Prevention and Wellness Care in General Medicine: What

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Prevention and Wellness Care in General Medicine
Whats the Evidence?

• Donna E. Sweet, MD, AAHIVS, MACP
• Professor of Medicine
• The University of Kansas School of Medicine -
  Wichita

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What In the World Do you Do?? What do you
choose to address??
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Preventive ServicesRecommended by theUSPSTF
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All recommendation are linked to a letter grade
that reflects1) The magnitude of net benefit
2) The strength and certainty of the evidence
supporting the provision of a specific
preventive service.
Recommendations of the U.S. Preventive Services
Task Force
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Magnitude/Certainty of Net Benefit and Letter
Grades
Certainty of Net Benefit
Magnitude of Net Benefit (Benefit Minus Harms)
Substantial Moderate Small Zero/Negative
High A B C D
Moderate B B C D
Low I Insufficient Evidence
A B Recommend use C Optional
recommendation for use D Recommend against
use I No recommendation insufficient
evidence
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In my opinion
Top Issues
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Lipids
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USPSTF Summary of Recommendations
Lipid Screening

• Screening Men
• Strongly recommends screening men aged 35 and
  older for lipid disorders.  Grade A
  Recommendation.
• Recommends screening men aged 20 to 35 for lipid
  disorders if they are at increased risk for
  coronary heart disease. Grade B
  Recommendation.

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USPSTF Summary of Recommendations
Lipid Screening

• Screening Women at Increased Risk
• Strongly recommends screening women aged 45 and
  older for lipid disorders if they are at
  increased risk for coronary heart disease.
   Grade A Recommendation.
• Recommends screening women aged 20 to 45 for
  lipid disorders if they are at increased risk for
  coronary heart disease. Grade B
  Recommendation.

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USPSTF Summary of Recommendations
Lipid Screening

• Screening Young Men and All Women Not at
  Increased Risk
• The USPSTF makes no recommendation for or against
  routine screening for lipid disorders in men aged
  20 to 35, or in women aged 20 and older who are
  not at increased risk for coronary heart disease.
• Grade C Recommendation.

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Increased Risk Defined
Lipid Screening

• For this purpose, Increased Risk is defined as
  those with a presence of any of the following
  factors
• Diabetes.
• Previous personal history of CHD or non-coronary
  atherosclerosis (e.g., abdominal aortic aneurysm,
  peripheral artery disease, carotid artery
  stenosis).
• A family history of cardiovascular disease before
  age 50 in male relatives or age 60 in female
  relatives.
• Tobacco use.
• Hypertension.
• Obesity (BMI gt30).

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NCEP ATPIII, AHA, and ADA Recommended Lipid Goals
Parameter ATP III1 AHA Women2 ADA Position3(for adults with diabetes)
LDL-C - Very high risk lt100 mg/dLlt70 mg/dL4 lt100 mg/dL lt100 mg/dL
Non-HDL-C lt130 mg/dL lt130 mg/dL --
HDL-C gt40 mg/dL gt50 mg/dL gt40 mg/dL men gt50 mg/dL women
TGs lt150 mg/dL lt150 mg/dL lt150 mg/dL
Non-HDL-C Total cholesterol HDL-C.

• National Cholesterol Education Program. NIH
  Publication No. 02-5215 September 2002.
• Mosca L et al. Circulation. 2007.
• American Diabetes Association. Diabetes Care.
  200830S4-S41.
• Grundy SM et al. Circulation. 2004110227-239.

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Hypertension
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Hypertension in the U.S.

• Responsible fore 35 of all CV events (MI/CVA)
• 49 of all episodes of heart failure
• 34 of all premature deaths
• Those with hypertension have 2-4 X more risk for
  stroke, MI, heart failure and PVD than those
  without hypertension

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HTN

• HTN Can be effectively detected through office
  measurement of BP
• Treatment of elevated BP reduces CV events
• Magnitude of risk reduction depends on the degree
  of HTN and presence of other CV risk factors
• Studies find no important adverse effects in
  those screened and labeled as Hypertensive

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USPSTF Summary of Recommendations
Hypertension Screening

• The U.S. Preventive Services Task Force (USPSTF)
  recommends screening for high blood pressure in
  adults aged 18 and older.
• Grade A Recommendation.

http//www.ahrq.gov/clinic/pocketgd09/pocketgd09.p
df
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How Often to Measure?
Hypertension Screening

• Measure every 2 years if normal
• Measure every 1 year if borderline blood pressure

