ74, every 2 years (USPSTF 2024 update -lowered from 50 to 40)
Shared decision 40โ49 in prior guidelines. Now routine. High-risk (BRCA, family hx) โ may add MRI.
Cervical
Pap ยฑ HPV
21โ65. Pap q3 years (21โ29). Pap + HPV co-test q5 years or HPV alone q5 years (30โ65).
Stop at 65 if adequate prior screening. No screening if hysterectomy (no cervix) for non-cancer indication.
Colorectal
Colonoscopy, FIT, Cologuard
45โ75. Colonoscopy q10 years, FIT annually, Cologuard q3 years.
USPSTF 2021 lowered from 50 to 45. 76โ85 = selective. Family hx โ start 10 years before youngest affected relative or age 40.
Lung
Low-dose CT (LDCT)
50โ80, โฅ 20 pack-years, current or quit within 15 years. Annual.
55โ69: shared decision-making. USPSTF does NOT recommend routine screening.
PSA has high false-positive rate โ unnecessary biopsies. Discuss benefits/harms. Not recommended > 70.
Other Key Screenings
Condition
Screening
Population
AAA
One-time abdominal US
Men 65โ75 who ever smoked
Hepatitis C
Anti-HCV antibody
All adults 18โ79 (one-time). USPSTF 2020.
HIV
HIV Ag/Ab combo
All adults 15โ65 (one-time or more if high-risk). USPSTF 2019.
Diabetes
Fasting glucose, A1c, or OGTT
35โ70 with overweight/obesity. Screen q3 years.
Osteoporosis
DEXA scan
Women โฅ 65. Younger postmenopausal if FRAX 10-year hip fracture risk โฅ 3%.
Depression
PHQ-2 โ PHQ-9
All adults. USPSTF 2016.
โค๏ธ Cardiovascular Risk
Statin Therapy (ACC/AHA 2018)
Group
Recommendation
1. Clinical ASCVD (prior MI, stroke, PAD)
High-intensity statin (atorvastatin 40โ80 mg or rosuvastatin 20โ40 mg) 4S, 1994. Target LDL < 70. Add ezetimibe if not at goal โ add PCSK9 inhibitor if still not at goal.
Moderate to high-intensity statin. If borderline (5โ7.5%) โ consider risk enhancers (family hx, CAC score, CRP, ABI).
Hypertension (ACC/AHA 2017)
Stage 1 HTN: 130โ139/80โ89. Lifestyle ร 3โ6 months first if ASCVD risk < 10%. Start medication if โฅ 10% risk or if not at goal after lifestyle.
First-line agents: ACEi/ARB (preferred if DM, CKD, proteinuria, HF), thiazide (chlorthalidone preferred), CCB (amlodipine). Start 2 of 3 for stage 2.
Resistant HTN (โฅ 3 drugs at max doses): screen for OSA, hyperaldosteronism, renal artery stenosis. Add spironolactone PATHWAY-2, 2015.
๐ฅ Rounds
Pimp Questions
USPSTF recently lowered the mammography screening start age. What changed and why?
In 2024, USPSTF lowered the recommended start age for mammography screening from 50 to 40, with biennial screening through age 74. The change was driven by rising breast cancer incidence in women under 50 -particularly Black women, who have higher rates of aggressive subtypes (triple-negative) and present at younger ages. The prior recommendation (50โ74, with "individual decision" for 40โ49) led to disparities in screening uptake.
A 52-year-old male with no history of heart disease has an LDL of 130 and a 10-year ASCVD risk of 8%. Does he need a statin?
This falls into ACC/AHA Group 4: non-DM, LDL 70โ189, 10-year ASCVD risk 7.5โ20% โ moderate to high-intensity statin is recommended. At 8% risk, a statin is indicated. However, for borderline cases (5โ7.5%), you'd use risk enhancers to guide the decision: family history of premature ASCVD, persistently elevated CRP (> 2), elevated Lp(a), South Asian ancestry, metabolic syndrome, or coronary artery calcium (CAC) score > 0.
When do you start lung cancer screening with LDCT and who qualifies?
USPSTF 2021 recommendation: Annual LDCT for adults aged 50-80 with โฅ 20 pack-year smoking history who currently smoke OR quit within the last 15 years. This was expanded from the previous criteria (55-80, โฅ 30 pack-years) to capture more at-risk individuals. Stop screening when: the person has not smoked for 15 years, develops a health problem that limits life expectancy or willingness to have curative surgery, or turns 81.
What cancer screenings are recommended by USPSTF and at what ages?
