Screening Recommendations:
Breast Cancer
Breast cancer is the most commonly diagnosed cancer in American women and a leading cause of cancer death. Incidence of breast cancer tends to increase with age. About 98% of new cases occur in those who are 35 and older and 94% of breast cancer deaths occur in women 45 and older. Women in their 20s and 30s have the lowest incidence of breast cancer. Between 2011 and 2015, women between the ages of 20 and 34 represented only 1.9% of new breast cancer cases, according to the National Cancer Institute.
Recommendations for women with average risk
Women with average risk have no personal or family history of breast cancer and no other risk factors for breast cancer. Because of the low incidence of breast cancer in women younger than 40, mammograms aren’t recommended for those of average risk.
The American College of Obstetricians and Gynecologists (ACOG) recommends that women ages 25 to 39 with no known risk factors for breast cancer be offered a clinical breast exam by a healthcare professional every 1 to 3 years as part of their regular health exam.
According to ACOG, average-risk women of all ages should discuss breast self-awareness with their healthcare provider and immediately report any change in their breasts’ normal appearance and feel. These changes could include pain, a mass, nipple discharge other than breast milk, or redness.
Increased Risk
Family history and genetics can contribute to a high lifetime risk. Other risk factors for breast cancer include, for example, a personal history of breast cancer, obesity, beginning your period at a younger age, having dense breasts, and alcohol consumption.
Some of the important factors contributing to a high lifetime risk include:
- Carrying a mutated BRCA1 or BRCA2 gene, or having a close relative with the gene
- Having had chest radiation at a young age (between 10 and 30 years old)
- Certain family histories, such as multiple close relatives with breast or ovarian cancer
If you suspect you are at an increased risk for breast cancer, you should consult your healthcare provider and consider developing an individualized screening program.
Cervical Cancer
Most deaths from cancer of the cervix (the lower part of the uterus, or womb) can be avoided by having regular checkups and and cervical cancer screens. Cervical cancer is slow-growing and can take several years to develop. Most often, cancerous cells are seen in women 40 years of age or older. Routine screening can help identify cervical cancer early on, at a time when it is highly curable. Screening even finds precancerous lesions that can be monitored or removed before cancer ever starts to develop.
Recommendations
Cervical cancer screening guidelines for young women from the American College of Obstetricians and Gynecologists (ACOG), the American Cancer Society (ACS), and the U.S. Preventive Services Task Force (USPSTF) recommend that women between the ages of 21 and 29 have a Pap test every 3 years.
ACOG, USPSTF and ACS guidelines recommend more frequent screening for women with risk factors such as exposure to DES (diethylstilbestrol) in utero, previous diagnosis of a high-grade precancerous cervical lesion or cervical cancer, HIV infection, or a compromised immune system. (See the section on Risk Factors in the Cervical Cancer article.)
A Pap test for women younger than 21 is not recommended because the incidence of cancer in this age group is very low. False-positive results may occur due to normal cell changes and are somewhat common. The false-positive results may generate unnecessary and costly treatment as well as emotional anxiety.
Pap tests are available from family planning clinics and public health departments as well as from healthcare providers (including pediatricians, family physicians, obstetrician-gynecologists, and nurse practitioners). Even if you do not need a Pap test each year, for most women an annual well-woman exam is still recommended, reminds ACOG.
HPV Testing
In general, screening for the presence of human papilloma virus (HPV DNA test) is not recommended in women younger than age 25 because infections with HPV are relatively common in this age group and often resolve without treatment or complications. However, HPV testing may be used as a follow-up test for women between the ages of 21 and 29 years who have abnormal results on a Pap test known as “atypical squamous cells of undetermined significance” (ASCUS) [see Pap Test Terminology]. Results may be used to determine the need for colposcopy, a procedure that allows a health practitioner to visually inspect the vagina and cervix under magnification for the presence of abnormal cells.
Significant changes to these recommendations may be on the horizon, however. The Food and Drug Administration (FDA) approved an HPV DNA test as a primary screening tool for cervical cancer, meaning it may be used without a Pap test. Individual health organizations have yet to update their screening recommendations, but an expert panel issued interim (temporary) guidelines in 2015. These guidelines say that:
- The HPV test may be offered to women aged 25 and older without a Pap test.
- If initial results are negative, women should be screened again no sooner than 3 years.
Women interested in this new option should talk to their healthcare provider. The interim guidelines acknowledge that more studies are needed to further evaluate the HPV test and its role in cancer screening. For example, there are still questions about whether age 25 is the best age to start offering it as a primary screening option and how often women should be screened.
Chlamydia and Gonorrhea
Chlamydia and gonorrhea are the most common bacterial sexually transmitted diseases (STDs) in the United States today, but many infected people have no symptoms. These infections usually affect the genitals but may also cause infections of other areas, such as the throat and rectum. Pregnant women may transmit the infections to their newborns. Left untreated, these diseases can cause infertility and other health complications. However, both diseases can be cured with antibiotics.
In the United States, reported rates of chlamydia and gonorrhea are highest among adolescent girls (15-19 years of age) and young women (20-24 years old). However, any sexually active person can get infected with chlamydia or gonorrhea. Many people have both infections at the same time.
Recommendations for Women
- The U.S. Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) recommend annual chlamydia and gonorrhea screening for all sexually active women age 25 and younger. Annual screening is also recommended for women older than age 25 who are at increased risk, such as having a new sex partner or multiple sex partners.
- The U.S. Preventive Services Task Force (USPSTF) and The American Academy of Family Physicians (AAFP) recommend chlamydia and gonorrhea screening for all sexually active women age 24 and younger and for women 25 and older who are at increased risk.
For screening recommendations during pregnancy, see Pregnancy & Prenatal Testing.
Recommendations for Men
- These organizations do not recommend routine screening for healthy, sexually active, heterosexual men. Health care providers may, however, use their judgment and consider risks, such as prevalence in the community. It is important to remember that an infected man can spread these diseases and even re-infect a partner if he does not complete treatment.
- For sexually active men who have sex with men, the CDC recommends chlamydia and gonorrhea screening at least annually.
