The Adult Well Male Examination



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Am Fam Physician. 2012 May 15;85(10):964-971.

  Related Editorial

  Patient information: See related handout on men's health, written by the authors of this article.

  Related letter: Additional Screenings in the Adult Well Male Examination

The adult well male examination should incorporate evidence-based guidance toward the promotion of optimal health and well-being, including screening tests shown to improve health outcomes. Nearly one-third of men report not having a primary care physician. The medical history should include substance use; risk factors for sexually transmitted infections; diet and exercise habits; and symptoms of depression. Physical examination should include blood pressure and body mass index screening. Men with sustained blood pressures greater than 135/80 mm Hg should be screened for diabetes mellitus. Lipid screening is warranted in all men 35 years and older, and in men 20 to 34 years of age who have cardiovascular risk factors. Ultrasound screening for abdominal aortic aneurysm should occur between 65 and 75 years of age in men who have ever smoked. There is insufficient evidence to recommend screening men for osteoporosis or skin cancer. The U.S. Preventive Services Task Force has provisionally recommended against prostate-specific antigen–based screening for prostate cancer because the harms of testing and overtreatment outweigh potential benefits. Screening for colorectal cancer should begin at 50 years of age in men of average risk and continue until at least 75 years of age. Screening should be performed by high-sensitivity fecal occult blood testing every year, flexible sigmoidoscopy every five years combined with fecal occult blood testing every three years, or colonoscopy every 10 years. [corrected] The U.S. Preventive Services Task Force recommends against screening for testicular cancer and chronic obstructive pulmonary disease. Immunizations should be recommended according to guidelines from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.

The goals of the adult well male examination are to provide evidence-based guidance toward the promotion of optimal health and well-being, to prevent premature morbidity and mortality from chronic diseases, and to provide age-appropriate screenings and immunizations. The primary source of preventive care guidelines is the U.S. Preventive Services Task Force (USPSTF),1 which informs the clinical policies of the American Academy of Family Physicians.2 Guidelines produced by specialty groups may offer additional guidance, but can provide conflicting recommendations. Currently, there is no consensus regarding the optimal frequency of adult well male examinations.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Adult males should be counseled about healthy lifestyle habits, including the following:

Smoking cessation

A

17

Limiting alcohol intake

B

7

Reducing their risk of sexually transmitted infections

C

1315

Screening for human immunodeficiency virus in men at increased risk

A

15

Dyslipidemia screening in men 35 years and older, and in younger men with cardiovascular risk factors

A

23

Colorectal cancer screening beginning at 50 years of age and continuing to at least 75 years of age

A

42

Age- and interval-appropriate immunizations, including a tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) booster, regardless of time since the previous booster

C

64


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Adult males should be counseled about healthy lifestyle habits, including the following:

Smoking cessation

A

17

Limiting alcohol intake

B

7

Reducing their risk of sexually transmitted infections

C

1315

Screening for human immunodeficiency virus in men at increased risk

A

15

Dyslipidemia screening in men 35 years and older, and in younger men with cardiovascular risk factors

A

23

Colorectal cancer screening beginning at 50 years of age and continuing to at least 75 years of age

A

42

Age- and interval-appropriate immunizations, including a tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) booster, regardless of time since the previous booster

C

64


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

Male socialization, coupled with challenges in accessing health care services, creates significant problems for men in knowing when to access preventive care.3 In 2007, men between 15 and 65 years of age were significantly less likely than women to seek preventive care from a primary care physician (15 percent versus 44 percent, respectively, as a percentage of total visits).4 Nearly one in three men reports having no primary care physician, compared with one in five women.5  Data from the Centers for Disease Control and Prevention (CDC) show that a substantial percentage of men have suboptimal health status, risk factors, and insurance coverage (Table 16).

Table 1.

Current Statistics on Men's Health and Well-Being

48 percent do not regularly engage in physical activity*

33 percent are obese†

32 percent have had five or more alcoholic drinks in one day at least once in the past year*

31 percent have hypertension†

22 percent smoke*

20 percent of men younger than 65 years do not have health insurance

12 percent rate their overall health as fair or poor*


*—18 years and older.

†—20 years and older.

Information from reference 6.

Table 1.   Current Statistics on Men's Health and Well-Being

View Table

Table 1.

Current Statistics on Men's Health and Well-Being

48 percent do not regularly engage in physical activity*

33 percent are obese†

32 percent have had five or more alcoholic drinks in one day at least once in the past year*

31 percent have hypertension†

22 percent smoke*

20 percent of men younger than 65 years do not have health insurance

12 percent rate their overall health as fair or poor*


*—18 years and older.

†—20 years and older.

Information from reference 6.

History

The medical history of adult males should comprise medical and surgical histories, as well as current medication use and allergies. Family history of chronic diseases and cancer should be obtained. Social history should focus on lifestyle risks that contribute to premature morbidity and mortality, including substance use, risk factors for sexually transmitted infections (STIs), and current diet and exercise habits (Table 22,717).

Table 2.

Screening Guidelines for Lifestyle Risks in Men

Risk USPSTF/AAFP recommendation (evidence rating*) Comments

Alcohol misuse

Screen and offer behavioral counseling interventions to reduce alcohol misuse (B).7

Inquire about alcohol consumption to identify men who consume more than 14 drinks per week or more than four drinks per occasion; recommend no more than two drinks per occasion.