Breast: Mammography every 2 years, ages 40-74 (updated 2024 -lowered from 50). Cervical: Pap every 3 years ages 21-29, Pap + HPV co-test every 5 years ages 30-65. Colorectal: Start at 45 (updated from 50). Options: colonoscopy q10y, FIT annually, Cologuard q3y, CT colonography q5y, flex sig q5y. Lung: Annual LDCT ages 50-80 with โฅ 20 pack-year history + currently smoke or quit within 15 years. Prostate: Shared decision-making ages 55-69 (PSA screening -NOT universal recommendation). Not recommende
๐ Overview
Overview
Preventive medicine is the highest-yield intervention. USPSTF Grade A/B recommendations guide screening. Key domains: cancer screening, CV risk, immunizations, behavioral counseling.
๐งช Workup
Workup
Cancer screening: mammogram, Pap/HPV, colonoscopy, LDCT
Very limited role in primary prevention.ASCEND, 2018: bleeding offsets benefit in diabetes. USPSTF 2022: do NOT initiate for age โฅ 60. Consider only age 40โ59 with โฅ10% ASCVD risk via shared decision-making.
๐ On Rounds
๐ฃ Sample Presentation
One-Liner
"Mrs. Thompson is a 52-year-old healthy woman presenting for her annual wellness visit. She is up to date on Pap smear (last year, normal) and mammogram (last year, normal). No colonoscopy yet. BMI 26, BP 128/82."
Key Points to Cover on Rounds
Cancer screening: colonoscopy due (age 52, average risk -schedule). Mammogram current (biennial, next in 1 year). Pap current (every 3 years with HPV co-test). Lung CT: not indicated (non-smoker). CV risk: 10-year ASCVD risk 4.2% (low) -no statin currently indicated. BP 128/82 (elevated, not yet HTN -lifestyle counseling). Fasting glucose 94, A1c 5.4 (normal, rescreen in 3 years). Immunizations: flu (today), COVID booster (due), Tdap (up to date), shingrix (not yet eligible -age 50). Depression screening: PHQ-2 negative. Osteoporosis: not yet (screen at 65). Plan: colonoscopy referral, lifestyle counseling (diet, exercise, weight), return in 1 year.
โก Summary
Summary
Cancer Screening
Breast: mammogram q2y 40-74. Cervical: Pap/HPV 21-65. Colon: start at 45 (colonoscopy q10y or FIT annual). Lung: LDCT 50-80 if โฅ 20 pack-years.
CV Risk
10-year ASCVD risk calculator. Statin: moderate if 7.5-20%, high-intensity if โฅ 20% or known ASCVD. ASA: limited role (USPSTF: ages 40-59 if โฅ 10% risk, shared decision).
Immunizations
Flu (annual), COVID (per current guidance), Tdap/Td (q10y), shingrix (โฅ 50), PCV20 (โฅ 65), HPV (through age 26, catch-up to 45).
Depression Screening
PHQ-2 then PHQ-9 annually in primary care. Universal screening recommended by USPSTF.
Diabetes Screening
Fasting glucose, A1c, or OGTT. Screen every 3 years age 35-70 if overweight/obese. Screen earlier if risk factors (FH, ethnicity, GDM history).
Osteoporosis
DEXA at age 65 (women), 70 (men). Earlier if risk factors (steroids, low BMI, FH hip fracture). Treat: bisphosphonates first-line.
RoundsRx Licensed Content - Unauthorized Use Prohibited๐ One Pager
Breast: mammogram q2y 40-74. Cervical: Pap q3y (21-29) or Pap/HPV q5y (30-65). Colon: start age 45 (colonoscopy q10y, FIT annually, Cologuard q3y). Lung: LDCT 50-80 if โฅ 20 pack-year smoker.
๐จ Cardiovascular Prevention
10-year ASCVD risk calculator. Statin: moderate if 7.5-20%, high-intensity if โฅ 20% or known ASCVD. ASA: limited role (ages 40-59, โฅ 10% risk, shared decision). BP target < 130/80 [SPRINT, 2015].
๐ Other Screening
Depression: PHQ-2 annually. Diabetes: A1c q3y if โฅ 35 + overweight. Osteoporosis: DEXA at 65F/70M. Hepatitis C: one-time for all 18-79. HIV: at least once for all 15-65.
๐ Key Drugs
Flu vaccineAnnual
Shingrixโฅ 50 (2 doses)
PCV20โฅ 65
ColonoscopyEvery 10 years starting at 45
โ ๏ธ Pitfalls
Not doing colonoscopy at 45 (USPSTF lowered from 50)
Missing LDCT eligibility in former smokers
PSA screening without shared decision-making
Forgetting Hepatitis C screening (one-time, all adults)