Risk
Sexually active young adults age 24 and younger have higher risk of chlamydia and gonorrhea infection than adults age 25 and older.
Examples of other risk factors include:
- Previous chlamydia or gonorrhea infections, even if you were treated successfully
- Having STDs, especially HIV
- Having new or multiple sex partners
- Having a sex partner diagnosed with an STD
- Using condoms inconsistently
- Exchanging sex for money or drugs
- Using illegal drugs
- Living in a detention facility
Because reinfection rates are high, the CDC recommends that both women and men who are treated for chlamydia or gonorrhea infection be retested approximately 3 months after treatment or at their next health care visit, regardless of whether they believe that their sex partners were treated. It is important to continue annual screening for these diseases because reinfection is always possible.
TEST | DESCRIPTION | SCREENING INTERVAL FOR PEOPLE AT AVERAGE RISK | PROS | CONS |
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Tier 1 tests | ||||
Colonoscopy | Examination of the rectum and entire colon with a lighted instrument | Every 10 years | Can examine the entire colon
Detects pre-cancerous polyps and cancer Can remove polyps and take biopsies for pathological testing |
Extensive full bowel preparation ahead of time
Sedation needed to perform Takes at least one day for prep and recovery Risk of bleeding, infection or bowel tears |
Fecal Immuno-chemical test (FIT) stool test | Test to detect hidden blood in stool samples | Annually | No dietary or drug restrictions
No bowel preparation No direct risk to bowel Samples can be collected at home |
Cannot detect precancerous changes
May miss some cancers May need to have colonoscopy if positive result |
Tier 2 tests | ||||
Flexible sigmoidoscopy | Examination of the rectum and lower colon with a rigid or flexible lighted instrument | Every 5-10 years | Minimal preparation ahead of time
Detects pre-cancerous polyps and cancer Does not usually need sedation Fairly quick and safe |
Only examines about 30% of colon
Small risk of bleeding, infection or bowel tear May need to have colonoscopy if abnormal result found |
Virtual colonoscopy (CTC, or computed tomographic colonography) | Examination of the rectum and entire colon to the small intestine using x-rays and computers; tube inserted in rectum and bowel is inflated with air | Every 5 years | No sedation required
Can view entire colon Detects pre-cancerous polyps and cancer Relatively safe; minimal risk of tear to colon |
Full bowel preparation required
May need standard colonoscopy if abnormal results Effectiveness as a screening tool is not fully accepted |
Fecal Immunochemical test (FIT)-DNA | Detects blood and mutations in specific genes associated with colon cancer in DNA isolated from a stool sample | Every three years, according to the American Cancer Society and MSTF | No bowel preparation or dietary restrictions
Sample can be collected at home No risk of bowel tear |
Cannot detect precancerous changes
Not as effective as annual FIT Adequate stool sample must be obtained Special handling needed May need colonoscopy if abnormal result found |
Capsule colonoscopy | Examination of the colon performed by swallowing an indigestible pill with embedded video cameras | Every 5 years per MSTF | Detects pre-cancerous polyps and cancer
No sedation required Relatively safe |
May need standard colonoscopy if abnormal results
Not approved by the FDA for screening people at average risk |
No Tier recommendation | ||||
Guaiac-based fecal occult blood test (gFOBT) stool test | Test to detect hidden blood in stool sample | Annually | No bowel preparation
No direct risk to bowel Sample can be collected at home |
Dietary restrictions before testing
Cannot detect precancerous changes Detects any blood, not just from cancers but from food or dental procedures May need colonoscopy if positive result |
Colon Cancer
Colon cancer is the uncontrolled growth of abnormal cells within the layers of tissue that line the colon. It is the third most common, non-skin cancer in adults and the third leading cause of cancer deaths in men and women in the United States. The lifetime risk of developing colon cancer is about 1 in 21 (or 4.7%) for men and 1 in 23 (4.4%) for women, according to the American Cancer Society (ACS).
The incidence of colon cancer has decreased over the last several years in people age 55 and older due in part to screening tests that have resulted in the removal of cancerous and precancerous polyps. However, there has been a 51% increase in colon cancer among people younger than age 50 since 1994. In 2018, the ACS lowered their recommended starting age for colon cancer screening to age 45 for people with an average risk of colon cancer. ACS says they decided to make the change in their latest guidelines because of increasing rates of colon cancer among younger people in recent years.
Furthermore, if you have one or more risk factors for colon cancer you should talk to your healthcare practitioner who can help you assess your individual risk factors and determine if you should begin screening at a younger age and more frequently. As the Centers for Disease Control and Prevention (CDC) notes, any of the recommended tests is better than no test.
Screening Recommendations
Several health organizations have colon cancer screening recommendations. In 2017, screening guidelines for the early detection of pre-cancerous polyps and colon cancer were released by the US Multi-Society Task Force (MSTF) on Colorectal Cancer. The US Preventive Services Task Force released updated similar recommendations in 2016 and the American Cancer Society (ACS) updated their guidelines in 2018. While these groups may differ on which tests to use and how often, they each support screening for colon cancer. Recommendations are based on your age and level of risk.
Increased and High Risk:
Risk of colon cancer increases with age, being overweight or obese, and with the occurrence of cancers in other parts of the body. Examples of other risk factors include:
- Family history—having one or more family members with colon cancer or multiple polyps, especially if they were younger than age 60 at diagnosis
- Diet—high fat and meat diets are risk factors, especially combined with not eating enough fruits, vegetables, and/or high-fiber foods
- Lifestyle—these risk factors include cigarette smoking, drinking excessive amounts of alcohol, and lack of regular exercise
- Having ulcerative colitis, a form of inflammatory bowel disease
- Having type 2 diabetes
- Racial or ethnic background—African Americans and Ashkenazi Jews have higher risk and rates of colon cancer compared to others.
- Having a personal history of colon cancer and/or high risk precancerous polyps
- Having a rare inherited disease called familial adenomatous polyposis (FAP)—this causes benign polyps to develop early in life and causes cancer in almost all affected persons unless the colon is removed. (See the Genetics Home Reference article on FAP)
- Having a genetic syndrome called Lynch syndrome (hereditary non-polyposis colon cancer or HNPCC) (See the Genetics Home Reference article on Lynch syndrome.)