Depression

Screen all men when care support systems are in place (B); do not screen routinely when they are not (C).8

Healthy diet

Provide intensive behavioral dietary counseling for adults with hyperlipidemia and other risk factors for cardiovascular and diet-related chronic disease (not rated).2

The U.S. Department of Health and Human Services recommends that adults decrease their daily intake of saturated fat, cholesterol, sodium, and added sugar.9

Illicit drug use

Evidence is insufficient to balance benefits and harms of routine screening (I).10

Obesity

Screen all men for obesity, and offer intensive counseling and behavioral interventions to promote sustained weight loss (B).11

Encourage gradual and sustained weight loss in persons whose weight exceeds the ideal for their height.

Physical activity

The AAFP recognizes that physical activity is desirable, but the effectiveness of physician advice and counseling is uncertain.2

The U.S. Department of Health and Human Services recommends that men participate in at least 150 minutes of moderate-intensity aerobic exercise per week, as well as muscle strengthening at least twice per week.12[corrected]

Sexually transmitted infections

Screen and provide high-intensity behavioral counseling to men at high risk of sexually transmitted infections (B), syphilis (A), and human immunodeficiency virus infection (A).1315

The Centers for Disease Control and Prevention recommends screening all men 64 years and younger for human immunodeficiency virus infection at least once, regardless of risk factors.16

Evidence is insufficient to assess the balance of benefits and harms of behavioral counseling to prevent sexually transmitted infections in adults who are not at increased risk (I).13

Evidence is insufficient to assess the balance of benefits and harms of screening asymptomatic men for gonorrhea or chlamydia, even in those at high risk (I).

Tobacco use

Inquire about tobacco use and provide cessation interventions (A).17

Short behavioral counseling sessions and pharmacotherapy are effective in increasing the proportion of smokers who successfully quit and remain abstinent for one year.


AAFP = American Academy of Family Physicians; USPSTF = U.S. Preventive Services Task Force.

*—Evidence ratings: A = the USPSTF recommends the service; there is high certainty that the net benefit is substantial. B = the USPSTF recommends the service; there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. C = the USPSTF recommends against routinely providing the service; there may be considerations that support providing the service in an individual patient; there is at least moderate certainty that the net benefit is small. D = the USPSTF recommends against the service; there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. I = the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service; evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Information from references 2, and 7 through 17.

Table 2.   Screening Guidelines for Lifestyle Risks in Men

View Table

Table 2.

Screening Guidelines for Lifestyle Risks in Men

Risk USPSTF/AAFP recommendation (evidence rating*) Comments

Alcohol misuse

Screen and offer behavioral counseling interventions to reduce alcohol misuse (B).7

Inquire about alcohol consumption to identify men who consume more than 14 drinks per week or more than four drinks per occasion; recommend no more than two drinks per occasion.

Depression

Screen all men when care support systems are in place (B); do not screen routinely when they are not (C).8

Healthy diet

Provide intensive behavioral dietary counseling for adults with hyperlipidemia and other risk factors for cardiovascular and diet-related chronic disease (not rated).2

The U.S. Department of Health and Human Services recommends that adults decrease their daily intake of saturated fat, cholesterol, sodium, and added sugar.9

Illicit drug use

Evidence is insufficient to balance benefits and harms of routine screening (I).10

Obesity

Screen all men for obesity, and offer intensive counseling and behavioral interventions to promote sustained weight loss (B).11

Encourage gradual and sustained weight loss in persons whose weight exceeds the ideal for their height.

Physical activity

The AAFP recognizes that physical activity is desirable, but the effectiveness of physician advice and counseling is uncertain.2

The U.S. Department of Health and Human Services recommends that men participate in at least 150 minutes of moderate-intensity aerobic exercise per week, as well as muscle strengthening at least twice per week.12[corrected]

Sexually transmitted infections

Screen and provide high-intensity behavioral counseling to men at high risk of sexually transmitted infections (B), syphilis (A), and human immunodeficiency virus infection (A).1315

The Centers for Disease Control and Prevention recommends screening all men 64 years and younger for human immunodeficiency virus infection at least once, regardless of risk factors.16

Evidence is insufficient to assess the balance of benefits and harms of behavioral counseling to prevent sexually transmitted infections in adults who are not at increased risk (I).13

Evidence is insufficient to assess the balance of benefits and harms of screening asymptomatic men for gonorrhea or chlamydia, even in those at high risk (I).

Tobacco use

Inquire about tobacco use and provide cessation interventions (A).17

Short behavioral counseling sessions and pharmacotherapy are effective in increasing the proportion of smokers who successfully quit and remain abstinent for one year.


AAFP = American Academy of Family Physicians; USPSTF = U.S. Preventive Services Task Force.

*—Evidence ratings: A = the USPSTF recommends the service; there is high certainty that the net benefit is substantial. B = the USPSTF recommends the service; there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. C = the USPSTF recommends against routinely providing the service; there may be considerations that support providing the service in an individual patient; there is at least moderate certainty that the net benefit is small. D = the USPSTF recommends against the service; there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. I = the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service; evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Information from references 2, and 7 through 17.