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Clinical Considerations
Hypertension Screening

• Clinicians should consider the patients overall
  cardiovascular risk profile when making treatment
  decisions including
• smoking
• diabetes
• abnormal blood lipid
• values
• age
• sex
• sedentary lifestyle
• obesity

http//www.ahrq.gov/clinic/pocketgd09/pocketgd09.p
df
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Treatment Does Reduce BP and the Incidence of CV
Events

• The degrees of risk reduction depends on patients
  levels and duration of elevation, their other
  risks for CVD and the choice of anti-hypertensive
  treatment

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Is It Done?
Hypertension Screening

• Recent NHANES III (National Health and Nutrition
  Exam Survey) shows
• 31 of HTN Americans are unaware they have HTN
• 17 are aware but not in treatment
• 29 are treated, but not controlled

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Diabetes Screening
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Ann Intern Med 2008148846-854.
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Detection

• The USPSTF found convincing evidence that
  available screening tests accurately detect type
  2 diabetes during an early, asymptomatic phase.

Ann Intern Med 2008148846-854.
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Diabetes ScreeningUSPSTF Summary of
Recommendations

• Summary of Recommendations
• The USPSTF recommends screening for type 2
  diabetes in asymptomatic adults with sustained
  blood pressure (either treated or untreated)
  greater than 135/80 mm Hg.Grade B
  Recommendation.
• The USPSTF concludes that the current evidence is
  insufficient to assess the balance of benefits
  and harms of screening for type 2 diabetes in
  asymptomatic adults with blood pressure of 135/80
  mm Hg or lower.Grade I Statement.

Ann Intern Med 2008148846-854.
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Screening for Type 2 Diabetes Mellitus Update of
2003 Systematic Evidence Review for the U.S.
Preventive Services Task Force

• Conclusion
• Persons with hypertension probably benefit from
  screening, because blood pressure targets for
  persons with diabetes are lower than those for
  persons without diabetes.
• Intensive lifestyle and pharmacotherapeutic
  interventions reduce the progression of
  prediabetes to diabetes,
• Few data examine the effect of these
  interventions on long-term health outcomes.

Evidence Syntheses, No. 61. Investigators Susan
L Norris, MD, MPH, Devan Kansagara, MD, Christina
Bougatsos, BS, Peggy Nygren, MA, and Rongwei Fu,
PhD. Oregon Evidence-based Practice Center
Rockville (MD) Agency for Healthcare Research
and Quality (US) June 2008. PMID 20722158.
Publication No. 08-05116-EF-1
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Osteoporosis in Postmenopausal Women
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USPSTF Osteoporosis Screening Guidelines

• Summary of Recommendations
• The U.S. Preventive Services Task Force (USPSTF)
  recommends that women aged 65 and older be
  screened routinely for osteoporosis. The USPSTF
  recommends that routine screening begin at age 60
  for women at increased risk for osteoporotic
  fractures. Grade B Recommendation.
• The USPSTF makes no recommendation for or against
  routine osteoporosis screening in postmenopausal
  women who are younger than 60 or in women aged
  60-64 who are not at increased risk for
  osteoporotic fractures.Grade C Recommendation.

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Osteoporosis Guidelines
Guideline Group Year Screen women? Screen men? Screen method Treatment
USPSTF United States Preventive Services Task Force 2002 65, gt 60 if RF No rec lt 60 or 60-64 w/o RF No guidance DEXA Others? Bisphos used in Rx trials
ACOG- American Congress of Obstetrics and Gynecology 2004 As USPSTF Dont repeat _at_ lt 2 yrs No guidance DEXA Prevent B, Ralox, Est Treat Add Calcitonin, PTH
NAMS North American Menopause Society 2006 DEXA 65, lt 65 if risk Repeat DEXA interval 2 yrs. No guidance Yearly Ht/Wt /Back pain/ Kyphosis? DEXA Rx based on BMD and RF
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Osteoporosis Guidelines
Guideline Group Year Screen women? Screen men? Screen method Treatment
NICE-National Institute for Health and Clinical Excellence 2008 DEXA or gt 70 yr. DEXA or gt 70 yr. -- Primary P AlgtRis/Etid 2oAlgtRis/EtidgtRalox
ACPM American College of Preventive Medicine 2009 65, younger if risks 70, younger if RF DEXA Risk FRAX, etc. calculators useful Ca 1200D 800 for all 50 Treat if OP table
ACP American College of Physicians 2010 -- 50 Recommended if known or at risk DEXA Choose according to assessment of need
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Summary