People with increased or high risk of colon cancer may be advised to start screening at a younger age (e.g. age 40). A colonoscopy is usually recommended because it is the most accurate and thorough. Also, the recommended screening interval for high-risk individuals is shorter than for people with average risk (such as every 1-2 years compared to every 10 years).
Additionally, people who have been screened and found to have colon cancer or high risk pre-cancerous polyps also need more frequent re-testing, usually at least every 3 years. (This is called surveillance.) For example, the MSTF guidelines advise enhanced surveillance for people with 3-10 small tubular adenomas as well as those with 1 or more high-risk polyps (i.e., villous features, larger than 10 mm diameter tubular adenoma or serrated sessile polyp, or any polyp that has very atypical features, called high grade dysplasia). On the other hand, those with 1-2 small (less than 10 mm) tubular adenomas in the colon can be re-screened at normal intervals (i.e., every 10 years). Another common polyp, termed a hyperplastic polyp, is not felt to increase risk of colon cancer.
For more information on these types of polyps, read the American Cancer Society’s webpage Understanding Your Pathology Report: Colon Polyps
Average Risk
This includes people with no known risk factors other than age. The ACS recommends that all average-risk people begin screening at age 45. Both the MSTF and the USPSTF recommend that people with average risk for colon cancer begin screening at age 50. MSTF recommends that African-Americans begin at age 45.
Screening Tests
The following table summarizes the screening tests that are options for people with average risk. Tier 1 tests are the tests of choice, according to the MSTF, while tier 2 tests have some disadvantages compared to tier 1 tests. The ACS guidelines do not prioritize a particular screening test and instead says patients and their healthcare practitioners should choose from among several tests based on the patient’s preference.
Diabetes
Diabetes is the seventh leading cause of death in the United States and is becoming more common at younger ages. The Centers for Disease Control and Prevention (CDC) estimates that 30.2 million people age 18 and older, or 12.2% of all people in this age group, have diagnosed or undiagnosed diabetes. Of these, 4.6 million are 18-44 years old.
While most cases of type 1 diabetes are diagnosed in those under the age of 18, the signs and symptoms often develop rapidly and the diagnosis is often made in an emergency room setting. Thus, screening for type 1 diabetes is not necessary. On the other hand, some youth with type 2 diabetes will have no signs or symptoms, especially early in the disease, and screening can be a useful tool. Type 2 diabetes accounts for 90-95% of all diagnosed cases of diabetes among adults. Unhealthy weight and physical inactivity, both contributing factors, have also become national health problems.
It is estimated that 84.1 million American adults age 18 years or older have prediabetes, meaning that their blood glucose levels are higher than normal but not yet high enough to be diagnosed with diabetes. Detecting prediabetes allows individuals to take steps to stop or slow the development of type 2 diabetes and its complications. These complications include heart attack, stroke, hypertension, blindness and eye problems, kidney disease, and nervous system maladies. More than 60% of lower limb amputations occur in people with diabetes.
Risk Factors
Being overweight – having a body mass index (BMI) equal to or greater than 25 kg/m2 – is a major risk factor for type 2 diabetes.
Other risk factors related to your own health include:
- Physical inactivity
- Having high blood pressure (hypertension), meaning blood pressure of 140/90 mmHg or higher or receiving therapy for hypertension
- History of cardiovascular disease
- Having a HDL-cholesterol level less than 40 mg/dL (1.00 mmol/L) and/or a triglyceride level greater than 150 mg/dL (1.70 mmol/L)
- Having a previous hemoglobin A1c test result equal to or greater than 5.7%, impaired glucose tolerance (glucose tolerance test result 140 to 199 mg/dL (7.8 to 11.1 mmol/L)), or impaired fasting glucose (fasting glucose level 100 to 125 mg/dL (5.6 to 6.9 mmol/L))
- Having other conditions associated with insulin resistance, such as severe obesity and acanthosis nigracans
Family-related risk factors are:
- Having a parent or sibling with diabetes
- Being of African American, Latino, Native American, Asian American, or Pacific Islander descent
Women’s risk factors include:
- Delivering a baby weighing more than 9 pounds or having had gestational diabetes
- Having polycystic ovary syndrome
Screening tests for men and non-pregnant women
- Fasting glucose (fasting blood glucose, FBG) – this test measures the level of glucose in the blood after an 8-12 hour fast.
- Hemoglobin A1c (also called hemoglobin A1c or glycated hemoglobin) – this test evaluates the average amount of glucose in the blood over the last 2 to 3 months and has been recommended as another test to screen for diabetes.
- 2-hour glucose tolerance test (OGTT) – this test involves drawing a fasting blood sample for glucose measurement, followed by having the person drink a solution containing 75 grams of glucose and then drawing another sample two hours after the person begins to consume the glucose solution.
If any of these initial results is abnormal, the test is repeated on another day. If the repeat result is also abnormal, a diagnosis of diabetes is made.
Recommendations
The American Diabetes Association (ADA) and the U.S. Preventive Services Task Force (USPSTF) recommend the following:
- Consider screening if you are overweight and have at least one other risk factor for diabetes.
- Even if the initial screening results are normal, get repeat testing at least every 3 years, say the ADA and USPSTF. If a person is identified as having prediabetes, repeat testing yearly.
The American Association of Clinical Endocrinologists (AACE) also recommends diabetes screening for asymptomatic people with these risk factors, as well as those on antipsychotic therapy for schizophrenia or who have severe bipolar disease.As public health experts work to educate Americans on what to do to avoid diabetes and its serious complications, be aware that healthy eating habits and activity choices can lower your risk of developing type 2 diabetes and of suffering complications from the disease.
Hepatitis B
According to the Centers for Disease Control and Prevention (CDC), approximately 850,000 to 2.2 million people in this country have chronic infection with hepatitis B virus (HBV). Many of these people are unaware that they are infected.
HBV is one of five “hepatitis viruses” identified so far that are known to mainly infect the liver. It is spread through contact with blood or other body fluids from an infected person, such as during sex or by sharing needles, razors or toothbrushes, and can also be passed from an infected mother to her baby during or after birth.