SUBSTANCE USE

Men should be asked about tobacco and alcohol use at every visit; evidence is insufficient to recommend screening for illicit drug use.7,10,17 The “5-A” behavioral counseling framework is recommended to engage patients in discussions about smoking cessation: (1) ask about tobacco use; (2) advise the patient to quit through clear, personalized messages; (3) assess the patient's willingness to quit; (4) assist the patient in quitting; and (5) arrange follow-up and support.17 Screening for alcohol misuse can accurately identify men whose amount and patterns of consumption may meet criteria for alcohol dependence and increase their risk of associated morbidity and mortality from disease and accidents.7 The CAGE (feeling the need to Cut down, Annoyed by criticism, Guilty about drinking, and need for an “Eye-opener” in the morning) questionnaire is the most popular screening test for detecting alcohol abuse or dependence in primary care.18 For men, risky drinking is defined as more than 14 drinks per week, or more than four drinks per occasion.7

SEXUALLY TRANSMITTED INFECTIONS

Risk factors for STIs (e.g., multiple sex partners, unprotected intercourse, men who have sex with men) should be determined to select appropriate candidates for screening.1315 In men at increased risk, high-intensity behavioral counseling to prevent STIs has been shown to be effective if performed in multiple group sessions over three to nine hours; single sessions lasting less than 30 minutes were found to be ineffective.19 Screening for human immunodeficiency virus infection should be performed routinely in persons who report no individual risk factors but are seen in high-risk or high-prevalence clinical settings (e.g., STI clinics, correctional facilities, homeless shelters, tuberculosis clinics, adolescent health clinics with a high prevalence of STIs, clinics that serve men who have sex with men).15 A summary of the USPSTF and CDC recommendations for STI screening is available at http://www.aafp.org/afp/2008/0315/p819.html.

DEPRESSION

Although women have higher rates of depression compared with men, many men remain undiagnosed because of a lack of willingness to seek help and discuss their symptoms.3 Factors that increase the risk of depression include concomitant psychiatric disorders (including alcohol and drug abuse), family history of depression, chronic medical conditions, unemployment, and lower socioeconomic status.8

Physical Examination

Evidence-based components of the adult well male physical examination include blood pressure and body mass index (BMI) screening11,20  (Table 311,2029).

Table 3.

Screening Guidelines for Chronic Diseases in Men

Disease USPSTF/AAFP recommendation (evidence level*) Other guidelines

Abdominal aortic aneurysm

Screen once with ultrasonography in men 65 to 75 years of age if they have a family history or have smoked at least100 cigarettes in their lifetime (B).21

NA

No recommendation for or against screening in men 65 to 75 years of age who have never smoked (C).21

Chronic obstructive pulmonary disease

Do not screen adults with spirometry (D).22

NA

Dyslipidemia

Screen men 35 years and older (A), and men 20 to 34 years of age who have cardiovascular risk factors (B).23

The National Cholesterol Education Program–Adult Treatment Panel III recommends screening with a fasting lipoprotein profile once every five years.24

Hypertension

Screen men 18 years and older; evidence is lacking on optimal screening interval (A).20

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommends screening every two years in patients with a blood pressure less than 120/80 mm Hg, and every year in those with a blood pressure of 120/80 to 139/89 mm Hg.25

Obesity (body mass index greater than 30 kg per m2)

Screen all men and offer intensive counseling and behavioral interventions to promote sustained weight loss (A).11

NA

Evidence is insufficient to recommend for or against counseling with behavioral interventions to promote sustained weight loss in men with body mass index of 25 to 30 kg per m2 (I).11

Osteoporosis

Evidence is insufficient to assess the balance of benefits and harms of screening (I); men most likely to benefit from screening would have 10-year risks for osteoporotic fracture equal to or greater than those of 65-year-old white women who have no additional risk factors.27

The National Osteoporosis Foundation recommends performing bone mineral density testing in all men 70 years and older, and in men 50 to 69 years of age who have additional risk factors.26

Type 2 diabetes mellitus

Screen men with a sustained blood pressure greater than 135/80 mm Hg (B).28

The American Diabetes Association recommends screening all men 45 years and older, or older asymptomatic men with a body mass index greater than 25 kg per m2 and cardiovascular risk factors.29

Evidence is insufficient to assess the balance of benefits and harms of screening in asymptomatic men with a blood pressure less than 135/80 mm Hg (I).28


AAFP = American Academy of Family Physicians; NA = not available; USPSTF = U.S. Preventive Services Task Force.

*—Evidence ratings: A = the USPSTF recommends the service; there is high certainty that the net benefit is substantial. B = the USPSTF recommends the service; there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. C = the USPSTF recommends against routinely providing the service; there may be considerations that support providing the service in an individual patient; there is at least moderate certainty that the net benefit is small. D = the USPSTF recommends against the service; there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. I = the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service; evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Information from references 11, and 20 through 29.

Table 3.   Screening Guidelines for Chronic Diseases in Men

View Table

Table 3.

Screening Guidelines for Chronic Diseases in Men

Disease USPSTF/AAFP recommendation (evidence level*) Other guidelines

Abdominal aortic aneurysm

Screen once with ultrasonography in men 65 to 75 years of age if they have a family history or have smoked at least100 cigarettes in their lifetime (B).21

NA

No recommendation for or against screening in men 65 to 75 years of age who have never smoked (C).21

Chronic obstructive pulmonary disease

Do not screen adults with spirometry (D).22

NA

Dyslipidemia

Screen men 35 years and older (A), and men 20 to 34 years of age who have cardiovascular risk factors (B).23

The National Cholesterol Education Program–Adult Treatment Panel III recommends screening with a fasting lipoprotein profile once every five years.24

Hypertension

Screen men 18 years and older; evidence is lacking on optimal screening interval (A).20

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommends screening every two years in patients with a blood pressure less than 120/80 mm Hg, and every year in those with a blood pressure of 120/80 to 139/89 mm Hg.25

Obesity (body mass index greater than 30 kg per m2)

Screen all men and offer intensive counseling and behavioral interventions to promote sustained weight loss (A).11