• Osteoporosis screening and treatment is
  evidence-based in older adults (women gt men)
• DEXA is best validated tool
• Multiple medications are effective
• Current choice should be individualized
• Many questions remain-based on current literature
• Risk factors and risk groups
• Frequency of measurement
• Duration of treatment

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HIV Testing
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CDC Recommends Routine HIV Testing

• Sept. 21, 2006
• The CDC recommends routine screening for persons
  aged 13-64 years and pregnant women and retesting
  at least annually for all persons likely to be at
  high risk for HIV

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USPSTF HIV Guidelines

• All adolescents and adults at increased risk for
  HIV infection. 
• Rating 'A'
• All pregnant women for HIV.  
• Rating  'A'
• Routine screening adolescents and Adults who are
  not at increased risk for HIV infection.  
• Rating  'C'

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Awareness of HIV Status among Persons with HIV,
United States
At the end of 2006, an estimated

• 1,106,400 persons in the United States were
  living with HIV infection
• (95 confidence interval 1,056,400 - 1,156,400)
• 21 of those are undiagnosed.
• 56,300 people were newly infected with HIV in
  2006 (the most recent year that data are
  available)

http//www.cdc.gov/hiv/topics/surveillance/basic.h
tmhivaidsage
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Late HIV Testing, 1996-2005

• 281,421 received diagnosis of HIV
• 38.3 had ADIS diagnosis within 1 year of HIV
  diagnosis
• 6.7 between 1-3 years
• 45 with AIDS Diagnosis in lt3 years

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Those Most Likely to Test Late Include

• Heterosexuals
• Those with a low-perceived risk of HIV
• People aged 18-29
• African-Americans and Latinos

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Mortality and HAART Use Over Time HIV Outpatient
Study, CDC, 1994-2003
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0.9
0.8
12
0.7
10
0.6
Patients on HAART
8
Deaths per 100 PY
0.5
Patients on HAART
Deaths per 100 PY
0.4
6
0.3
4
0.2
2
0.1
0
0
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Year
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PACTG 076 USPHS ZDV Recs
CDC HIV screening Recs
95 reduction
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Testing Changes Behavior
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Testing Changes Behavior
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Written Consent is No Longer Required in the VA
for HIV Testing

• Diagnosis of HIV testing in VA requires that a
  patient be provided with written educational
  materials and give specific verbal informed
  consent to HIV testing.
• The patient's verbal consent should be documented
  in the patient's electronic health record.

(August 2009)
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Summary of Review of Evidence

• HIV meets the criteria for screening, and
  effective treatment is available
• Many patients with HIV visit healthcare providers
  but their infection goes undetected
• People decrease their risk behaviors when they
  find out they are infected with HIV
• HIV screening in healthcare settings is
  cost-effective
• Opt-out screening increases testing rates

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Cancer Screening
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What We Tell Our Patients
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Breast Cancer Screening
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Breast cancer is the 2nd Leading Cause of
Cancer-Related Death in the U.S.
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Breast cancer incidence in women in the United
States is 1 in 8 (about 13).
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Mammography Benefits and Harms
Age False Females screened Results
39-49 9.78 1904 1 death prevented
50-59 8.86 1339 1 death prevented
60-69 377 1 death prevented
Age 40-49 For every 1000 screened 84 required more imaging 9.3 required biopsy
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Summary of USPSTF Guidelines for Breast Cancer
Screening
Ages 40-49 50-74 Older than 74
Timing of Screening Do NOT screen routinely, but individualize this decision Screen every 2 years No screening
Grade C recommendation B recommendation I Statement
Source The Female Patient. Vol 35, May 2010
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Summary of USPSTF Guidelines for Breast Cancer
Screening
Screening Modality Teaching Self breast exam Clinical breast exam Breast MRI and digital mammogram
Does not reduce breast cancer mortality Benefit beyond mammogram is inadequate Evidence is lacking as substitute for mammography
Grade D recommendation I Statement I Statement
Source The Female Patient. Vol 35, May 2010
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Sensitivity and Specificity of 5 Breast Cancer
Screening Modalities
Increased Sensitivity Less False-Positive
Results Less Unwarranted Anxiety/Unnecessary
(Costly) Interventions
Increased Specificity Less False-Negative
Results Less Mortality
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Benefits and risks of mammography

• Benefits
• Mortality rate reduction
• Morbidity rate reduction
• Reassurance
• Harms
• Radiation induced cancer
• False-positive mammograms
• Overdiagnosis
• False reassurance
• Pain or discomfort