HBV infection can be acute or chronic, with the course of infection varying from a mild form that lasts only a few weeks to a more serious form lasting years that can lead to complications such as cirrhosis or liver cancer. According to the CDC, approximately 1,800 people die every year in the U.S. from HBV-related liver disease.
The vast majority of those with chronic infections will have no symptoms. A test for hepatitis B surface antigen (HBsAg) may be used for screening asymptomatic people who fall into one of the high-risk categories for chronic HBV. Effective vaccines against HBV are available; however, those who have not been vaccinated or who are at high risk and were vaccinated before being screened for HBV infection may want to consider getting tested.
Recommendations
Since the prevalence of HBV infection is low in the general U.S. population and most of those infected do not develop complications, HBV screening is not recommended for those who are not at increased risk.
For people with increased risk of infection, several health organizations including the CDC, the American Association for the Study of Liver Diseases (AASLD) and the U.S. Preventive Services Task Force recommend screening for HBV. Examples of people at risk include:
- Healthcare and public safety workers with possible exposure to infected blood or other body fluids
- People born in areas of the world that have a greater than 2% prevalence of HBV (for example, much of Asia and Africa), regardless of whether they have been vaccinated
- People born in the U.S. but who were not vaccinated early in life and whose parents are from an area with greater than 8% prevalence of HBV
- Men who have sex with men
- Injection drug users
- People who have elevated liver enzymes (ALT and AST) with no known cause
- People with certain medical conditions that require that their immune system be suppressed, such as organ transplant recipients
- Dialysis patients
- People who are in close contact with someone infected with HBV or who have a sexual partner with HBV (i.e., have tested positive for HBsAg)
- Those infected with HIV
- People who were vaccinated for HBV after they had already begun high-risk behavior (e.g., men who have sex with men and injection drug users)
In addition, the AASLD recommends HBV screening for:
- People with multiple sex partners
- Those who have a history of sexually transmitted diseases (STDs)
- Prison inmates
- People with hepatitis C infection
Recommendations for HBV screening during pregnancy are addressed separately. For more information, read the Pregnancy article.
Why get tested?
People with chronic HBV can unknowingly spread the infection to others and remain at risk for serious complications of the infection.
Hepatitis C
More Americans today die from hepatitis C than from HIV, according to a 2012 study by the Centers for Disease Control and Prevention (CDC). Although many people with hepatitis C (HCV) have no symptoms for decades, if left undiagnosed and unmanaged, hepatitis C infection can progress to chronic liver damage.
Over 2.7 million Americans are living with chronic HCV infection, which can cause long-term liver damage; without treatment, it is estimated that as many as half will develop cirrhosis and/or hepatocellular carcinoma, a type of liver cancer, both of which can be fatal. The CDC noted that the observed rise in deaths primarily affects those people born between 1945 and 1965, most of whom are unaware that they have even been infected by this slowly progressing disease.
Risk
Hepatitis C is spread by exposure to contaminated blood, for example, through sharing of needles during intravenous (IV) drug abuse. Though the risk is low, transmission can also occur through sexual activity and from an infected mother to her baby during childbirth. Prior to 1992, when HCV screening of donated blood became routine, it was also possible to become infected with HCV through blood transfusion or organ transplant. Health care workers who have been exposed to infected blood are also at risk.
Recommendations
- The CDC recommends one-time testing of all people born during the 1945-1965 time period, regardless of their risk factors for hepatitis C. Those who test positive should receive screening for alcohol use and intervention as needed, followed by referral to appropriate care for the hepatitis C infection and related conditions.
- Likewise, the United States Preventive Services Task Force (USPSTF) recommends screening for all adults at high risk of hepatitis C and for anyone born between 1945 and 1965, since prevalence is highest in this group.
Why get screening?
Many people who may have contracted the virus several years ago are unaware of their condition. A one-time test for older adults could detect infections contracted long ago, allowing for timely treatment and prevention of complications.
HCV-related disease and death is preventable if detected and treated. Before 2000, chronic HCV was curable in only 10% of cases. Now, treatments for HCV can cure over 90% of those detected before late complications occur.
High Blood Pressure
Almost half of adults in the U.S. have high blood pressure, according to the American Heart Association. Blood pressure is the force that your blood puts on your artery walls. High blood pressure, also called hypertension, happens when that force is consistently too high.
Detecting and treating high blood pressure is important because it can damage your circulatory system and increases your risk of having a heart attack, stroke, and other health problems later in life. Hypertension contributes to one out of every seven deaths in the U.S. In general, the longer you have high blood pressure, the greater the potential for damage to your heart and other organs including your kidneys, brain, and eyes.
While the risk of developing high blood pressure increases with age, young adults should still pay attention to their blood pressure. Elevated blood pressure before age 40 is a risk factor for heart disease later in life.
Most people with high blood pressure aren’t aware of it because there are often no obvious symptoms. Young adults tend to lag behind older adults in hypertension awareness and treatment. Studies have shown that men age 18 to 39 have especially low rates of high blood pressure awareness. The only way to find out if you have high blood pressure is to get tested.
How is blood pressure measured?
Blood pressure was traditionally measured in healthcare settings using a blood pressure cuff with a pressure gauge (sphygmomanometer). This air-filled cuff wraps around the upper arm and obstructs blood flow. By releasing small amounts of air from the cuff, blood slowly flows back into the arm. The pressure measured inside the cuff is the same as the pressure inside the arteries.
There are two numbers measured for blood pressure. Systolic blood pressure is the pressure when your heart beats. Diastolic pressure is when the heart relaxes between beats and the pressure drops. Together, they are written as systolic over diastolic pressure. For instance, a blood pressure of 120/80 mm Hg (millimeters of mercury) corresponds to a systolic pressure of 120 and a diastolic pressure of 80.
Using a sphygmomanometer is still considered the best method but, more commonly, devices that combine a blood pressure cuff with electronic sensors are used to measure blood pressure. Another method is to have you wear a device that monitors and records the blood pressure at regular intervals during the day to evaluate your blood pressure over time. This is especially helpful during the diagnostic process and can help rule out “white coat” hypertension, the high measurements that can occur when you are at the doctor’s office and not at other times.
