Cancer care: clinical guidance and practice resources

The USPSTF found insufficient evidence to determine whether screening for bladder cancer in asymptomatic adults improves health outcomes. Because the accuracy of available tests and the benefits and harms of screening and treatment are unclear, the USPSTF concludes evidence is inadequate to assess the balance of benefits and harms.

See the full recommendation for more information (PDF)

The USPSTF recommends primary care clinicians assess women with a personal or family history of breast, ovarian, tubal or peritoneal cancer—or ancestry associated with BRCA1/2 gene mutations—using a brief familial risk assessment tool. Women with positive assessments should receive genetic counseling and, if indicated, testing. The USPSTF recommends against routine risk assessment, genetic counseling or genetic testing for women whose history or ancestry is not associated with BRCA1/2 mutations.

See the full recommendation for more information

The USPSTF recommends offering risk-reducing medications such as tamoxifen, raloxifene or aromatase inhibitors to women aged 35 years and older who are at increased risk for breast cancer and at low risk for adverse effects. It recommends against routinely prescribing these drugs for women not at increased risk and notes this guidance does not apply to women with current or past breast cancer or ductal carcinoma in situ.

See the full recommendation for more information

USPSTF recommends screening mammography every two years for women aged 40 to 74 years. For women aged 75 years and older and for those with dense breasts considering additional imaging such as ultrasound or MRI, the USPSTF finds the evidence insufficient to determine benefits versus harms.

See the full recommendation for more information.

The USPSTF recommends screening for cervical cancer every 3 years with cytology alone for women aged 21 to 29 years. For women aged 30 to 65 years, screening may be done every 3 years with cytology alone or every 5 years with high-risk human papillomavirus testing, with or without cytology. The USPSTF recommends against screening women younger than 21 years, women aged 65 years and older who have had adequate prior screening and are not at high risk, and women who have had a hysterectomy with removal of the cervix and no history of high-grade lesions or cervical cancer.

See the full recommendation for more information

Rationale:

The AAFP has reviewed the US Preventive Services Task Force recommendation for colorectal cancer screening in adults. The AAFP agrees with the USPSTF that screening should be recommended for adults aged 50-75 based on substantial net benefit for this age group.

Screening in this setting refers to asymptomatic individuals using fecal immunochemical tests (e.g. high sensitivity gFOBT, FIT, and sDNA-FIT), flexible sigmoidoscopy, computed tomography colonoscopy, or colonoscopy. The decision of which screening modality to use should be based on a shared decision-making discussion of the benefits and harms of each modality. Patient preferences and values as well as transportation, access to healthcare services, and other social determinants of health are all necessary in the shared decision-making process.

These recommendations do not apply to individuals who are symptomatic or at increased risk for colorectal cancer (e.g. family history, prior diagnosis of colon cancer, adenomatous polyps, or inflammatory bowel disease).

The AAFP also agrees with the USPSTF that screening for colorectal cancer in adults 76 years and older should be selectively offered as the net benefit in this age group is small and will be dependent on patient screening history, overall health status and individual preferences.

The AAFP does not agree with the USPSTF that there is sufficient evidence for screening for colorectal cancer in adults aged 45 to 49 years. The USPSTF recommendation for this age group centered on indirect evidence from modeling studies. Many of the trials did not include individuals under age 50 or did not provide these data separately decreasing the confidence in the data inputs. Additionally, the modeling studies assumed 100% adherence to screening and follow up protocols which may artificially elevate life years gained from earlier screening.

The AAFP noted that while the incidence of colorectal cancer in younger individuals is increasing,¹ it is still relatively small and that the increased risk in this age group may be overestimated. There was also concern that there is no evidence that tumors in younger adults behave similarly to tumors in older adults and that early detection would be as beneficial.

These concerns decrease the confidence that the balance of benefits and harms is moderate in this age group. Further, decreasing the age for onset of screening may exacerbate disparities due to differences in access to healthcare and screening facilities. Studies have shown that disparities in colorectal cancer mortality are driven by differences in screening rates and not in true incidence of disease.²

The AAFP recognizes the increased incidence and mortality rates of colorectal cancer in Black individuals due to health disparities arising from systemic racism in the healthcare system. To reduce disparities, family physicians should have a standardized screening protocol and monitor their practices for disparities. Family physicians must be aware of the role of systemic racism in healthcare and work within their practices to develop anti-racism policies and practices. AAFP has provided resources on social determinants of health and implicit bias as part of The EveryOne Project.