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Mortality

• 9 trials, many meta-analyses
• USPSTF meta-analysis (8 published trials)
• 15 reduction in breast cancer mortality after
  11-20 years of f/u
• Relative risk 0.85 (CrI 0.75 to 0.96)
• Number needed to screen to prevent a breast
  cancer death 1904 (929 to 6378)
• Absolute mortality reduction 0.56 per 1000 women
  (0.1 to 1.3 per 1000)
• USPSTF 2009 Update Nelson et al Ann Intern Med
  2009 151727
• USPSTF 2002 Update

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Harms Overdiagnosis

• Overdiagnosis screening identifies a cancer that
  would not have become clinically evident
• Concern is about ductal carcinoma in situ (DCIS)
• Evidence sparse, but not all DCIS progresses
• Largest series, 80 patients, 14 had cancer dx
  after several decades
• Other series 8 to 66 developed invasive breast
  cancer
• Dx of DCIS 1999,
• 28 had mastectomy
• 64 lumpectomy (and of those half had radiation
  therapy)

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Harms false positive mammograms

• Harvard Pilgrim Health Plan
• After 10 mammograms 56 of women had false
  positive
• Of these, 20 had biopsies
• Other studies 20 to 40 FP after 10 mammograms
• Annual screening 40 to 69 2250 FP per 1000
  women
• FP increase anxiety, but generally modest and
  transient

Mandelblatt et al Ann Intern Med 2009
151738-747
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An example of breast screening outcomes (Elmore)

• 10,000 women screened for 10 years
• 6 have decreased breast cancer mortality
• 9994 receive no benefit
• 5000 have at least one false-positive

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ACP Breast Cancer Screening Guidelines April,
2007

• Recommendation 1 In women 40 to 49 years of age,
  clinicians should periodically perform
  individualized assessment of risk for breast
  cancer to help guide decisions about screening
  mammography.

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Informing patients

• Recommendation 2 Clinicians should inform women
  40 to 49 years of age about the potential
  benefits and harms of screening mammography.

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Change in Mammography Guidelines May Adversely
Affect Young Minority Women

• Wednesday, May 04, 2011 - Elsevier Global Medical
  News

• A retrospective study derived from a large state
  cancer registry found that Hispanic, Asian, and
  black women aged 40-49 years were
• Up to 60 more likely to be diagnosed with ductal
  cancer in situ (DCIS)
• Up to 80 more like to have small invasive breast
  tumors (T1N0) than were their white counterparts.
• These women were significantly more likely to
  have tumors that respond best to very early
  therapy, but if their cancers are not detected
  through mammography, women in these groups might
  not receive such therapy.

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Colorectal Cancer Screening
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Colorectal Cancer 2nd Leading Cancer Killer in
the U.S. in 2006

• 139,127 Diagnosed
• 53,196 Died

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Incidence of CRC

• Higher in men
• Greater after age 40
• (60.4men vs. 40.9women/100,000 per year)

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Recommendation Summary

• The U.S. Preventive Services Task Force (USPSTF)
  recommends screening for colorectal cancer using
  fecal occult blood testing, sigmoidoscopy, or
  colonoscopy in adults, beginning at age 50 years
  and continuing until age 75 years. The risks and
  benefits of these screening methods may vary.
• Grade A Recommendation.

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Recommendation Summary

• The USPSTF recommends against routine screening
  for colorectal cancer in adults 76 to 85 years of
  age. There may be considerations that support
  colorectal cancer screening in an individual
  patient.
• Grade C Recommendation

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Recommendation Summary

• The USPSTF recommends against screening for
• colorectal cancer in adults older than age 85
  years.
• Grade D Recommendation

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Recommendation Summary

• The USPSTF concludes that the evidence is
  insufficient to assess the benefits and harms of
  computed tomographic colonography and fecal DNA
  testing as screening modalities of colorectal
  cancer.
• Grade I Statement.