A single measurement of blood pressure is not enough to diagnose hypertension. Typically, multiple readings are taken on different days. A diagnosis of high blood pressure is made if measurements are consistently high.
What is normal blood pressure?
Guidelines on “normal” blood pressure differ. Read the article on Hypertension to find out what your blood pressure readings may mean.
Risk Factors
Some risk factors are related to things you can’t change, such as:
- African American descent
- A family history of high blood pressure
- Older age
Others are lifestyle factors that are under your control including:
- Being overweight or obese
- Not getting enough exercise
- Smoking
- Heavy alcohol drinking
- A diet high in salt
Sometimes medication, illegal drug use, or underlying conditions such as diabetes, kidney disease or thyroid disease, can cause hypertension. This is called secondary hypertension and treating these conditions, or stopping the medication, may remove the underlying cause of high blood pressure.
Screening Recommendations
The 2017 American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines recommends annual screening for adults with blood pressure less than 120/80 mmHg.
- If you have higher blood pressure, and are otherwise at low risk for cardiovascular disease, the guidelines recommend re-screening in 3-6 months after the initial high reading.
- If you have hypertension and are at high risk for cardiovascular disease, more frequent screenings are necessary, according to your heart disease risk and your blood pressure readings. Treatment with anti-hypertension drugs is likely necessary in these cases.
The U.S. Preventive Services Task Force (USPSTF), along with the American Academy of Family Physicians, recommends screening adults 18 and older for high blood pressure.
- Adults 18 to 39 years old with normal blood pressure (less than 130/85 mm Hg), who do not have other risk factors, should be rescreened every 3 to 5 years.
- Adults at increased risk for high blood pressure should be screened every year. The USPSTF also recommends confirming high blood pressure measurements outside of an office setting, with repeated measurements before diagnosis and treatment.
High Cholesterol
Beginning in childhood, the waxy substance called cholesterol and other fatty substances known as lipids start to build up in the arteries, hardening into plaques that narrow the passageway. During adulthood, plaque buildup and resulting health problems occur not only in arteries supplying blood to the heart muscle but in arteries throughout the body (a problem known as atherosclerosis). For both men and women in the United States, the number one cause of death is heart disease, and the amount of cholesterol in the blood greatly affects a person’s chances of suffering from it.
Monitoring and maintaining healthy levels of cholesterol are important in staying healthy. Screening for high cholesterol, typically with a lipid profile, is important because there are usually no symptoms. A lipid profile usually includes total cholesterol, HDL-cholesterol, LDL-cholesterol, and triglycerides. Non-HDL-cholesterol can also be calculated by subtracting the HDL-C value from the total cholesterol result. Typically, fasting for 9-12 hours before having the blood sample drawn is required; only water is permitted. However, some laboratories offer non-fasting lipid profiles. In particular, children and teens may have testing done without fasting.
Recommendations
Since screening recommendations are not always consistent between healthcare organizations, it’s important to work with your healthcare provider to develop a cholesterol-screening plan that is right for you.
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- The American Academy of Pediatrics (AAP) recommends routine lipid testing once between 17 and 21.
- The American Heart Association (AHA) recommends cholesterol testing (a fasting lipid profile) for all adults 20 or older every 4-6 years. More frequent testing is recommended for those at increased risk.
- The U.S. Preventive Services Task Force (USPSTF) recommends screening for high cholesterol in youths 20 and younger only if they are at increased risk. Currently, there is not enough evidence to recommend for or against routine screening in this age group, according to the Task Force.
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For adults 21 to 39, the USPSTF’s 2016 guidelines do not recommend for or against cholesterol screening. This is based on a lack of evidence that screening before age 40 has an effect on cardiovascular health. The USPSTF recommends that clinicians use their judgment when deciding to screen people in this age group.
The USPSTF advises healthcare practitioners and their patients to go beyond screening for high cholesterol and evaluate a person’s overall risk for heart disease to determine who may benefit from treatment with cholesterol-lowering statins.
Risk Factors
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- Family History: Young adults are at increased risk if they have a parent, grandparent, aunt/uncle, or sibling who has high cholesterol or if they have a family history of cardiovascular disease (prior to age 55 in male relative and age 65 in female relative).
- Personal Health: Young adults are also at higher risk if they:
- Are overweight or obese
- Have a diet high in fats, especially saturated or trans fat
- Get little or no exercise
- Have diabetes or hypertension (high blood pressure)
- Smoke cigarettes or using other tobacco products
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Human Immunodeficiency Virus (HIV)
HIV is the virus that causes AIDS (acquired immunodeficiency syndrome), a life-threatening disease. Initially, an HIV infection may cause no symptoms or cause non-specific, flu-like symptoms that resolve after a short time period. The only way to determine whether a person has been infected is through HIV testing.
If the infection is not detected and treated, eventually symptoms of AIDS emerge and begin to progressively worsen. Without treatment, HIV destroys the immune system over time and leaves a person’s body vulnerable to debilitating infections.
HIV is spread in the following ways:
- By having sex with an infected partner
- By sharing needles or syringes (such as with intravenous injection drug abuse)
- During pregnancy or birth; if a pregnant woman is infected with HIV, the virus can be passed to and infect her developing baby.
- Through contact with infected blood
- In the U.S. today, because of screening blood for transfusion and heat-treating techniques and other treatments of blood derivatives, the risk of getting HIV from transfusions is extremely small. However, before donated blood was screened beginning in 1985 in the U.S. and before treatments were introduced to destroy HIV in some blood products, such as factor 8 and albumin, HIV was transmitted through transfusion of contaminated blood or blood components.
Why Get Screening?
Screening for HIV is now part of routine healthcare in the United States and is an important part of wellness and prevention. This is because diagnosis early in the course of infection leads to timely, effective treatment that decreases the risk of progression to AIDS. A major National Institutes of Health (NIH) clinical trial published in 2015 found that individuals with HIV have a lower risk of developing AIDS and other serious illnesses if they start antiretroviral therapy sooner rather than later.