NA

Evidence is insufficient to recommend for or against counseling with behavioral interventions to promote sustained weight loss in men with body mass index of 25 to 30 kg per m2 (I).11

Osteoporosis

Evidence is insufficient to assess the balance of benefits and harms of screening (I); men most likely to benefit from screening would have 10-year risks for osteoporotic fracture equal to or greater than those of 65-year-old white women who have no additional risk factors.27

The National Osteoporosis Foundation recommends performing bone mineral density testing in all men 70 years and older, and in men 50 to 69 years of age who have additional risk factors.26

Type 2 diabetes mellitus

Screen men with a sustained blood pressure greater than 135/80 mm Hg (B).28

The American Diabetes Association recommends screening all men 45 years and older, or older asymptomatic men with a body mass index greater than 25 kg per m2 and cardiovascular risk factors.29

Evidence is insufficient to assess the balance of benefits and harms of screening in asymptomatic men with a blood pressure less than 135/80 mm Hg (I).28


AAFP = American Academy of Family Physicians; NA = not available; USPSTF = U.S. Preventive Services Task Force.

*—Evidence ratings: A = the USPSTF recommends the service; there is high certainty that the net benefit is substantial. B = the USPSTF recommends the service; there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. C = the USPSTF recommends against routinely providing the service; there may be considerations that support providing the service in an individual patient; there is at least moderate certainty that the net benefit is small. D = the USPSTF recommends against the service; there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. I = the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service; evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Information from references 11, and 20 through 29.

BLOOD PRESSURE SCREENING

Hypertension is defined as a systolic blood pressure of 140 mm Hg or more, or a diastolic blood pressure of 90 mm Hg or more. It should be diagnosed only after two or more elevated readings are obtained on at least two visits over a period of one to several weeks.25 The USPSTF states that in patients with hypertension, the global risk of cardiovascular disease (smoking status, diabetes mellitus, dyslipidemia, age, sex, sedentary lifestyle, and obesity) should be considered when making treatment decisions.20 The Framingham risk calculator (available at http://hp2010.nhlbihin.net/atpiii/calculator.asp) can be used to determine the 10-year risk of cardiovascular events in men 20 years and older who have not been diagnosed with cardiovascular disease or diabetes.

BMI SCREENING

Height and weight measurements should be obtained at every visit.11 Physicians may also consider measuring abdominal waist circumference in some men; measurements greater than 40 inches (101.6 cm) are associated with an increased risk of type 2 diabetes, dyslipidemia, hypertension, and cardiovascular disease in men with BMIs of 25 to 34.9 kg per m2.30 In men with BMIs of 35 kg per m2 or greater, waist circumference has limited additional predictive power of cardiovascular disease risk beyond that of BMI alone.30 In Asian and black men, waist circumference may be a better indicator of cardiovascular risk than BMI.31

Screening for Chronic Diseases

DIABETES

Thirteen million U.S. men 20 years and older (nearly one in eight) have diabetes.32 Diabetes is considered a cardiovascular risk equivalent because it confers an elevated 10-year risk.28 The American Diabetes Association defines diabetes as an A1C level of at least 6.5 percent; a fasting plasma glucose level of at least 126 mg per dL (6.99 mmol per L); a plasma glucose level of at least 200 mg per dL (11.10 mmol per L) two hours after ingesting a 75-g glucose load; symptoms of uncontrolled hyperglycemia (e.g., polyuria, polydipsia, polyphagia); and a random plasma glucose level of at least 200 mg per dL.29 The USPSTF recommends screening for diabetes in men with a sustained blood pressure of at least 135/80 mm Hg.

DYSLIPIDEMIA

Men 35 years and older, and men 20 to 34 years who have additional cardiovascular risk factors, should be screened for dyslipidemia.23 The fasting lipoprotein profile is the preferred screening test.23,24 For nonfasting samples, total cholesterol and high-density lipoprotein cholesterol levels are recommended.23 The optimal interval for screening is not known, and no age has been established at which physicians should stop screening.

ABDOMINAL AORTIC ANEURYSM

Abdominal aortic aneurysm (AAA) occurs in 5 to 10 percent of men 65 to 79 years of age.33 The mortality rate after dissection and rupture approaches 80 percent for men who reach the hospital and 50 percent for men who undergo emergent surgical repair.33 Risk factors include smoking, hypertension, dyslipidemia, family history, and atherosclerosis. Smoking is the risk factor most strongly associated with AAA (odds ratio = 5.1) and accounts for 75 percent of all aneurysms at least 4.0 cm in diameter.34 Twelve to 19 percent of first-degree relatives of men with an AAA will develop an aneurysm.35 Only 30 percent of asymptomatic AAAs are discovered on physical examination, with sensitivity and specificity of 68 and 75 percent, respectively.36,37

The USPSTF recommends a one-time ultrasound screening for AAA in men 65 to 75 years of age who have ever smoked,21 because randomized trials have shown that the benefits of screening and surgical repair in this high-risk group outweigh the harms. One trial found a number needed to screen of 349 to prevent one AAA-related death over 4.3 years.38

OSTEOPOROSIS

Although the USPSTF found insufficient evidence to recommend screening for osteoporosis in men, it states that if the relative benefits and harms of therapy for osteoporosis are similar in men and women, the men most likely to benefit from screening would have 10-year risks for osteoporotic fracture equal to or greater than those of 65-year-old white women who have no additional risk factors.27 The National Osteoporosis Foundation recommends bone mineral density testing in all men 70 years or older and in men 50 to 69 years of age who have additional risk factors.26 The Institute of Medicine recommends that men 19 to 70 years of age aim for a dietary intake of 1,000 mg of calcium and 600 IU of vitamin D3 daily, whereas men 71 years and older should consume 1,200 mg of calcium and 800 IU of vitamin D daily, using supplements if dietary intake falls short of these goals.39