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Survival Closely Linked to Clinical and
Pathologic Stage at Diagnosis

• 65 - present with advanced disease
• 90 - 5 year survival - limited to bowel wall
• 35 36 - when lymph nodes involved
• lt10 with metastatic disease

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Early Detection Important

• Decreased CRC morbidity and mortality can be
  achieved with early detection of early stage
  cancer and tumor identification and removal of
  adenomatous polyps, the precursors of colorectal
  cancer

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The Newest Do-It-Yourself Kit
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How Much Does Colonoscopy Reduce Colon Cancer
Mortality?
Baxter, et al Annals of IM, Jan 2009
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Average Private-Sector Cost of Colorectal Cancer
Screening Methods (in year 2004 dollars)
http//www.businessgrouphealth.org/benefitstopics/
topics/purchasers/condition_specific/evidencestate
ments/colorectalcancer_es.pdf
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Colonoscopy Safe But
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Prostate Cancer Screening
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American Cancer SocietyNew Guidelines March
2010
PSA level Test
4.0ng/ml or higher Consider further evaluation. i.e. biopsy
2.5 ng/ml. or higher Screen annually
Under 2.5 ng/ml or lower Screen every 2 years
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USPSTF Summary of RecommendationsProstate
Cancer Screening

• The USPSTF concludes that the current evidence is
  insufficient to assess the balance of benefits
  and harms of prostate cancer screening in men
  younger than age 75 years.
• Grade I Statement
• The USPSTF recommends against screening for
  prostate cancer in men age 75 years or older.
• Grade D Recommendation

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Göteborg randomised population-based
prostate-cancer screening trial
Lancet Oncol 2010 11 72532 Published
Online July 1, 2010 DOI10.1016/S1470- 2045(10)701
46-7
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Cumulative incidence of prostate cancer in the
screening group and in the control group
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Cumulative risk of death from prostate cancer
using Nelson-Aalen cumulative hazard estimates
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Conclusions

• PSA screening every 2 years in men aged 50 to 69
  years is associated with a 64 higher rate of
  diagnosis of prostate cancer vs no screening.
• PSA screening every 2 years in men aged 50 to 69
  years is associated with lower mortality rates
  from prostate cancer.

Lancet Oncol 2010 11 72532 - Published Online.
July 1, 2010 DOI10.1016/S1470-2045(10)70146-7
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Ovarian Cancer Screening
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Summary of Recommendation

• The U.S. Preventive Services Task Force (USPSTF)
  recommends against routine screening for ovarian
  cancer.
• Grade D Recommendation

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Clinical Considerations

• Because there is a low incidence of ovarian
  cancer in the general population (age-adjusted
  incidence of 17 per 100,000 women), screening for
  ovarian cancer is likely to have a relatively low
  yield.
• The great majority of women with a positive
  screening test will not have ovarian cancer
  (i.e., they will have a false-positive result).
• In women at average risk, the positive predictive
  value of an abnormal screening test is, at best,
  approximately 2 (i.e., 98 of women with
  positive test results will not have ovarian
  cancer).

Ann Fam Med. 20042260-262.
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Clinical Considerations

• There is no existing evidence that any screening
  test, including CA-125, ultrasound, or pelvic
  examination, reduces mortality from ovarian
  cancer.
• Furthermore, existing evidence that screening can
  detect early-stage ovarian cancer is insufficient
  to indicate that this earlier diagnosis will
  reduce mortality.

Ann Fam Med. 20042260-262.
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Clinical Considerations

• The positive predictive value of an initially
  positive screening test would be more favorable
  for women at higher risk.
• For example, the lifetime probability of ovarian
  cancer increases from about 1.6 in a 35-year-old
  woman without a family history of ovarian cancer
  to about 5 if she has 1 relative and 7 if she
  has 2 relatives with ovarian cancer.
• If ongoing clinical trials show that screening
  has a beneficial effect on mortality rates, then
  women at higher risk are likely to experience the
  greatest benefit.

Ann Fam Med. 20042260-262.
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Ovarian Cancer Screening Study
July 13, 2010 -

• A new study conducted by doctors at the
  University of Kentucky Chandler Medical
  Center-Markey Cancer Center suggests that
  ultrasound outperforms symptom analysis when it
  comes to detecting ovarian cancer among women

http//news.uky.edu/news/display_article.php?artid
4897
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Ovarian Cancer Screening Study

• 272 women participating in annual trans-vaginal
  screening (TVS)
• from 31,748 women enrolled in a free screening
  project at the university,
• compared symptom results to ultrasound and
  surgical pathology findings.

http//news.uky.edu/news/display_article.php?artid
4897
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Ovarian Cancer Screening Study

• Observations
• TVS performed better than symptoms analysis for
  detecting malignancies-73.3 per cent versus 20
  per cent sensitivity.
• Symptoms analysis performed better for
  distinguishing benign tumors (91.3 versus 74.4
  specificity),
• Adding symptom analysis to TVS actually resulted
  in poorer identification of malignancy
  (sensitivity 16.7), even as it improved the
  ability to distinguish benign tumors (specificity
  97.9).

http//news.uky.edu/news/display_article.php?artid
4897
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Cervical Cancer Screening
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Clinical Considerations

• The optimal age to begin screening is unknown.
• Data on natural history of HPV infection and the
  incidence of high-grade lesions and cervical
  cancer suggest that screening can safely be
  delayed until 3 years after onset of sexual
  activity or until age 21, whichever comes first.