Early diagnosis also has important benefits for others and society at large. Thousands of people are diagnosed with HIV each year, and about 1 in 8 people in the United States with HIV are unaware that they have it. An individual can prevent further disease spread by learning their status, modifying behavior and not exposing others to infected blood or body fluids. Pregnant women who have HIV can start treatment to prevent spreading the disease to their children.
If an HIV screening test shows a person is not infected, he or she can take steps to avoid infection. For individuals who are HIV-negative but at high risk for HIV, the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) recommend that they consider taking pre-exposure prophylaxis (PrEP), a daily pill to help prevent infection. For people taking PrEP consistently, the risk of HIV infection is significantly lower compared to those who did not take it.
Know Your Risk
Several situations put you at high risk of contracting HIV:
- You’ve had unprotected sex with more than one partner.
- You have or have had a sexually transmitted disease (STD), which appears to make people more susceptible to and at higher risk for acquiring HIV infection during sex with infected partners.
- You’re a man who has had sexual contact with another man.
- You have exchanged sex for money or drugs or had anonymous sex.
- You use or used injection drugs and are likely to have shared unsterilized needles.
- You have an HIV-positive sexual partner.
- You have had sex with anyone who falls into one of the categories listed above or are uncertain about your sexual partner’s risk behaviors.
- You’ve been diagnosed with or treated for hepatitis or tuberculosis (TB).
How often you are tested should depend on your risk, activities, and sexual contacts. For example, during a long-term, truly monogamous sexual relationship, you may want just one test. However, if you or your partner have had sexual contact with more than one person in recent months, your risk of infection is greater. If you or a person with whom you’ve had sexual contact (even unwanted sexual contact) engaged in some risky behavior, you have even more reason to be tested.
Screening Tests
Different types of tests are available for HIV screening:
- Combination HIV antibody and HIV antigen test—this is the recommended screening test for HIV. It is available only as a blood test. It detects the HIV antigen called p24 plus antibodies to HIV-1 and HIV-2. (HIV-1 is the most common type found in the United States, while HIV-2 has a higher prevalence in parts of Africa.) By detecting both antibody and antigen, the combination test increases the likelihood that an infection is detected soon after exposure. These tests can detect HIV infections in most people by 2-6 weeks after exposure.
- HIV antibody testing—all HIV antibody tests used in the U.S. detect HIV-1, and some tests have been developed that can also detect HIV-2. These tests are available as blood tests or tests of oral fluid. HIV antibody tests can detect infections in most people 3-12 weeks after exposure.
Various options are available for getting tested:
- A blood or oral sample can be collected in a healthcare provider’s office or a local clinic and sent to a laboratory for testing. In these same settings, a rapid test may available in which results are generated in about 20 minutes.
- A home collection kit approved by the U.S. Food and Drug Administration (FDA) is available for HIV antibody testing. This allows a person to take a sample at home and then mail it to a testing center. Results are available over the phone, along with appropriate counseling.
- The FDA has approved an HIV test for home use. The testing kit is the same as that used in many healthcare providers’ offices and clinics in which an oral sample is collected for testing and results are available in about 20 minutes. Though the home test is convenient, it has limitations. It is less sensitive than a blood test so the home test may miss some cases of HIV that a blood test would detect and it is not as accurate when it is performed at home by a lay person compared to when it is performed by a trained healthcare professional. Care must be taken to avoid errors when performing the test. (For more, see the article on Home Testing, Avoiding Errors.)
Screening tests have limitations, so it is important to remember that:
- A negative screening test means only that there is no evidence of disease at the time of the test. If you have increased risk of HIV infection but negative screening results, it is very important to get screening tests on a regular basis.
- HIV tests will not detect the virus immediately after infection. Still, talk to your healthcare provider immediately if you think you’ve been infected. If exposure to the virus is recent, then antibody levels may be too low to detect. If an initial test is negative, it may be necessary to repeat testing at a later time with another antibody test or combination HIV antibody/antigen test. In the case of a negative result, the CDC recommends retesting three months after likely exposure.
- A positive screening test is not a diagnosis. A positive result must be followed by a second antibody test that differentiates between HIV-1 and HIV-2 to establish a diagnosis.
For more details on HIV screening, see the article on HIV Antibody and p24 Antigen.
Screening Recommendations
- The Centers for Disease Control and Prevention (CDC) recommends that everyone 13 to 64 years old have an HIV screening test at least once. The CDC recommends getting tested each year if you’ve engaged in an activity that can put you at increased risk of infection and spreading the disease. Additionally, men who have sexual contact with other men should be tested be tested every three to six months.
- The United States Preventive Services Task Force (USPSTF) recommends that all teens and adults ages 15 to 65 be screened for HIV infection. It also recommends that younger adolescents and older adults at increased risk undergo screening for HIV. As for how often, the Task Force says a reasonable approach is one-time testing for all people ages 15 to 65 and at least annual screenings for those at very high risk of HIV, such as men who have sex with men, injection drug users, and those who live or receive medical care in areas where the rate of HIV infection is high. Individuals at increased but not very high risk may be screened less frequently than every year. The USPSTF recommends every three to five years as a guideline. The Task Force points out that risk is “on a continuum” and health professionals should use their own discretion in deciding how frequently to test people for HIV.
- The American College of Physicians agrees with the CDC that everyone aged 13 to 64 be offered an HIV screening test in healthcare settings. It also recommends that healthcare practitioners should determine the frequency of repeat screening on an individual basis.
- The American Academy of Pediatrics (AAP) recommends targeted HIV screening for all sexually active youth. In addition, the academy advises routine testing starting at age 16 for all teens who live in areas where prevalence is high; that is, where more than 1 in 1,000 individuals are infected.
- For recommendations specific for pregnant women, see the article on Pregnancy.
Aside from these recommendations, certain individuals should get tested and learn their status. These include:
- People diagnosed with hepatitis, TB, or an STD
- People who received a blood transfusion prior to 1985 or had a sexual partner who received a transfusion and later tested positive for HIV
- A healthcare worker with direct exposure to blood on the job
- Any individual who thinks he or she may have been exposed
Talk to your healthcare provider
Don’t be surprised if a healthcare practitioner, in any care setting, offers you an HIV screening test, in keeping with CDC recommendations. If your healthcare provider does not bring up sexual health topics, you can simply ask for a test or a risk assessment. You can also use confidential services to obtain testing or counseling.