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

The USPSTF recommends against screening adults for chronic obstructive pulmonary disease using spirometry.22 Men with this condition, including those with mild or moderate illness, will benefit from smoking cessation and annual influenza vaccination. Although moderate evidence suggests that influenza vaccination reduces exacerbations of chronic obstructive pulmonary disease, no studies have assessed whether spirometry leads to increased influenza vaccination rates.40

Cancer Screening

The USPSTF recommends against screening for testicular cancer in adolescent and adult males41  (Table 4 4149). Because the incidence is low and treatment is often effective even in advanced stages, the benefits of earlier detection are minimal and are likely outweighed by the harms of false-positive results and unnecessary work-ups for benign conditions.41 There is insufficient evidence to assess the balance of benefits and harms of a whole-body skin examination by a primary care clinician or patient skin self-examination for the early detection of skin cancer in men.48

Table 4.

Cancer Screening Guidelines for Men

Type of cancer USPSTF/AAFP recommendations (evidence rating*) Other guidelines

Colorectal

Begin screening at 50 years of age in men of average risk, and continue until 75 years of age; offer fecal occult blood testing every year, flexible sigmoidoscopy every five years combined with fecal occult blood testing every three years, or colonoscopy every 10 years (A).42[corrected]

The American College of Gastroenterology endorses colonoscopy as the preferred screening test, and does not recommend double-contrast barium enema.43

Recommendations from the American Cancer Society are the same as those of the USPSTF and AAFP, but include the options of computed tomographic colonography every five years, fecal immunochemical testing every year, or fecal DNA testing (no currently established interval).44

Prostate

PSA-based screening should not be performed at any age because the harms outweigh the benefits (D; draft recommendation).45 Men older than 75 years should not be screened because the harms outweigh the benefits (D).45

The American Urological Association recommends offering PSA testing and digital rectal examination to well-informed men beginning at 40 years of age and continuing until life expectancy is less than 10 years.46

The American Cancer Society recommends discussing the risks and benefits of screening with men 50 to 75 years of age, and initiating screening at45 years of age in black men and in those with a first-degree relative who was diagnosed with prostate cancer before 65 years of age.47

Additional screening options, including age-adjusted PSA values, free PSA levels, PSA velocity, and doubling time, have been suggested. No current evidence suggests that these testing strategies improve outcomes.

Skin

There is insufficient evidence to assess the balance of benefits and harms of whole-body skin examination or patient skin self-examination for the early detection of skin cancer (I; 2009).48

NA

Testicular

Do not routinely perform clinical screening or self-examination (D).41

The National Cancer Institute states that screening would result in unnecessary diagnostic procedures with attendant morbidity.49


AAFP = American Academy of Family Physicians; NA = not available; PSA = prostate-specific antigen; USPSTF = U.S. Preventive Services Task Force.

*—Evidence ratings: A = the USPSTF recommends the service; there is high certainty that the net benefit is substantial. B = the USPSTF recommends the service; there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. C = the USPSTF recommends against routinely providing the service; there may be considerations that support providing the service in an individual patient; there is at least moderate certainty that the net benefit is small. D = the USPSTF recommends against the service; there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. I = the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service; evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Information from references 41 through 49.

Table 4.   Cancer Screening Guidelines for Men

View Table

Table 4.

Cancer Screening Guidelines for Men

Type of cancer USPSTF/AAFP recommendations (evidence rating*) Other guidelines

Colorectal

Begin screening at 50 years of age in men of average risk, and continue until 75 years of age; offer fecal occult blood testing every year, flexible sigmoidoscopy every five years combined with fecal occult blood testing every three years, or colonoscopy every 10 years (A).42[corrected]

The American College of Gastroenterology endorses colonoscopy as the preferred screening test, and does not recommend double-contrast barium enema.43

Recommendations from the American Cancer Society are the same as those of the USPSTF and AAFP, but include the options of computed tomographic colonography every five years, fecal immunochemical testing every year, or fecal DNA testing (no currently established interval).44

Prostate

PSA-based screening should not be performed at any age because the harms outweigh the benefits (D; draft recommendation).45 Men older than 75 years should not be screened because the harms outweigh the benefits (D).45

The American Urological Association recommends offering PSA testing and digital rectal examination to well-informed men beginning at 40 years of age and continuing until life expectancy is less than 10 years.46

The American Cancer Society recommends discussing the risks and benefits of screening with men 50 to 75 years of age, and initiating screening at45 years of age in black men and in those with a first-degree relative who was diagnosed with prostate cancer before 65 years of age.47

Additional screening options, including age-adjusted PSA values, free PSA levels, PSA velocity, and doubling time, have been suggested. No current evidence suggests that these testing strategies improve outcomes.

Skin

There is insufficient evidence to assess the balance of benefits and harms of whole-body skin examination or patient skin self-examination for the early detection of skin cancer (I; 2009).48

NA

Testicular

Do not routinely perform clinical screening or self-examination (D).41

The National Cancer Institute states that screening would result in unnecessary diagnostic procedures with attendant morbidity.49


AAFP = American Academy of Family Physicians; NA = not available; PSA = prostate-specific antigen; USPSTF = U.S. Preventive Services Task Force.