In addition to strongly encouraging more data for screening individuals under age 50, the impact of social determinants including systemic racism, the AAFP continues to advocate for more research on the efficacy and harms of the newer screening modalities.

^{1. Siegel RL, Miller KD, Fedewa SA, et al. Colorectal cancer statistics, 2017. CA Cancer J Clin. 2017;67(3):177-193.}

^{2. Rutter CM, Knudsen AB, Lin JS, et al. Black and white differences in colorectal cancer screening and screening outcomes: a narrative review. Cancer Epidemiol Biomarkers Prev. 2021 Jan;30(1):3-12.}

See the full recommendation for more information

The AAFP supports the United States Preventive Services Task Force (USPSTF) recommendation for annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. (2021)

The AAFP has reviewed the evidence and has determined there is sufficient evidence to support a B recommendation for lung cancer screening in adults at increased risk. However, the AAFP acknowledges that the harms from annual screening with LDCT are not well documented at this time and that there are considerable barriers to screening for lung cancer in the community setting. Future research is needed to determine the harms of annual screening with LDCT including overdiagnosis, unnecessary procedures due to incidental findings, and barriers to care among communities of color. (2021)

See the full recommendation for more information

The USPSTF found insufficient evidence to determine whether screening for oral cancer in asymptomatic adults improves health outcomes. Evidence was inadequate on the accuracy of oral screening exams performed by primary care clinicians and on the benefits or harms of early detection and treatment. Because of limited and low-quality data, the USPSTF could not assess the balance of benefits and harms and therefore does not make a recommendation for or against screening.

See the full recommendation for more information (PDF)

The USPSTF found screening for ovarian cancer does not reduce mortality and can cause moderate to substantial harm, including unnecessary surgeries resulting from false-positive results. It recommends against screening for ovarian cancer in asymptomatic women who are not known to have a high-risk hereditary cancer syndrome.

See the full recommendation for more information

The USPSTF found no evidence that screening for pancreatic cancer improves outcomes and concluded that potential benefits are small while potential harms—such as complications from unnecessary procedures—are at least moderate. It recommends against screening for pancreatic cancer in asymptomatic adults.

See the full recommendation for more information

The USPSTF recommends men aged 55 to 69 years make an individual decision about prostate cancer screening after discussing the potential benefits and harms with their clinician. Because screening can lead to overdiagnosis and treatment complications, the USPSTF recommends against prostate-specific antigen (PSA)-based screening for men aged 70 years and older.

See the full recommendation for more information

The USPSTF recommends counseling children, adolescents, young adults and parents of young children aged 6 months to 24 years with fair skin types on ways to reduce ultraviolet (UV) exposure to lower their risk of skin cancer. Clinicians may also selectively offer this counseling to adults aged 25 years and older with fair skin types, considering individual risk factors, but evidence is insufficient to assess the benefits of counseling adults on skin self-examination.

See the full recommendation for more information

The USPSTF found insufficient evidence to determine whether visual skin examination by a clinician reduces skin cancer morbidity or mortality in asymptomatic adolescents and adults. It therefore concludes the balance of benefits and harms cannot be determined and recommends neither for nor against routine clinician screening for skin cancer.

See the full recommendation for more information

The USPSTF recommends against screening for testicular cancer in asymptomatic adolescent and adult males. Evidence shows testicular cancer is rare, most cases are found by patients themselves and treatment outcomes are excellent even in advanced stages. Screening by clinician examination or self-examination has not been shown to improve health outcomes, and potential harms include false positives and unnecessary anxiety or procedures. Overall, the USPSTF concludes there is moderate certainty screening has no net benefit.

See the full recommendation for more information (PDF)

The USPSTF found screening for thyroid cancer offers no greater than a small potential benefit and carries at least moderate potential harm due to overdiagnosis and overtreatment. It recommends against screening for thyroid cancer in asymptomatic adults.

See the full recommendation for more information