Obesity
More than one-third of adults in the U.S. are obese, according to the Centers for Disease Control and Prevention. Over the past 20 years, the rate of obesity has increased steadily throughout the U.S. in all age ranges and remains high.
Obesity is a serious health concern because it increases the risk of many conditions, such as high blood pressure (hypertension), dyslipidemias (high cholesterol and/or high triglycerides), type 2 diabetes, coronary heart disease, stroke, and some cancers.
Calculating a person’s body mass index (BMI) can be useful for assessing their body fat. It is a screening tool for determining if someone has a weight problem. For adults, the following formula and classifications are used:
BMI = (Weight in pounds) / (height in inches squared) x 703
BMI < 18.5 Underweight
BMI 18.5-24.9 Normal weight
BMI 25.0 – 29.9 Overweight
BMI 30 and above Obese
Recommendations
The U.S. Preventive Services Task Force (USPSTF) recommends that healthcare practitioners screen all adult patients for obesity, and the American Academy of Family Physicians agrees. In 2012, the USPSTF published an updated recommendation that clinicians offer or refer obese patients to intensive behavioral interventions, which can lead to weight loss, possibly improving glucose tolerance and other cardiovascular disease (CVD) risk factors. The Task Force is currently (2016) reviewing its recommendations.
Osteoporosis
Osteoporosis is a growing concern for Americans. According to the National Osteoporosis Foundation, 10 million Americans have this disease and 43 million are at risk. It is also estimated that half of all women over age 50 will break a bone because of osteoporosis and so will 1 in 4 men.
With aging comes an increased risk of fractures as well as a reduced ability to recover from such injuries. Fracturing the hip, spine, or wrist can cause pain, disability, and deformity for an older person. Being immobilized in this way often means losing independence and needing long-term care.
Because osteoporosis often is “silent” until a fracture occurs, you may not notice you have this disease or realize you are at risk. Getting screened for low bone mass and osteoporosis and treating the problem can help reduce your risk of a fracture.
Risk Factors
The following factors increase a person’s risk of bone loss and osteoporosis:
- Being female (of those with osteoporosis, 80% are women)
- Older age
- Small, thin body size
- Being white or Asian in ethnicity
- Having a family history of osteoporosis or broken bones
- Having low levels of sex hormones (estrogen in women, testosterone in men), such as during menopause in women
- Having anorexia nervosa
- Deficiencies in calcium and vitamin D
- Lack of exercise
- Smoking cigarettes and drinking alcohol
- Use of certain medications
Recommendations
The bone mineral density (BMD) test is the primary test used to identify osteoporosis and low bone mass. One of the preferred and most accurate ways to measure BMD is Dexa-Scan (dual-energy X-ray absorptiometry or DXA). It uses a low energy X-ray to evaluate bone density in the hip and/or spine.
A number of organizations have published screening guidelines for osteoporosis.
The American College of Obstetricians and Gynecologists (ACOG) has guidelines for women and recommends:
- Bone mineral density screening for all women beginning at age 65.
- Postmenopausal women younger than 65 can be screened with DXA if they have significant risk factors for osteoporosis and/or bone fracture.
- In the absence of new risk factors, DXA screening should not be performed more frequently than every two years.
- Use of FRAX, a fracture risk assessment tool, to further predict someone’s risk of bone fracture in the next 10 years; can be done annually to monitor effect of age on fracture risk.
The U.S. Preventive Service Task Force (USPSTF) recommends:
- Osteoporosis screening for women 65 years of age or older and for younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors.
- For men, the Task Force says the current evidence is insufficient to assess whether screening for osteoporosis would be beneficial or harmful.
The National Osteoporosis Foundation recommends screening adults with bone mineral density testing as follows:
- Women 65 years of age and older as well as some younger postmenopausal women who have risk factors or who have had a fracture as an adult.
- Men age 70 and older as well as those age 50 to 69 who have risk factors or have had a fracture as an adult.
Osteoporosis screening guidelines for men published in May 2008 by the American College of Physicians point out that this condition is underdiagnosed in men.
- The guidelines recommend periodic risk assessment for osteoporosis in older men and DXA for men who are at increased risk and are candidates for drug therapy.
The Endocrine Society issued guidelines in 2012 for managing osteoporosis in men that recommend:
- Men at high risk for osteoporosis (e.g., those aged 70 and older; those aged 50-69 with risk factors like low body weight, smoking, and previous fracture) should be screened with DXA.
Prostate Cancer
Prostate cancer is the second most frequently diagnosed cancer in men, after skin cancer. It is also the second leading cause of cancer death, after lung cancer. As many as 1 in 7 American men will develop it during their lifetime, with most cases diagnosed in men 65 years of age or older. Some prostate cancers progress quickly and cause death within months or a few years, but most grow slowly and never pose a major health threat.
Screening for prostate cancer is important for men to discuss with their healthcare providers. Many complicated issues are involved:
- Current technology cannot tell a slow-growing cancer from a fast one, and the cancer may never significantly affect a man’s health or life expectancy.
- Screening tests for prostate-specific antigen (PSA) do not detect all cases, and some elevated PSA results do not prove to be cancer.
- Diagnosis through biopsy (with a small risk of infection and bleeding) and side effects of treatment (which could cause erectile dysfunction and incontinence) can potentially be harmful itself. Most prostate cancers are slow-growing and may not cause any trouble.
- Results from long-term trials on whether PSA testing improves prostate cancer survival rates have been inconclusive.
Informed decisions
In spite of the questions surrounding prostate cancer screening, most health organizations agree that men should receive balanced information about prostate cancer screening and recommend that men discuss it with their healthcare provider. You need to know the risks, uncertainties, benefits, and limits of prostate cancer testing and treatment and should work with your healthcare provider to understand your options and decide what is best for you. Before choosing prostate screening, you should weigh the pros and cons based on your age, life expectancy, family history, race, overall health, previous test results, and individual risk tolerance.