*—Evidence ratings: A = the USPSTF recommends the service; there is high certainty that the net benefit is substantial. B = the USPSTF recommends the service; there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. C = the USPSTF recommends against routinely providing the service; there may be considerations that support providing the service in an individual patient; there is at least moderate certainty that the net benefit is small. D = the USPSTF recommends against the service; there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. I = the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service; evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Information from references 41 through 49.

PROSTATE CANCER

Significant controversy exists about prostate cancer screening in primary care.4547 The prostate-specific antigen (PSA) serologic assay is the most commonly used test for detection of prostate cancer, but the proportion of clinically significant prostate cancer detected is unknown. The lifetime risk of prostate cancer is 16 percent, and the lifetime risk of dying from the disease is 3.4 percent.46,50 A subgroup analysis of a single large randomized controlled trial suggested that PSA screening may decrease mortality (number needed to screen to prevent one prostate cancer–related death = 1,410).51 The USPSTF recently released a draft recommendation against PSA-based screening in men of all ages, based on its conclusion that the harms from screening and overtreatment outweigh potential benefits.45,52,53 Expert opinion from the American Urological Association and data from an uncontrolled trial suggest that if prostate cancer screening is performed, it should combine digital rectal examination and the PSA test, which improves detection compared with either test alone.46,54

COLORECTAL CANCER

Colonoscopy is increasingly becoming the preferred screening test for colorectal cancer, but there are no randomized controlled trials comparing colonoscopy, flexible sigmoidoscopy, and fecal occult blood testing (FOBT) with a definable outcome of cancer-specific or all-cause mortality.42,55,56 No randomized trial has compared colonoscopy with other screening modalities or no screening, and observational studies suggest that the incremental benefits of colonoscopy compared with other modalities may be exaggerated, given the increased harms associated with the procedure and sedation.57,58 A study evaluating colorectal cancer detection rates estimated that if 10,000 persons were screened, sigmoidoscopy would detect 168 with advanced neoplasms versus 191 using colonoscopy.59

A meta-analysis revealed that FOBT offered a 13 percent relative reduction in colorectal cancer mortality with a number needed to screen of 833 over 12 years, but did not reduce all-cause mortality.60 Fecal immunochemical testing and guaiac-based FOBT have similar sensitivity (82 percent versus 62 percent, respectively), but both modalities have poor sensitivity in the detection of adenomas (30 percent versus 41 percent, respectively).61 Fecal DNA testing yields more false-positive results compared with FOBT (16 percent versus 5 percent).62 Computed tomographic colonography has an 88 percent specificity in classifying results as negative, but it does not detect one out of 25 advanced lesions.63 The USPSTF recommends beginning screening for colorectal cancer at 50 years of age and continuing until at least 75 years of age, using high-sensitivity FOBT every year, flexible sigmoidoscopy every five years combined with FOBT every three years, or colonoscopy every 10 years.42[corrected]

Immunizations

Current immunization guidelines from the CDC's Advisory Committee on Immunization Practices are available online (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6104a9.htm). Annual influenza vaccination is strongly encouraged for all adults. For men younger than 65 years, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination is recommended, regardless of the time since the previous booster.64 Tdap is also recommended over tetanus and diphtheria toxoids (Td) vaccination for adults 65 years and older who will be in contact with children younger than one year.

Data Sources: We reviewed the U.S. Preventive Services Task Force, Cochrane, Agency for Healthcare Research and Quality, DynaMed, Essential Evidence Plus, and National Guideline Clearinghouse databases. A Medline search was conducted using the key words men's health, guidelines, sexually transmitted infections, hypertension, blood pressure screening, abdominal aortic aneurysm, diabetes mellitus, dyslipidemia, obesity, osteoporosis, chronic obstructive pulmonary disease, prostate cancer, colorectal cancer, testicular cancer, skin cancer, and immunizations. Search dates: April, May, and October 2011.

The Authors

JOEL J. HEIDELBAUGH, MD, FAAFP, FACG, is a clinical associate professor of family medicine and urology, and is the clerkship director in the Department of Family Medicine at the University of Michigan Medical School, Ann Arbor.

MICHELLE TORTORELLO, MD, is a third-year family medicine resident at the University of Michigan Medical School.

Address correspondence to Joel J. Heidelbaugh, MD, FAAFP, FACG, Ypsilanti Health Center, 200 Arnet, Ste. 200, Ypsilanti, MI 48198 (e-mail: jheidel@umich.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations to disclose.

REFERENCES

1. U.S. Preventive Services Task Force. USPSTF A-Z topic guide. http://www.uspreventiveservicestaskforce.org/uspstopics.htm. Accessed April 2, 2011.

2. American Academy of Family Physicians. Clinical preventive services. http://www.aafp.org/online/en/home/clinical/exam.html. Accessed April 2, 2011.

3. White AK. Report on the scoping study on men's health. London, UK: Department of Health; 2001.

4. Hsiao CJ, Cherry DK, Beatty PC, Rechtsteiner EA. National ambulatory medical care survey: 2007 summary. http://www.cdc.gov/nchs/data/nhsr/nhsr027.pdf. Accessed May 1, 2011.

5. Sandman D, Simantov E, An C. Out of touch: American men and the health care system. Commonwealth Fund Men's and Women's Health Survey findings. http://www.usrf.org/breakingnews/Men_out_of_touch.pdf. Accessed April 13, 2011.

6. Centers for Disease Control and Prevention. FastStats: men's health. http://www.cdc.gov/nchs/fastats/mens_health.htm. Accessed April 22, 2011.

