Preventive Care & Screening
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.
🔬 Cancer Screening (USPSTF)
| Cancer | Test | Age / Frequency | Key Notes |
|---|---|---|---|
| Breast | Mammography | 40–74, every 2 years (USPSTF 2024 update -lowered from 50 to 40) | Shared decision 40–49 in prior guidelines. Now routine. High-risk (BRCA, family hx) → may add MRI. |
| Cervical | Pap ± HPV | 21–65. Pap q3 years (21–29). Pap + HPV co-test q5 years or HPV alone q5 years (30–65). | Stop at 65 if adequate prior screening. No screening if hysterectomy (no cervix) for non-cancer indication. |
| Colorectal | Colonoscopy, FIT, Cologuard | 45–75. Colonoscopy q10 years, FIT annually, Cologuard q3 years. | USPSTF 2021 lowered from 50 to 45. 76–85 = selective. Family hx → start 10 years before youngest affected relative or age 40. |
| Lung | Low-dose CT (LDCT) | 50–80, ≥ 20 pack-years, current or quit within 15 years. Annual. | NLST, 2011: 20% mortality reduction. NELSON, 2020: confirmed. Shared decision-making required. |
| Prostate | PSA | 55–69: shared decision-making. USPSTF does NOT recommend routine screening. | PSA has high false-positive rate → unnecessary biopsies. Discuss benefits/harms. Not recommended > 70. |
Other Key Screenings
| Condition | Screening | Population |
|---|---|---|
| AAA | One-time abdominal US | Men 65–75 who ever smoked |
| Hepatitis C | Anti-HCV antibody | All adults 18–79 (one-time). USPSTF 2020. |
| HIV | HIV Ag/Ab combo | All adults 15–65 (one-time or more if high-risk). USPSTF 2019. |
| Diabetes | Fasting glucose, A1c, or OGTT | 35–70 with overweight/obesity. Screen q3 years. |
| Osteoporosis | DEXA scan | Women ≥ 65. Younger postmenopausal if FRAX 10-year hip fracture risk ≥ 3%. |
| Depression | PHQ-2 → PHQ-9 | All adults. USPSTF 2016. |
❤️ Cardiovascular Risk
Statin Therapy (ACC/AHA 2018)
| Group | Recommendation |
|---|---|
| 1. Clinical ASCVD (prior MI, stroke, PAD) | High-intensity statin (atorvastatin 40–80 mg or rosuvastatin 20–40 mg) 4S, 1994. Target LDL < 70. Add ezetimibe if not at goal → add PCSK9 inhibitor if still not at goal. |
| 2. LDL ≥ 190 | High-intensity statin. Likely familial hypercholesterolemia. Lipid specialist referral. |
| 3. DM age 40–75, LDL 70–189 | Moderate-intensity statin (atorvastatin 10–20 mg, rosuvastatin 5–10 mg). High-intensity if 10-year ASCVD risk ≥ 7.5%. |
| 4. Non-DM, LDL 70–189, 10-yr ASCVD ≥ 7.5% | Moderate to high-intensity statin. If borderline (5–7.5%) → consider risk enhancers (family hx, CAC score, CRP, ABI). |
Hypertension (ACC/AHA 2017)
- Stage 1 HTN: 130–139/80–89. Lifestyle × 3–6 months first if ASCVD risk < 10%. Start medication if ≥ 10% risk or if not at goal after lifestyle.
- Stage 2 HTN: ≥ 140/90. Start 2-drug combination therapy. Reassess in 1 month.
- Target: < 130/80 for most adults SPRINT, 2015.
- 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 (≥ 3 drugs at max doses): screen for OSA, hyperaldosteronism, renal artery stenosis. Add spironolactone PATHWAY-2, 2015.
🏥 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 (50–74, with "individual decision" for 40–49) 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 70–189, 10-year ASCVD risk 7.5–20% → moderate to high-intensity statin is recommended. At 8% risk, a statin is indicated. However, for borderline cases (5–7.5%), 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 ≥ 20 pack-year smoking history who currently smoke OR quit within the last 15 years. This was expanded from the previous criteria (55-80, ≥ 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 ≥ 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
🔍 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.
🧪 Workup
Workup
- Cancer screening: mammogram, Pap/HPV, colonoscopy, LDCT
- CV risk: ASCVD calculator, lipids, BP
- Metabolic: A1c q3y if ≥35 + overweight
- Depression: PHQ-2 annually
- Hep C: one-time 18-79
- HIV: at least once 15-65
- Osteoporosis: DEXA 65F/70M
🚨 Management
Management
- Statin: moderate 7.5-20% risk, high-intensity ≥20%
- ASA: limited -40-59yo if ≥10% risk, shared decision
- BP <130/80 [SPRINT, 2015]
- Smoking: 5 A's + varenicline+NRT
- Vaccines: flu, COVID, Tdap, shingrix≥50, PCV20≥65, HPV≤26
💊 Medications
Medications
| Drug | Dose | Route | Notes |
|---|---|---|---|
| Atorvastatin (Lipitor) | 40-80mg | PO | High-intensity statin |
| Varenicline | 1mg BID × 12wk | PO | Smoking cessation |
| ASA 81mg | Daily | PO | Very limited role in primary prevention. ASCEND, 2018: bleeding offsets benefit in diabetes. USPSTF 2022: do NOT initiate for age ≥ 60. Consider only age 40–59 with ≥10% ASCVD risk via shared decision-making. |
📋 On Rounds
📣 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.