Risk
One important factor to consider is your personal risk of developing prostate cancer:
- Average risk: Healthy men with no known risk factors
- Increased risk: African American men or men who have a father or brother who was diagnosed before they were 65
- High risk: Men with more than one relative who was affected at a young age
Tests
If you choose to undergo screening, the following tests may be recommended:
- Prostate specific antigen (PSA)—blood test that measures the level of PSA in the blood
- Digital rectal exam (DRE)—part of a physical exam that the health practitioner performs to examine the prostate gland
Recommendations
Most organizations do not recommend prostate cancer screening for men 49 and younger, unless they have increased or high risk. The exception is the National Comprehensive Cancer Network.
- The National Comprehensive Cancer Network (NCCN) recommends a baseline test at age 45 for men who want screening, which will determine when and how often to have future tests. It advises using the DRE and the PSA test, in combination, for the broadest detection of cancer in its early stages. If the PSA test result is greater than 1.0 ng/mL, or if the man is at a higher risk, it recommends a DRE and PSA test at one- to two-year intervals.
- The U.S. Preventive Services Task Force (USPSTF) says that for men younger than age 50 at increased risk, including African American men and men with a family history of prostate cancer, a reasonable approach is to discuss the benefits and harms of PSA screening to make an informed decision. The decision is based on the harm that can come from false-positive PSA test results which then may lead to surgical or radiation treatment that may ultimately provide little benefit.
- The American Cancer Society (ACS) recommends that healthy men with average risk who wish to be screened consider waiting to get tested until age 50. ACS recommends considering earlier testing for higher-risk groups.
- If you are African American or have a father or brother who was diagnosed before they were 65, ACS recommends considering testing at 45 years of age.
- If more than one relative was affected at a young age, you could begin testing at 40 years old; then, depending on the results, get tested again at age 45 or earlier as results warrant.
- ACS recommends re-screening every two years if your PSA level is less than 2.5 ng/mL and annual screening if it is 2.5 ng/mL or higher.
- The American Urological Association (AUA) recommends waiting to have a baseline PSA and DRE until age 55 for men at average risk who wish to be screened. For those at increased or high risk, AUA advises that decisions regarding prostate cancer screening be individualized based on patient preferences and an informed discussion about benefits and harms.
- The American College of Physicians advises against screening men younger than age 50.
Thyroid Dysfunction
Thyroid diseases are primarily conditions that affect the amount of thyroid hormones being produced and thyroid cancer, which usually does not affect the level of thyroid hormones. It is estimated that 20 million Americans have some form of thyroid disease, and approximately 60% of those do not know it. Women are more likely than men to have thyroid problems, with 1 in 8 developing thyroid dysfunction during her life.
Examples of thyroid dysfunction include hypothyroidism, in which too little thyroid hormone is produced, and hyperthyroidism, in which too much is produced. Although people may experience symptoms, these can be so vague – like fatigue and weight changes – that many of those affected do not realize that they have an underactive or overactive thyroid. If left untreated, thyroid disorders can lead to other health problems, including heart disease.
Recommendations
Opinions vary on who can benefit from screening and at what age to begin.
- The U.S. Preventive Services Task Force reviewed the evidence for and against screening in 2004 and announced it could not determine the balance of benefits and harms of screening asymptomatic adults for thyroid disease.
The American Thyroid Association and the American Association of Clinical Endocrinologists released clinical practice guidelines in 2012 that recommend the following:
- Screening for hypothyroidism should be considered in patients over the age of 60.
On the other hand, if you have symptoms that might or might not be due to thyroid dysfunction, no matter what your age or sex, a number of organizations recommend testing to rule out thyroid dysfunction as a cause. Talk to your doctor about whether getting tested would be appropriate. As you age and experience what seem to be natural signs of aging, particularly if you are a woman, be alert to the possibility of thyroid problems.
Tuberculosis
Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis bacteria. TB primarily targets the lungs but may affect any area of the body. It can be spread through the air from person to person through droplets of respiratory secretions such as sputum or aerosols released by coughing, sneezing, laughing, or breathing.
Most people who become infected with M. tuberculosis manage to confine the mycobacteria to a few cells in their lungs, where they stay alive but in an inactive form. This latent TB infection does not make the person sick or infectious and, in most cases, it does not progress to active tuberculosis. However, some people – especially those with compromised immune systems – may progress directly from initial TB infection to active tuberculosis. People who have HIV are much more likely to become sick if they contract TB. A person who has latent TB and their immune system becomes weakened may then develop active TB. Another increasing concern is drug-resistant forms of TB that are resistant to the antibiotics typically prescribed to treat the disease.
TB is one of the world’s deadliest diseases, although it is relatively uncommon in the U.S. Still, it is a large health issue among at-risk groups. Current guidelines call for targeted screening among such groups.
At Risk
- People who have close contact with a person who has known or suspected TB disease
- People with weakened immune systems such as resulting from HIV infection, malnutrition, advanced age, or substance abuse including alcohol and drugs
- Immigrants from countries with a high rate of TB disease (many countries in Latin America, Africa, Asia, Eastern Europe, and Russia)
- Medically underserved people, such as those from a low-income environment
- Residents of long-term care facilities (such as nursing homes, mental health facilities, prisons, AIDS care facilities, and homeless shelters)
- People who live in unclean or crowded environments and/or without a healthy diet
- Healthcare workers who work in any of the above situations or with patients who are at increased risk
- Laboratorians who work with specimens that may contain TB or with TB cultures
Recommendations
The U.S. Centers for Disease Control and Prevention (CDC) and the U.S. Preventive Services Task Force (USPSTF) recommend use of TB tests to identify people who will likely benefit from treatment, including those at increased risk for M. tuberculosis infection or for progression to active TB if they are infected. There are two types of tests that might be performed:
- IGRA TB blood test (preferred): also known as interferon gamma release assay, requires a blood sample to be drawn.
- Tuberculin skin test (TST) also called the Mantoux tuberculin skin test, the TST (or PPD for Purified Protein Derivative) is performed by injecting a small amount of fluid (called tuberculin) into the skin in the lower part of the arm. Following this test, you must return within 48 to 72 hours for a trained healthcare worker to measure the reaction and determine if it indicates exposure to M. tuberculosis.