7. U.S. Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse. http://www.uspreventiveservicestaskforce.org/3rduspstf/alcohol/alcomisrs.htm. Accessed May 21, 2011.

8. U.S. Preventive Services Task Force. Screening for depression in adults. http://www.uspreventiveservicestaskforce.org/uspstf/uspsaddepr.htm. Accessed May 15, 2011.

9. US Department of Agriculture, U.S. Department of Health and Human Services. Dietary guidelines for Americans, 2010. http://www.cnpp.usda.gov/publications/DietaryGuidelines/2010/PolicyDoc/PolicyDoc.pdf. Accessed October 28, 2011.

10. U.S. Preventive Services Task Force. Screening for illicit drug use. http://www.uspreventiveservicestaskforce.org/uspstf/uspsdrug.htm. Accessed May 21, 2011.

11. U.S. Preventive Services Task Force. Screening for obesity in adults. http://www.uspreventiveservicestaskforce.org/uspstf/uspsobes.htm. Accessed May 14, 2011.

12. U.S. Department of Health and Human Services. 2008 Physical activity guidelines for Americans. http://www.health.gov/paguidelines. Accessed October 28, 2011.

13. U.S. Preventive Services Task Force. Behavioral counseling to prevent sexually transmitted infections. http://www.uspreventiveservicestaskforce.org/uspstf/uspsstds.htm. Accessed May 21, 2011.

14. U.S. Preventive Services Task Force. Screening for syphilis infection. http://www.uspreventiveservicestaskforce.org/uspstf/uspssyph.htm. Accessed May 21, 2011.

15. U.S. Preventive Services Task Force. Screening for HIV. http://www.uspreventiveservicestaskforce.org/uspstf/uspshivi.htm. Accessed May 21, 2011.

16. Branson BM, Handsfield HH, Lampe MA, et al.; Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1–17.

17. U.S. Preventive Services Task Force. Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women. http://www.uspreventiveservicestaskforce.org/uspstf/uspstbac2.htm. Accessed May 21, 2011.

18. Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA. 1984;252(14):1905–1907.

19. Lin JS, Whitlock E, O'Connor E, Bauer V. Behavioral counseling to prevent sexually transmitted infections: a systematic review for the U.S. Preventive Services Task Force Ann Intern Med. 2008;149(7):497–508.

20. U.S. Preventive Services Task Force. Screening for high blood pressure. Reaffirmation recommendation statement. http://www.uspreventiveservicestaskforce.org/uspstf07/hbp/hbprs.htm. Accessed May 7, 2011.

21. U.S. Preventive Services Task Force. Screening for abdominal aortic aneurysm. http://www.uspreventiveservicestaskforce.org/uspstf/uspsaneu.htm. Accessed May 15, 2011.

22. U.S. Preventive Services Task Force. Screening for chronic obstructive pulmonary disease using spirometry. http://www.uspreventiveservicestaskforce.org/uspstf/uspscopd.htm. Accessed October 11, 2011.

23. U.S. Preventive Services Task Force. Screening for lipid disorders in adults. http://www.uspreventiveservicestaskforce.org/uspstf/uspschol.htm. Accessed May 25, 2011.

24. National Cholesterol Education Program. Detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). Executive summary. NIH Publication No. 01-3670. http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3xsum.pdf. Accessed February 9, 2012.

25. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42(6):1206–1252.

26. National Osteoporosis Foundation. Clinician's guide to prevention and treatment of osteoporosis. http://www.nof.org/sites/default/files/pdfs/NOF_ClinicianGuide2009_v7.pdf. Accessed March 23, 2012.

27. U.S. Preventive Services Task Force. Screening for osteoporosis. http://www.uspreventiveservicestaskforce.org/uspstf/uspsoste.htm. Accessed May 8, 2011.

28. U.S. Preventive Services Task Force. Screening for type 2 diabetes mellitus in adults. http://www.uspreventiveservicestaskforce.org/uspstf/. Accessed May 25, 2011.

29. American Diabetes Association. Standards of medical care in diabetes—2010 [published correction appears in Diabetes Care. 2010; 33(3):692]. Diabetes Care. 2010;33(suppl 1):S11–S61.

30. National Heart Lung and Blood Institute. Guidelines on overweight and obesity: electronic textbook. http://www.nhlbi.nih.gov/guidelines/obesity/e_txtbk/txgd/4142.htm. Accessed May 7, 2011.

31. Gallagher D, Visser M, Sepúlveda D, Pierson RN, Harris T, Heymsfield SB. How useful is body mass index for comparison of body fatness across age, sex, and ethnic groups? Am J Epidemiol. 1996;143(3):228–239.

32. National Diabetes Information Clearinghouse. National diabetes statistics, 2011. http://www.diabetes.niddk.nih.gov/dm/pubs/statistics/#fast. Accessed May 25, 2011.

33. Cosford PA, Leng GC. Screening for abdominal aortic aneurysm Cochrane Database Syst Rev. 2007(2):CD002945.

34. Lederle FA, Johnson GR, Wilson SE, et al.; Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators. The Aneurysm Detection and Management Study screening program: validation cohort and final results. Arch Intern Med. 2000;160(10):1425–1430.

35. van Vlijmen-van Keulen CJ, Pals G, Rauwerda JA. Familial abdominal aortic aneurysm: a systematic review of a genetic background. Eur J Vasc Endovasc Surg. 2002;24(2):105–116.

36. Simon G, Nordgren D, Connelly S, Shultz PJ. Screening for abdominal aortic aneurysms in a hypertensive patient population. Arch Intern Med. 1996;156(18):2081–2084.