⚡ Summary
Summary
Cancer Screening: Know the Ages
Breast: mammography every 2 years from 40 to 74 (lowered from 50 in 2024). Cervical: Pap every 3 years from 21 to 29, then Pap plus HPV co-test every 5 years from 30 to 65. Colorectal: start at 45 (lowered from 50), by colonoscopy every 10 years, annual FIT, stool DNA every 3 years, or CT colonography every 5. Lung: annual low-dose CT from 50 to 80 with a 20 pack-year history in current smokers or those who quit within 15 years.
Prostate Screening Is a Conversation, Not a Protocol
Shared decision-making from 55 to 69; it is not a universal recommendation. The tradeoff is a modest mortality benefit against overdiagnosis and the morbidity of treating cancers that would never have caused harm. Document the discussion rather than reflexively ordering or omitting the PSA.
Statins by Risk, Not by LDL Alone
Clinical ASCVD or LDL 190 or above: high-intensity statin regardless of calculated risk. Diabetes aged 40 to 75: at least moderate-intensity. Otherwise use the risk estimator, treating at 7.5% or above and considering it at 5 to 7.5% with risk enhancers. Coronary artery calcium scoring resolves the intermediate-risk patient: a score of zero permits deferral, and a score above 100 argues for treatment.
Use the Current Blood Pressure Thresholds
Normal below 120/80, elevated 120 to 129 systolic, stage 1 hypertension 130 to 139 or 80 to 89, stage 2 at 140/90 or above. Confirm with out-of-office readings before labeling anyone hypertensive, because white coat hypertension is common and a diagnosis made on a single clinic reading commits the patient to lifelong therapy.
Screen for the Non-Cancer Conditions Too
Diabetes or prediabetes from 35 to 70 in overweight adults. One-time abdominal aortic aneurysm ultrasound in men 65 to 75 who have ever smoked. Osteoporosis with DEXA in women 65 and over. Hepatitis C once in all adults 18 to 79, hepatitis B and HIV at least once, with more frequent HIV testing by risk. Depression, intimate partner violence and unhealthy alcohol use in all adults.
Vaccinate on Schedule
Influenza annually, COVID-19 per current guidance, Tdap once then Td every 10 years, shingles (Shingrix, two doses) from 50, pneumococcal from 50, RSV in older adults, and HPV through 26 with shared decision-making to 45. Hospital admission is an opportunity, since inpatient vaccination reaches people who do not attend primary care.
Screening Has Harms as Well as Benefits
False positives, overdiagnosis, procedural complications and the anxiety of incidental findings are real costs, which is why the recommendations specify ages and intervals rather than 'more is better'. Stop screening when life expectancy is under about 10 years, since the benefit of finding an early cancer accrues years later while the harms are immediate.
Behavioral Counseling Outperforms Most Tests
Smoking cessation is the single highest-yield intervention in medicine. Add diet and physical activity counseling, alcohol reduction, and weight management. These change more outcomes than any screening test on the list, and they are what the screening visit exists to deliver.
📄 One Pager
Text version
📄 One Pager
Primary Care · One Pager
Preventive Care
Mammogram q2y 40-74. Pap/HPV 21-65. Colonoscopy at 45. LDCT 50-80 if ≥ 20 pack-years. ASCVD risk → statin threshold. PHQ-2 depression screen annually.
Cancer Screening
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 ≥ 20 pack-year smoker.
Cardiovascular Prevention
10-year ASCVD risk calculator. Statin: moderate if 7.5-20%, high-intensity if ≥ 20% or known ASCVD. ASA: limited role (ages 40-59, ≥ 10% risk, shared decision). BP target < 130/80 [SPRINT, 2015].
Other Screening
Depression: PHQ-2 annually. Diabetes: A1c q3y if ≥ 35 + overweight. Osteoporosis: DEXA at 65F/70M. Hepatitis C: one-time for all 18-79. HIV: at least once for all 15-65.
Key Drugs
Flu vaccineAnnual
Shingrix≥ 50 (2 doses)
PCV20≥ 65
ColonoscopyEvery 10 years starting at 45
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)
Related Topics
Obesity Management & GLP-1 AgentsOutpatient Diabetes ManagementOutpatient Lipid ManagementSmoking Cessation