USPSTF Issues Draft Recommendations for Obesity, Cervical Cancer Screening

The U.S. Preventive Services Task Force, or USPSTF, is updating its screening guidelines for both adult obesity and cervical cancer and has issued new draft recommendations on both topics. The task force also has released a draft recommendation regarding counseling to prevent skin cancer in young people.

All three recommendations currently are available for public comment. (Editor's Note: The public comment periods for all three draft recommendations expired as of Dec. 6, and the draft recommendations have been removed from the USPSTF website. When the recommendations are finalized, they will be posted on the USPSTF site.)

In 2003, the task force recommended that physicians screen all adult patients for obesity and offer adults identified as obese "intensive counseling and behavioral interventions to promote sustained weight loss." In that recommendation, the USPSTF defined intensive counseling as more than one session per month for at least three months.

The current draft recommendation, however, calls for physicians to screen adults for obesity, and "offer or refer patients with a body mass index greater than 30 kg/m2 to intensive, multicomponent behavioral interventions." In the Clinical Considerations section of the new draft recommendation, the USPSTF notes that patients with obesity lose an average of 6 percent of their baseline weight when they participate in 12-26 behavioral intervention sessions during the first year of treatment.

"We now have evidence that the intensive, multicomponent behavioral interventions can also improve glucose tolerance and other risk factors for cardiovascular disease in obese adults," said USPSTF Co-vice Chair Michael LeFevre, M.D., M.S.P.H., of Columbia, Mo.

Behavioral interventions include setting weight-loss goals, improving nutrition and increasing physical activity; addressing barriers to change; and self-monitoring. The recommendation acknowledges that such intensive interventions are rarely practiced in primary care settings, although patients can be referred to weight-loss programs where they are available.

The Patient Protection and Affordable Care Act calls for USPSTF recommendations with an A or a B rating to be covered by health plans without cost-sharing. The draft recommendation for obesity carries a B rating.

LeFevre, however, said that the task force is not involved in coverage decisions, and he could not predict how the recommendation will be used to influence third-party coverage for the screening or the behavioral interventions. That determination is up to HHS, he said.

"As a family physician, I would suggest that many of us do not have access to referral for the types of behavioral interventions that have been demonstrated to be effective," said LeFevre, who also is professor and vice chair in the department of family and community medicine at the University of Missouri, Columbia. "I believe that if the people making decisions about coverage would decide that this aspect of prevention is worth it, it's very likely we would see an increase in availability of such services.

"We could save some downstream morbidity as well as potential costs by covering these interventions. Cost is a barrier to getting some patients in these types of multicomponent behavioral interventions."

The draft recommendation also notes that treatments that combine medications with behavioral interventions resulted in weight loss and improvement in physiologic outcomes. However, the USPSTF cautioned that the FDA has linked orlistat to rare but severe liver disease, and long-term safety data for the drug are lacking. The task force also pointed out that metformin is not approved by the FDA for treating obesity.

"We were not able to find any evidence that patients kept weight off after discontinuing use of weight-loss medications," LeFevre said. "We're specifically recommending behavioral counseling rather than medications for weight loss."

The draft recommendation is based on an evidence review published last month. A public comment period on the proposed recommendation ends Nov. 23.

Also in 2003, the USPSTF recommended that women who have had sex and have a cervix have a Pap smear at least every three years. The task force's new draft recommendation on cervical cancer screening specifies that the test be done "every three years" in women ages 21-65 who have had vaginal sex and have a cervix.

The draft recommendation offers other specifics about age, stating that women younger than age 21, regardless of sexual history, should not be screened because there is moderate certainty that the harms of screening patients in this age group outweigh the benefits.

The USPSTF also now recommends against screening for cervical cancer using human papillomavirus, or HPV, testing -- alone or in combination with cytology -- in women younger than age 30 because the harms outweigh the benefits. Moreover, the task force says that evidence is insufficient to assess the balance of benefits and harms of HPV testing, alone or in combination with cytology, for screening women 30 and older.

LeFevre said the rate of false-positives associated with acute HPV infection is high, and most of those HPV infections resolve spontaneously.

"What we're interested in is not dealing with negative effects of cytology changes from acute infection but, rather, screening people with persistent infection who, therefore, have abnormal cytology later," he said.

The USPSTF draft recommendation, which is based on an evidence review published last month, differs from a draft recommendation published by the American Cancer Society, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology that calls for HPV testing in combination with cytology in women 30 and older every three to five years.

LeFevre said the USPSTF worked with the three other groups to deliberately publish both sets of draft recommendations on Oct. 19. The groups will continue to work together, he said, to "emphasize the commonalities, rather than differences, of opinion."

The USPSTF public comment period for the cervical cancer draft recommendation ends Nov. 16.

Finally, the task force, which concluded in 2003 that evidence was insufficient to recommend for or against routine counseling by primary care physicians to prevent skin cancer, published a draft recommendation on Nov. 8 that included a B-rated recommendation to counsel individuals ages 10-24 years who have fair skin about minimizing their exposure to ultraviolet radiation to reduce the risk for and prevent incidences of skin cancer.

Ultraviolet radiation includes not only sun exposure but also indoor tanning beds, booths and sunlamps.

"We found evidence that counseling helps reduce exposure to ultraviolet radiation and will help prevent skin cancer," LeFevre said. "People are more likely to use sunscreen and change their behaviors if they receive counseling from their physician."

The USPSTF concluded that evidence is insufficient to assess the balance of benefits and harms of counseling adults older than 24 about ultraviolet radiation.

The recommendation for younger patients discusses using booklets, videos and peer counseling to affect behaviors related to sun exposure, indoor tanning and the use of sunscreen.

The public comment period for this draft recommendation ends Dec. 6.

The AAFP's Commission on Health of the Public and Science has reviewed the draft recommendation for cervical cancer screening and submitted comments in support of the recommendation. The commission will review the draft recommendations for obesity and skin cancer prevention and likely will submit comments about those recommendations, as well.