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Clinical Considerations

• Although there is little value in screening women
  who have never been sexually active, many U.S.
  organizations recommend routine screening by age
  18 or 21 for all women, based on the generally
  high prevalence of sexual activity by that age in
  the U.S. and concerns that clinicians may not
  always obtain accurate sexual histories.

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USPSTF Summary of Recommendations

• Strongly recommends screening for cervical cancer
  in women who have been sexually active and have a
  cervix.
• Grade A Recommendation

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USPSTF Summary of Recommendations

• Recommends against routinely screening women
  older than age 65 for cervical cancer if they
  have had adequate recent screening with normal
  Pap smears and are not otherwise at high risk for
  cervical cancer (go to Clinical Considerations).
• Grade D Recommendation.

98
USPSTF Summary of Recommendations

• Recommends against routine Pap smear screening in
  women who have had a total hysterectomy for
  benign disease.
• Grade D Recommendation.

99
Less Frequent Screening Recommended
November 24, 2009

• November 24, 2009 First cervical cancer
  screening should be at age 21 years, and
  rescreening can be less frequent than previously
  recommended, according to newly revised
  evidence-based guidelines issued by the American
  College of Obstetricians and Gynecologists
  (ACOG).
• The ACOG's Committee on Practice
  BulletinsGynecology was posted online November
  20 and will appear in the December print issue of
  Obstetrics Gynecology.

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When To Discontinue Screening?

• Discontinuation of cervical cancer screening in
  older women is appropriate, provided women have
  had adequate recent screening with normal Pap
  results.
• The optimal age to discontinue screening is not
  clear, but risk of cervical cancer and yield of
  screening decline steadily through middle age.
• The USPSTF found evidence that yield of screening
  was low in previously screened women after age
  65.

101
Clinical Considerations

• American Cancer Society (ACS) recommendations
  suggest stopping cervical cancer screening at age
  70.
• Screening is recommended in older women who have
  not been previously screened, when information
  about previous screening is unavailable, or when
  screening is unlikely to have occurred in the
  past (e.g., among women from countries without
  screening programs).

102
Clinical Considerations

• Evidence is limited to define adequate recent
  screening.
• The ACS guidelines recommend that older women who
  have had three or more documented, consecutive,
  technically satisfactory normal/negative cervical
  cytology tests, and who have had no
  abnormal/positive cytology tests within the last
  10 years, can safely stop screening.

103
No Evidence For Annual Screening

• The USPSTF found no direct evidence that annual
  screening achieves better outcomes than screening
  every 3 years.
• Modeling studies suggest little added benefit of
  more frequent screening for most women.

104
Screening Concerns

• Because sensitivity of a single Pap test for
  high-grade lesions may only be 60-80, however,
  most organizations in the United States recommend
  that annual Pap smears be performed until a
  specified number (usually two or three) are
  cytologically normal before lengthening the
  screening interval.

105
Screening Concerns

• Waiting until age 30 before lengthening the
  screening interval the American College of
  Obstetricians and Gynecologists (ACOG) identifies
  additional risk factors that might justify annual
  screening but data are limited to determine the
  benefits of these strategies
• Including a history of cervical neoplasia
• Infection with HPV or other sexually transmitted
  diseases (STDs)
• High-risk sexual behavior

106
Technology Improvements

• Liquid-based cytology permits testing of
  specimens for HPV, which may be useful in guiding
  management of women whose Pap smear reveals
  atypical squamous cells.
• HPV DNA testing for primary cervical cancer
  screening has not been approved by the FDA and
  its role in screening remains uncertain.

107
Summary of Recommendations

• Evidence is insufficient to recommend for or
  against the routine use of new technologies to
  screen for cervical cancer.
• Grade I Statement.
• The USPSTF concludes that the evidence is
  insufficient to recommend for or against the
  routine use of human papillomavirus (HPV) testing
  as a primary screening test for cervical cancer.
• Grade I Statement.

108
Questions Discussion