37. Fink HA, Lederle FA, Roth CS, Bowles CA, Nelson DB, Haas MA. The accuracy of physical examination to detect abdominal aortic aneurysm. Arch Intern Med. 2000;160(6):833–836.

38. Lindholt JS, Juul S, Fasting H, Henneberg EW. Screening for abdominal aortic aneurysms: single centre randomised controlled trial [published correction appears in BMJ. 2005;331(7521):876]. BMJ. 2005;330 (7494):750.

39. Institute of Medicine. Dietary reference intakes for calcium and vitamin D. http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D.aspx. Accessed May 8, 2011.

40. Lin K, Watkins B, Johnson T, Rodriguez JA, Barton MB. Screening for chronic obstructive pulmonary disease using spirometry: summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2008;148(7):535–543.

41. U.S. Preventive Services Task Force. Screening for testicular cancer. http://www.uspreventiveservicestaskforce.org/uspstf/uspstest.htm. Accessed May 8, 2011.

42. U.S. Preventive Services Task Force. Screening for colorectal cancer. http://www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm. Accessed May 26, 2011.

43. Rex DK, Johnson DA, Anderson JC, Schoenfeld PS, Burke CA, Inadomi JM. American College of Gastroenterology guidelines for colorectal cancer screening 2009 [published correction appears in Am J Gastroenterol. 2009;104(6):1613]. Am J Gastroenterol. 2009;104(3):739–750.

44. American Cancer Society. American Cancer Society guidelines for the early detection of cancer. http://www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer. Accessed October 22, 2011.

45. Chou R, Croswell JM, Dana T, et al. Screening for prostate cancer: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2011;155(11):762–771.

46. American Urological Association. Prostate-specific antigen best practice statement: 2009 update. http://www.auanet.org/content/media/psa09.pdf. Accessed May 14, 2011.

47. American Cancer Society. Prostate cancer: early detection. http://www.cancer.org/Cancer/ProstateCancer/MoreInformation/ProstateCancerEarlyDetection/prostate-cancer-early-detection-acs-recommendations. Accessed February 9, 2012.

48. U.S. Preventive Services Task Force. Screening for skin cancer. http://www.uspreventiveservicestaskforce.org/uspstf/uspsskca.htm. Accessed October 10, 2011.

49. National Cancer Institute. Testicular cancer screening PDQ. http://www.cancer.gov/cancertopics/pdq/screening/testicular/HealthProfessional. Accessed October 22, 2011.

50. National Cancer Institute. SEER cancer statistics review, 1975–2005. http://seer.cancer.gov/csr/1975_2005. Accessed February 9, 2012.

51. Schröder FH, Hugosson J, Roobol MJ, et al.; ERSPC Investigators. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med. 2009;360(13):1320–1328.

52. Lin K, Lipsitz R, Miller T, Janakiraman S. Benefits and harms of prostate-specific antigen screening for prostate cancer: an evidence update for the U.S. Preventive Services Task Force. Ann Intern Med. 2008;149(3):192–199.

53. Wilt TJ, MacDonald R, Rutks I, Shamliyan TA, Taylor BC, Kane RL. Systematic review: comparative effectiveness and harms of treatments for clinically localized prostate cancer [published correction appears in Ann Intern Med. 2008;148(11):888]. Ann Intern Med. 2008;148(6):435–448.

54. Richie JP, Catalona WJ, Ahmann FR, et al. Effect of patient age on early detection of prostate cancer with serum prostate-specific antigen and digital rectal examination. Urology. 1993;42(4):365–374.

55. Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology. 2008;134(5):1570–1595.

56. Zapka JM, Klabunde CN, Arora NK, Yuan G, Smith JL, Kobrin SC. Physicians' colorectal cancer screening discussion and recommendation patterns. Cancer Epidemiol Biomarkers Prev. 2011;20(3):509–521.

57. Baxter NN, Goldwasser MA, Paszat LF, Saskin R, Urbach DR, Rabeneck L. Association of colonoscopy and death from colorectal cancer. Ann Intern Med. 2009;150(1):1–8.

58. Baxter NN, Rabeneck L. Is the effectiveness of colonoscopy “good enough” for population-based screening? J Natl Cancer Inst. 2010;102(2):70–71.

59. Segnan N, Senore C, Andreoni B, et al.; SCORE3 Working Group-Italy. Comparing attendance and detection rate of colonoscopy with sigmoidoscopy and FIT for colorectal cancer screening. Gastroenterology. 2007;132(7):2304–2312.

60. Moayyedi P, Achkar E. Does fecal occult blood testing really reduce mortality? A reanalysis of systematic review data. Am J Gastroenterol. 2006;101(2):380–384.

61. Allison JE, Sakoda LC, Levin TR, et al. Screening for colorectal neoplasms with new fecal occult blood tests: update on performance characteristics. J Natl Cancer Inst. 2007;99(19):1462–1470.

62. Ahlquist DA, Sargent DJ, Loprinzi CL, et al. Stool DNA and occult blood testing for screen detection of colorectal neoplasia Ann Intern Med. 2008;149(7):441–450W81.

63. Regge D, Laudi C, Galatola G, et al. Diagnostic accuracy of computed tomographic colonography for the detection of advanced neoplasia in individuals at increased risk of colorectal cancer. JAMA. 2009;301(23):2453–2461.

64. Centers for Disease Control and Prevention (CDC). Recommended adult immunization schedule—United States, 2011. MMWR Morb Mortal Wkly Rep. 2011;60(4):1–4.



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